key: cord- -w m cqlx authors: vancini, rodrigo luiz; de lira, claudio andre barbosa; andrade, marília santos; arida, ricardo mário title: covid- vs. epilepsy: it is time to move, act and encourage physical exercise’? date: - - journal: epilepsy behav doi: . /j.yebeh. . sha: doc_id: cord_uid: w m cqlx nan j o u r n a l p r e -p r o o f sedentary and have worse levels of physical fitness [ ] [ ] [ ] [ ] [ ] [ ] , which could be worse in this scenario. considering the current perspective and the recommendation from local and global health authorities for social isolation and quarantine, the aim of this article is to present the practice of physical activity as an alternative strategy with which to cope with the pandemic of covid- for people with epilepsy and the health professionals who take care of them. the pandemic of covid- is frightening the world due to its potential for transmission-dissemination-hospitalization-lethality among more vulnerable populations, such as elderly people [ , [ ] [ ] [ ] [ ] . this could include people with epilepsy because the prevalence of epilepsy is higher in elderly people. furthermore, many people with epilepsy have other comorbidities (depression, anxiety, hypertension and obesity) and risk factors (low levels of physical activity) associated or not with the side effects of anti-epileptic drugs [ ] . in addition, quarantine and social isolation, associated with the covid- pandemic, could impact negatively on the lifestyles (physical activity and diet) and health status (mental health) of health people and those with chronic diseases/morbidities [ ] . li et al. [ ] recently, an interesting article was published on this topic entitled "a tale of two pandemics: how will covid- and global trends in physical inactivity and sedentary behavior affect one another?" in this article, hall et al. [ ] highlight that the drastic change in people's daily lives (due to the recommendation for social isolation and quarantine) around the world, associated with the pandemic caused by covid- , could negatively impact physical activity habits and emphasize sedentary behaviors. it is clear that there is a need for a change in the way that health systems are conducted and in strategies for health/education promotion that include changes in lifestyle (encourage the practice of physical exercise) around the world in order to face and cope better with scenarios of this type. in this regard, a physical inactivity pandemic is a real fact and the practice of physical activity by people with epilepsy could improve their physical and mental health [ ] [ ] [ ] [ ] [ ] . coping with the covid- pandemic and the great emotional stress would make society (individually and collectively) stronger. coping is described as behavioral efforts (positive and/or negative) to deal with situations of harm and problem-solving techniques that are utilized to reduce psychological and emotional burden. strategies of coping may include emotional support, meditative techniques, and religiosity/spirituality and physical exercise practice [ ] [ ] [ ] . emotional and psychological stress before, during and after the covid- pandemic could include fear, change in sleep patterns, eating, physical inactivity, difficulty in concentration, worsening of chronic health problems and mental health conditions, and increased use of alcohol, tobacco, or other illicit drugs [ , ] . in such a j o u r n a l p r e -p r o o f "physical exercise is medicine" for many diseases [ ] [ ] [ ] , such as neurological (dementia), metabolic (obesity), cardiovascular (hypertension), pulmonary (asthma), musculoskeletal disorders (osteoporosis), and psychiatric (depression) conditions and also for epilepsy [ ] [ ] [ ] [ ] . however, people with epilepsy are known to have low levels of physical activity [ ] , which can negatively impact their overall health status, physical fitness and mental health [ ] [ ] [ ] [ ] [ ] . in this period of necessary social isolation and quarantine it is likely that the already low level of physical activity in people with epilepsy will further deteriorate and sedentary behaviors will increase. therefore, strategies are needed to at least maintain mental health and physical fitness in a safe way, such as practicing light and homebased physical exercises. this practice needs to be adapted to the home environment and directed by skilled health professionals; people with epilepsy should be guided/advised in practicing home-based exercise, which should include aerobic exercises, muscle strength exercises and flexibility exercises [ , ] . thus, it is necessary to outline effective education and health strategies [ , ] in the short, medium and long term in order to minimize the negative impact of social isolation and quarantine caused by covid- for the general population and people with epilepsy. "physical exercise is medicine and recommended for people with epilepsy" [ , ] and the general population. there are sufficient evidences that physical exercise produces positive effects on physical fitness, mental health, and lifestyle. the advice of the epilepsy society [ ] is to "try to keep healthy by following a nutritious diet and taking light exercise" during the covid- pandemic. the most prudent thing to do is to respect social isolation and quarantine and seek alternative strategies, such as home-j o u r n a l p r e -p r o o f based physical exercise, which may include popular social networks (instagram), video and information search sites (youtube) for health promotion among the general population and people with epilepsy. authors have no competing interests to declare. ilae official report: a practical clinical definition of epilepsy epilepsy society. epilepsy and the coronavirus (covid- ) faqs comorbidities of epilepsy: current concepts and future perspectives atherosclerosis in epilepsy: its causes and implications world health organization (who). ( a). coronavirus disease (covid mental health and psychosocial considerations during the covid- outbreak antiepilepsy drugs and the immune system antiepileptic drugs and the immune system adult epilepsy treatments for the prevention of sudden unexpected death in epilepsy (sudep) physical exercise in women with intractable epilepsy a prospective evaluation of the effects of a -week outpatient exercise program on clinical and behavioral outcomes in patients with epilepsy coping/managing-stress-anxiety.html evaluation and treatment coronavirus (covid- ). book chapter asian critical care clinical trials group. intensive care management of coronavirus disease (covid- ): challenges and recommendations neurological comorbidity and epilepsy: implications for treatment a tale of two pandemics: how will covid- and global trends in physical inactivity and sedentary behavior affect one another? the impact of covid- epidemic declaration on psychological consequences: a study on active weibo users diagnosing and treating depression in epilepsy large-scale physical activity data reveal worldwide activity inequality from depressive symptoms to depression in people with epilepsy: contribution of physical exercise to improve this picture physical activity and epilepsy: proven and predicted benefits exercise as medicine -evidence for prescribing exercise as therapy in different chronic diseases exercise as medicine for people with epilepsy alternative medicine as a coping strategy for people with epilepsy: can exercise of religion and spirituality be part of this context? who uses exercise as a coping strategy for stress? results from a national survey of canadians psychosocial adaptation to epilepsy: the role of coping strategies evaluation of physical exercise habits in brazilian patients with epilepsy could physical activity practice minimize the economic burden of epilepsy? low levels of maximal aerobic power impair the profile of mood state in individuals with temporal lobe epilepsy physical exercise as a coping strategy for people with epilepsy and depression physical exercise: potential candidate as coping strategy for people with epilepsy physical exercise as therapy to fight against the mental and physical consequences of covid- quarantine: special focus in older people why the communicable/non-communicable disease dichotomy is problematic for public health control strategies: implications of multimorbidity for health systems in an era of health transition to all health professionals and scientists who donate their knowledge and key: cord- - i bmnee authors: dean, elizabeth; jones, alice; yu, homer peng-ming; gosselink, rik; skinner, margot title: translating covid- evidence to maximize physical therapists’ impact and public health response date: - - journal: phys ther doi: . /ptj/pzaa sha: doc_id: cord_uid: i bmnee coronavirus disease (covid- ) has sounded alarm bells throughout global health systems. late may, , over , covid- related deaths were reported in the united state, the highest number of any country. this article describes covid- as the next historical turning point in the physical therapy profession’s growth and development. the profession has had over a -year tradition of responding to epidemics including poliomyelitis; two world wars and geographical regions experiencing conflicts and natural disasters; and the epidemic of noncommunicable diseases (ncds). the evidence-based role of non-invasive interventions (non-pharmacologic/non-surgical) that hallmark physical therapist practice has emerged as being highly relevant today in addressing covid- in two primary ways. first, despite some unique features, covid- presents as acute respiratory distress syndrome (ards) in its severe acute stage. ards is well familiar to physical therapists in intensive care units. body positioning and mobilization, prescribed based on comprehensive assessments/examinations, counter the negative sequelae of recumbency and bedrest; augment gas exchange and reduce airway closure, deconditioning and critical illness complications; and maximize long-term functional outcomes. physical therapists have an indisputable role across the covid- care continuum. second, over % of individuals who contract and die from covid- have co-morbidities, most notably cardiovascular disease, hypertension, chronic lung disease, type diabetes mellitus, and obesity. physical therapists need to redouble their efforts to address ncds by assessing patients for risk factors and manifestations and institute evidence-based health education (smoking cessation, whole-food plant-based nutrition, weight control, physical activity/exercise), and/or support patients’ efforts when these are managed by other professionals. effective health education is a core competency for addressing risk of covid- as well as ncds. covid- is a wake-up call to the profession, an opportunity to assert its role throughout the covid- care continuum and augment public health initiatives by reducing the impact of the current pandemic. for over years in industrialized countries, physical therapists have specialized in human movement and functioning irrespective of disease and its severity (from the community to the icu) and chronic disability. it has become the third largest established health profession in the world, excepting dentists and pharmacists who have distinct practice patterns. physical therapy has been largely hallmarked by its non-invasive approaches, ie, non-pharmacological and non-surgical approaches, and competencies, and has applied this perspective through a history of responding to epidemics including poliomyelitis, two world wars and geographical regions experiencing conflicts, wars and natural disasters, and most recently ncds. the profession has emerged from a tradition of applying passive interventions to maximize movement and function, to a more holistic comprehensive tradition of exploiting means of maximizing overall health and wellbeing to augment movement and function. throughout its history, the physical therapist profession has correspondingly responded in terms of maximizing people's health and function by exploiting non-invasive interventions to the because of this, the icf has been supported by the world confederation for physical therapy (wcpt) and its member organizations. this was another turning point that advanced patient assessment, evaluation and examination to include broad dimensions beyond limitations of structure and function, to activity and participation, and assessment of contextual factors such as the patient's environment and personal factors including lifestyle behaviors. all the while, the research intensity of the profession has been unprecedented and has grown exponential over the past years in terms of securing competitive grant monies and publishing in high-ranking peer-reviewed journals. about % of covid- cases are mild and may even be undetected. ten percent of those the physical therapy community has responded expediently with the publication of practice guidelines for the acute management of patients with covid- . [ ] [ ] [ ] these guidelines and recommendations largely build on the position statement for physical therapy for adults with critical illness published in . however, that patients in the icu generally do not do well months, often years, after post-icu discharge has reinforced the notion that the continuum of care including physical therapy needs to extend for months afterwards. [ ] [ ] [ ] with the association of comorbidities, ie, ncds, with increased susceptibility to covid- and poorer outcomes including survival, has been well documented. , given the prevalence of ncds in the united states and increasingly around the world, most people have one or more risk factors or manifestations, which makes them vulnerable to covid- infection. this being the era of ncds, physical therapists have long been urged to exploit lifestyle and behavioral medicine competencies, to reverse ncds and their risk factors, eg, atherosclerosis, smoking, hypertension, type diabetes mellitus and obesity, often within days or weeks, and atherosclerosis within one year or more. , in the united states, % of those who have succumbed to covid- have at least one comorbidity, primarily related to lifestyle-related ncds; in italy this figure is %. only in americans engage in or more healthy behaviors, whereas almost half of them participate in fewer than healthy behaviors. increased participation in numerous healthy behaviors can decrease premature mortality, decrease the burden of chronic diseases, improve life quality, and provide substantial economic benefits. thus, reducing such susceptibility is critical. improving lifestyle behaviors has been well documented to prevent, reverse, as well as manage ncds. a public health practice of targeting a constellation of behaviors as opposed to individual behaviors is needed. , smoking, sedentary behavior, physical inactivity, and obesity are an independent risk factors for metabolic syndrome, - as well as cardiovascular disease, and all associated with elevated markers of low grade systematic inflammation. consistent with the recent report of the lancet eat commission, the american college of lifestyle medicine advocates a whole-food plant-based nutrition to maximize health, prevent disease particularly ncds, reverse these conditions, and reduce disability, premature death and socioeconomic burdens associated with them. such a dietary regimen has been well established to reduce risk of heart disease, cancer, high blood pressure, type diabetes, and obesity, and their relative, metabolic syndrome, conditions unequivocally linked to more severe covid infections and poorer outcomes including death. in some instances, such as hypertension and elevated blood glucose, these can be reduced within days or weeks. atherosclerosis can also be reduced or resolved with dietary changes and exercise, however these effects can take many months. , overweight can be addressed with a healthy plantbased nutrient-dense diet and exercise. variations in host immune responses might be explained in large part by the healthfulness of the host's lifestyle and behavioral factors including nutritional choices. thus, immune responses to covid- and mechanisms of hyperinflammation-driven pathology warrant elucidation to best define therapeutic strategies for covid- , including nonpharmacologic strategies such as healthy nutrition and exercise. a secondary gain of healthy nutrition could be lower incidence of physical impairment, irrespective of body mass. effective health and lifestyle education are unique physical therapist competencies. as the leading established non-invasive health profession in the world, the profession needs to assume a leadership role with respect to including in their practices and entry-level education curricula, health and risk factor assessment and prescribing health promoting interventions or indications for referral to others. effective health and lifestyle education, ie, lifestyle knowledge translation, warrants being ever more so at the forefront of every physical therapist-patient interaction. at a broad level, the physical therapy profession needs to ensure that health providers and stakeholders continue to be updated about the profession and practitioners' competencies as the professions continues to evolve and serve global societies. this will ensure that stakeholders such as legislators, ministries of health and higher education, hospital managers, university administrators, and other health professions, continue to support the physical therapy profession in its practicing at its highest evidence-informed level, in the interest of health and participation for all. the unprecedented global crisis of covid- has become an unprecedented opportunity for the physical therapist profession to continue to advance along its evolving historic trajectory, commensurate with societal and global needs. the profession has an opportunity to respond impactfully. we conclude that the covid- pandemic could well augment the profile of the profession of physical therapy within the health professions and within public health, given its potential role in reducing covid- susceptibility, and its management from its most severe expression, ards, to maximizing functional return long after hospital or icu stays. prevention and outcome of covid- could be substantially impacted with exploitation of non-invasive strategies including health and lifestyle education and exercise, that are subsumed within contemporary physical therapist practice. this is an unparalleled opportunity for the physical therapist profession to step up to the plate, and to further establish itself among the health professions and demonstrate its worth. there is no funding to report. accessed june . . and reduce the burden of non-communicable diseases postmortem examination of patients with covid- endothelial cell infection and endotheliitis in covid- post-discharge cardiac care in the era of coronavirus : how should we prepare? world health organization. covid- significantly impacts health services for noncommunicable diseases cardiovascular and pulmonary physical therapy: evidence to practice ( th ed) long-term complications of critical care rehabilitation quality improvement in an intensive care unit setting: implementation of a quality improvement model long-term outcomes and healthcare utilization following critical illness -a population-based study home and community-based physical therapist management of adults with post-intensive care syndrome education and support needs during recovery in acute respiratory distress syndrome survivors physiotherapy management for covid- in the acute hospital setting. recommendations to guide clinical practice respiratory physiotherapy in patients with covid- infection in acute setting: a position paper of the italian association of respiratory physiotherapists (arir). monaldi arch chest dis acute care physiotherapy management of covid- patients in qatar: consensus-based recommendations physiotherapy for adult patients with critical illness. recommendations of the european respiratory society and european society of intensive care medicine task force on physiotherapy for critically ill patients recovery after critical illness: putting the puzzle together-a consensus of effects of intensive upright mobilisation on outcomes of mechanically ventilated patients in the intensive care unit: a randomised controlled trial with -months follow-up understanding inflammation. harvard medical school guide long-term adherence to healthy dietary guidelines and chronic inflammation in the prospective whitehall ii study potential interventions for novel coronavirus in china: a systematic review world health organization. covid- advice to the public diabetes is a risk factor for the progression and prognosis of covid - anti-inflammatory diet in clinical practice: a review health competency standards in physical therapist practice how not to die food based dietary patterns and chronic disease prevention istituto superiore di sanità. characteristics of sars-cov- patients dying in italy healthy behaviour adherence: the national health and nutrition examination survey clustering of unhealthy behaviours over time: implications for policy and practice the king's fund healthy living is the best revenge smoking as a modifiable risk factor for type diabetes in middle-aged men managing sedentary behavior to reduce the risk of diabetes and cardiovascular disease lack of exercise is a major cause of chronic diseases healthy diets from sustainable food systems. summary report of the eat-lancet commission adherence to a dietary approaches to stop hypertension (dash)-type diet over the life course and associated vascular function: a study based on the mrc british birth cohort avoiding revascularization with lifestyle changes: the multicenter lifestyle demonstration project intensive lifestyle change for reversal of coronary heart disease how not to diet & the sinai immunology review project. immunology of covid- : current state of the science greater adherence to the alternative healthy eating index is associated with lower incidence of physical function impairment in the nurses' health study american college of lifestyle medicine. competencies for prescribing lifestyle medicine the authors completed the icmje form for disclosure of potential conflicts of interest and reported no conflicts of interest. key: cord- -rnfn opa authors: anton, stephen d.; cruz-almeida, yenisel; singh, arashdeep; alpert, jordan; bensadon, benjamin; cabrera, melanie; clark, david j.; ebner, natalie; esser, karyn a.; fillingim, roger b.; goicolea, soamy montesino; han, sung min; kallas, henrique; johnson, alisa; leeuwenburgh, christiaan; liu, andrew c.; manini, todd m.; marsiske, michael; moore, frederick; qiu, peihua; mankowski, robert t.; mardini, mamoun; mclaren, christian; ranka, sanjay; rashidi, parisa; saini, sunil; sibille, kimberly t.; someya, shinichi; wohlgemuth, stephanie; tucker, carolyn; xiao, rui; pahor, marco title: innovations in geroscience to enhance mobility in older adults date: - - journal: exp gerontol doi: . /j.exger. . sha: doc_id: cord_uid: rnfn opa aging is the primary risk factor for functional decline; thus, understanding and preventing disability among older adults has emerged as an important public health challenge of the st century. the science of gerontology – or geroscience - has the practical purpose of “adding life to the years.” the overall goal of geroscience is to increase healthspan, which refers to extending the portion of the lifespan in which the individual experiences enjoyment, satisfaction, and wellness. an important facet of this goal is preserving mobility, defined as the ability to move independently. despite this clear purpose, this has proven to be a challenging endeavor as mobility and function in later life are influenced by a complex interaction of factors across multiple domains. moreover, findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, as well as the environment in which a person lives, can have a dramatic effect on an older person's mobility and function. for these reasons, behavioral interventions that incorporate complex walking tasks and other activities of daily living appear to be especially helpful for improving mobility function. other pharmaceutical interventions, such as oxytocin, and complementary and alternative interventions, such as massage therapy, may enhance physical function both through direct effects on biological mechanisms related to mobility, as well as indirectly through modulation of cognitive and socioemotional processes. thus, the purpose of the present review is to describe evolving interventional approaches to enhance mobility and maintain healthspan in the growing population of older adults in the united states and countries throughout the world. such interventions are likely to be greatly assisted by technological advances and the widespread adoption of virtual communications during and after the covid- era. stephen d. anton a (santon@ufl.edu), yenisel cruz-almeida b (cryeni@ufl.edu), arashdeep singh c (a.singh@ufl.edu), jordan alpert d (jordan.alpert@ufl.edu), benjamin bensadon a (bensadon@ufl.edu), melanie cabrera a (melanie.cabrera@ufl.edu), david while prolongation of life remains an important public health goal, of even greater significance is that extended life should involve preservation of the capacity to live independently and to function well [ ] . the field of geroscience seeks to understand the genetic, molecular, and cellular mechanisms that make aging a major risk factor and driver of common chronic conditions and diseases of older people. interventions targeting the fundamental biology of human aging have the potential to delay, if not prevent, the onset of aging-associated conditions [ ] [ ] [ ] [ ] [ ] . the unprecedented growth of the aging population and increasing prevalence of chronic disease have underscored an urgent need for such interventions. if this the current trend in aging continues, the number of older persons (aged > years) will nearly triple in size globally, increasing from million in to almost billion by [ ] . accordingly, the science of gerontologyor geroscience -has the practical purpose of understanding how aging processes enable diseases and to then apply this knowledge to reduce the emergence and progression of age-related diseases and disabilities. the ultimate goal is to develop feasible, practical, and safe interventions to delay the development of chronic diseases and conditions, while also increasing enjoyment, satisfaction, and quality of life, during the latter stages of an individual's lifespan. [ ] interventions that can achieve these objectives may also dramatically lower health care costs. as we have previously described, [ , ] a hallmark of successful aging is mobility, i.e. the ability to move without assistance, which is necessary for the maintenance of basic independent functioning [ , ] . additionally, mobility performance (i.e., walking speed) has emerged as a surrogate marker of overall health and functional ability among older adults. [ ] improvements in usual gait speed predict better survival and quality of life in older adults [ ] . in contrast, mobility limitation is associated with more rapid functional decline, reduced quality of life [ ] , as well as hospitalization, nursing home placement, and increased mortality [ ] [ ] [ ] [ ] [ ] (see figure ). for these reasons, understanding and preventing mobility disability among older adults has emerged as one of the most important public health opportunities of the st century. therefore, identification of promising interventions to preserve mobility that can be widely implemented in older adults is a major clinical and public health priority [ ] . since our previous review, [ ] several advances in the field of geroscience have been achieved and are highlighted in this paper. for example, discoveries made in the past few years have illuminated the complex interactions between the brain and the body in affecting changes in mobility with aging. more specifically, the important role that the central and neuromuscular systems have in affecting mobility has spawned a host of new treatment options, such as use of neuro-modulatory adjuvants (e.g., transcranial direct stimulation) to enhance the beneficial effects of physical activity. in line with this, a growing body of research indicates that interventions designed to improve cognitive/emotional function (e.g., oxytocin) also have benefits effects on mobility and physical function. thus, it appears virtually impossible to influence an individual's cognitive/emotional function without affecting their physical function, and vice-versa. an increased understanding of biopsychosocial factors that may contribute to functional decline can aid in the development of future interventions designed to improve mobility and function in at-risk older adults. aided by technological developments, the range of interventions now available has greatly increased in the past five years. thus, we have expanded our conceptual model to incorporate technology, neural factors, and environmental factors. although there is a strong consensus on this goal, there are challenges to developing such interventions as an older adult's mobility and functional level are affected by factors across j o u r n a l p r e -p r o o f journal pre-proof multiple domains. moreover, the complex interactions between factors within biological, psychological, and social domains may increase the risk for functional decline and other agerelated chronic disease conditions. as such, promising interventions will need to take into account these multifaceted interactions and also recognize that affecting change in one domain can lead to changes in other domains. with this goal in mind, we first review the role of specific biological contributors to functional decline. next, we describe key behavioral and psychosocial factors that can affect physical function and risk for functional decline in older adults. we then discuss promising interventions from clinical trials that can enhance physical function and mobility, as well as the role of smart and connected technologies in the delivery of these interventions (see figure ). in the final sections, we discuss the importance of preclinical models in guiding intervention selections, statistical considerations in aging research, as well as key strategies to effectively disseminate and implement efficacious interventions in clinical and community settings. the rising prevalence of metabolic syndrome in older adults, a condition diagnosed based on the presence of three or more metabolic risk factors, including abdominal obesity, high triglycerides (tg), low hdl-cholesterol (hdl-c), high blood pressure (bp), and impaired glucose tolerance, correlates with sedentary lifestyles, and poor nutrition habits [ ] [ ] [ ] [ ] . approximately one-third of older adults in the usa are obese; however, nearly % of those aged years or older are estimated to have metabolic syndrome [ ] . given the aging us population, the disproportionately high prevalence of the metabolic syndrome in older adults is a significant public health concern, as it substantially increases the risk for cardiovascular disease j o u r n a l p r e -p r o o f journal pre-proof (cvd) [ ] [ ] [ ] [ ] and is associated with increased all-cause mortality, disability, cvd mortality, myocardial infarction, and stroke [ ] . additionally, the metabolic syndrome is associated with impairments in basic activities of daily living, social activities, and lower extremity mobility [ , ] . aging typically promotes a loss of fat-free mass which parallels to the reduction in metabolic rate and energy expenditure, particularly after the age of [ ] . this age-related muscle loss (i.e., sarcopenia) can diminish both the metabolic and mechanical functions of the skeletal muscle, [ , ] a point of concern since skeletal muscle has the greatest contribution to an individual's metabolic rate [ ] . in addition to the loss of total muscle mass, the muscle quality also declines with age due to increased fat infiltration within the muscle thus resulting in decreased muscle strength [ ] and power [ ] . after the age of , it is noteworthy that adults lose muscle strength (i.e., dynapenia) at a much faster rate, approximately - % year, than they lose muscle mass, approximately - % per year. therefore, while muscle atrophy and weakness are certainly correlated, the former cannot fully explain lost muscle strength in late-life. moreover, muscle weakness is a major independent contributor to maintaining physical independence in later life. [ ] [ ] [ ] [ ] [ ] [ ] it was originally thought that the loss of skeletal muscle mass largely explained the muscle weakness observed in older adults; however, more recent findings suggest that other anatomical and physiological factors also play an important role in muscle weakness. the mechanisms determining loss of muscle strength or power output are related to both neurological and skeletal muscle properties, as it is well known that the output from these sources control j o u r n a l p r e -p r o o f journal pre-proof muscle force and power production. within the neuromuscular system, there are several potential mechanisms that may contribute to reductions in strength during aging, including reduced excitatory drive to the spinal motor neurons, reductions in motor neuron discharge rates, impairments in neuromuscular transmission, muscle cell death, muscle protein imbalance, reduced repair/regeneration of muscle cells and impairments in the excitation-contraction (e-c) coupling processes. aging in humans has been shown to be accompanied by robust reductions in the population of motor neurons and axon density [ ] [ ] [ ] [ ] . between the ages of and there is a ~ % reduction in the number of functional motor units (motor units = motoneuron and innervated muscle fibers) [ ] [ ] [ ] [ ] and once the loss of motor units reaches a critical threshold, muscle strength begins to decline [ ] . the exact underlying mechanisms of exhausted nmj plasticity and motor neuron cell death remain obscure, but many factors such as deregulated inflammation, autophagy, reduced igf- signaling, oxidative stress, and mitochondria dysfunction have been suggested to drive accelerated loss of muscle mass and function in late life [ , ] . many factors contribute to a loss of automaticity of walking in older adults. one likely factor is impairment of the communication between the nervous system and muscle. motor neurons innervate their axon terminals to the skeletal muscle fibers to form a neuromuscular junction (nmj), which allows the presynaptic motor neurons to transmit chemical signals to the post-synaptic muscle fibers, leading to muscle contraction. during most of the adult life, there is considerable plasticity of the nmj, where surviving motor units expand through collateral axonal sprouting to reinnervate any denervated nmjs [ ] [ ] [ ] . exhaustion of this plasticity (persistent denervation and failed reinnervation) accelerates muscle atrophy during aging and is associated with movement impairment and functional decline [ , ] . accumulating evidence supports that models of cognitive brain aging may help us understand the decline in walking function in older adults [ ] [ ] [ ] . changes in brain structure and function may also contribute directly to loss of automaticity, as well as reduce the capacity for recruiting additional resources to compensate for the loss of automaticity [ , ] . additional research is needed to better understand the major modifiable neural factors that influence control of walking with older age, so that targeted interventions can be designed [ ] . chronic pain conditions represent three of the five leading causes of disability in the us, including low back pain, which is the leading cause of disability both in the us and worldwide [ , ] . while pain affects individuals throughout the lifespan, older adults are disproportionately impacted [ ] . another important contributor to mobility decline among older adults is movement-evoked pain (mep). mep refers to pain that is generated or exacerbated through physical movement or activity, and some evidence suggests that mep may be driven by different mechanisms than pain at rest [ ] . recent findings in middle-aged and older adults with knee pain demonstrated a relationship between mep and physical performance, highlighting the need to directly measure mep when assessing functional performance in older adults [ ] . thus, one key mechanism through which pain may contribute to functional decline is through activity limitations among older adults [ ] [ ] [ ] [ ] [ ] [ ] [ ] . emerging evidence also suggests that pain may affect aging processes. indeed, several recent studies suggest that pain is associated with cellular aging. specifically, a combination of high psychosocial stress and high levels of knee pain were associated with shorter telomeres among j o u r n a l p r e -p r o o f journal pre-proof middle-aged and older adults [ ] , and subsequently these authors showed that more severe knee pain was associated with shorter telomeres [ ] . more recently, chronic pain in older adults has been associated with brain aging [ ] and a validated epigenetic measure of aging [ ] . thus, the relationship between pain and aging appears to be bidirectional and complex, impacting multiple body systems. one area that is gaining recognition for the potential to impact aging processes is circadian rhythms, which are endogenously generated h cycles that can be observed in behavior, physiology and metabolic processes. driven by the circadian clock, circadian rhythms are found in virtually every cell in the body [ ] . over the last ten years, research has uncovered that the circadian clock functions within cells to support daily tissue homeostasis, and disruption of the clocks leads to lowered resilience [ ] . studies in animal models support the decline in function of the circadian system with age, and this age-related decline appears to impact virtually all systems in the body including skeletal muscle and areas of the brain important for learning and memory [ ] [ ] [ ] . in humans, studies have shown that circadian output changes with aging of muscle mass and strength [ ] [ ] [ ] [ ] [ ] . thus, the available evidence to date strongly implicates mitochondria as having a pivotal role in the pathogenesis of age-related functional decline, and it has been suggested that a substantial decrease in mitochondrial oxidative capacity in aging muscle might contribute to reduced exercise capacity in older adults [ ] . why there is a decrease in mitochondrial function with aging remains under debate, but emerging science indicates that there is a clear connection between mitochondrial biogenesis and function with fuel metabolism and circadian rhythms [ ] . cardiovascular disease (cvd) is a leading cause of death among older adults in the united states and the prevalence increases proportionally with age. in particular, % of older adults between - years old and % of older adults years and older suffer from cvd [ ] . during aging, endothelial dysfunction induced by oxidative stress, inflammation and decline in bioavailability of nitric oxide (no) leads to arterial stiffness, which overloads the heart leading to ventricular hypertrophy and myocardial fibrosis [ ] . endothelial dysfunction and the overloaded heart reduce arterial-ventricular coupling, reflecting impaired global cardiovascular performance [ ] . recent evidence has demonstrated that subclinical declines in cardiovascular function contribute to functional decline by impaired peripheral tissue perfusion [ ] . although sepsis can affect all ages, it is recognized to be the "quintessential disease of the elderly" [ ] . studies have shown that both the incidence of sepsis and hospital mortality increases exponentially beyond the age of years, with more than million us medicare recipients hospitalized each year with sepsis. numerous age-related factors increase the risk for j o u r n a l p r e -p r o o f developing sepsis including comorbidities (e.g., chronic lung disease and renal insufficiency), malnutrition, increased aspiration risk from altered mental status and decreased gag/cough reflex and immobility. the diagnosis of sepsis is commonly delayed in older patients because of a blunted systemic inflammatory response syndrome (sirs) and the presence of comorbidities that can cause confounding symptoms. as a result, older patients present as septic later in the process. they are more likely to progress into septic shock due to limited cardiac reserve and have worsening of existing organ dysfunctions. the principal cause of sepsis is a dysregulated systemic immune response, which is negatively affected by aging. in contrast to younger adults, older patients have difficulty returning to immunity homeostasis, increasing their risk for sepsis recidivism. pre-existing sarcopenia, frailty and cognitive disabilities all adversely affect recovery. additionally, ongoing sirs induces profound catabolism with tremendous loss of vital lean body mass despite early nutritional support intervention. moreover, care for sepsis in the icu often involves bedrest and mechanical ventilation, exacerbating the ongoing loss of muscle mass and function. once sirs has resolved, older sarcopenic sepsis survivors have anabolic resistance that makes them nonresponsive to nutritional and physical therapy interventions. our senses, hearing, vision, touch, smell, and taste play critical roles in survival throughout the course of life. aging can affect all of these sensory systems, but the auditory system is thought to be especially vulnerable to age-related damages. hearing loss is the third most prevalent chronic health condition affecting older adults and age-related hearing loss (ahl) is the most common form of hearing impairment [ ] . the world health organization(who) estimates that one-third of persons over years are affected by hearing j o u r n a l p r e -p r o o f loss [ ] . worldwide, approximately million people suffer from hearing impairment and this number is expected to rise to million by and over million by . ahl is characterized by poor speech understanding (especially in noisy situations), central auditory processing deficits, and social isolation [ ] . as humans age, both males and females undergo various changes in hormone levels, leading to numerous long term and significant internal changes. although some of these changes may be more detrimental than others, common and problematic alterations include loss of muscle mass [ ] , decreased bone mass [ ] , and various cognitive impairments [ ] , which all increase risk for mobility loss and loss of independence. in men, aging is often associated with decreased testosterone [ ] , which has been linked to bone loss [ ] and decreased muscle mass [ ] . with the loss of muscle and bone comes an increased risk of sarcopenia, oftentimes resulting in frailty, decreased functional mobility, and growing difficulties with independent living. in females, decreased estrogen levels post-menopause are often postulated to increase one's risk of sarcopenia and frailty [ ] . loss of estrogen is accompanied by an increase of pro-inflammatory cytokine il- , which downregulates insulin-like growth factor- (igf- ) [ ] . high il- /low igf- levels have been shown to significantly limit walking and mobility tasks of daily living [ ] , increasing the risk for progressive disability in older females. in addition to sex hormones, a decline in growth hormone (gh) has been observed with aging and is often associated with various changes in body composition, as well as physical and psychological functions [ ] . as one approaches the fourth decade of life, there is a progressive decrease of gh secretion by ~ % each decade thereafter [ ] . age-related increases in body j o u r n a l p r e -p r o o f mass index (bmi) and diminished functional capacity tend to parallel the decline in gh secretion, although many other factors also likely contribute [ ] . in many cases, physical disability is directly caused or aggravated by acute events (stroke and hip fracture) and disease states (heart failure, coronary heart disease, diabetes, arthritis and peripheral artery disease) [ , ] . however, a large and growing number of older adults experience progressive declines in physical function over several years culminating in agerelated physical disability with no clear connection to a single disease [ , ] . research over the past decade has highlighted the role of multiple body/biological/health systems in contributing to this decline. moreover, many age-related conditions appear to affect other systems and may induce similar adverse changes at the cellular level. among the behavioral factors, low levels of physical activity combined with excessive and unhealthy calorie intake appear to strongly contribute to functional decline among older adults [ ] . in line with this, a recent review of trends in us health by the u.s. burden of disease collaborators found that high body mass index (bmi), smoking, and high fasting plasma glucose are the three most important risk factors for disease and disability in the united states [ ] . among these, only the prevalence of smoking is decreasing, while bmi and fasting plasma glucose levels are steadily increasing. skeletal muscle loses the ability to switch between metabolizing lipids and carbohydrates. in addition to the role caloric excess can have in promoting metabolic inflexibility, there is also increasing evidence that the "western-type" diet that is high in sugar, fat, and processed foods seems to be associated with less ideal aging phenotypes [ ] . high levels of sedentary behavior (sitting) contributes to lipid accumulation [ ] [ ] [ ] , metabolic impairments [ ] , and loss of muscle mass during aging [ ] , all of which strongly contribute to functional decline [ ] [ ] [ ] [ ] . these findings are of concern as the majority of middle-age americans spend over half their waking day (~ - hours) engaged in sedentary pursuits [ , ] , with older adults spending an even greater proportion ( %) of their waking hours engaged in sedentary behavior (~ hours per day) [ ] . moreover, each additional hour of sedentary behavior was associated with increased risk of the metabolic syndrome, whereas every additional hour of light intensity activity was associated with reduced risk. perhaps the most common complaint older adults have is the lack of quality sleep. sleep affects nearly every tissue and system in the body, from the brain, heart and muscle to metabolic, endocrine, cardiovascular and immune functions, as well as numerous cognitive processes such as learning and memory, emotion and motor control [ ] . similar to food and water, sleep is a basic human need, and sleep timing, duration, and quality are all essential to health. despite this, sleep deficiency is prevalent in modern society, including an insufficient amount of sleep, low quality sleep, and sleep at the wrong time of day. according to a recent report from the centers for disease control and prevention (cdc), % of u.s. adults report some form of sleep deficiency [ , ] . sleep deficiency is more prevalent in older adults, exhibiting common nighttime sleep abnormalities, such as early bedtime and rise time, sleep fragmentation (i.e. less consolidated sleep with frequent awakenings), short sleep duration, less total sleep, and deep sleep [ ] ; which is correlated with more frequent daytime naps. in fact, in older adults report severe daytime sleepiness that affects daytime mental and physical performance [ ] . these agerelated sleep deficiencies have significant consequences for brain and body health, increasing the risk of chronic inflammatory and neuropsychiatric diseases, metabolic and cardiovascular disease, as well as mental health problems and even pain. for example, poor sleep quality and chronic pain are both tied to significant reductions in quality of life in aging [ ] . emerging evidence from our group suggests that sleep may negatively impact brain structure and function in older individuals, which may lead to worse self-reported pain [ , ] . an increased understanding of the behavioral factors that contribute to functional decline in otherwise healthy older adults can assist in both identifying at-risk older adults and designing targeted interventions for individuals in the later stages of life that maintain mobility and slow the rate of functional decline. it is recognized that there are many causes of functional decline and ultimately disability. while we believe behavioral factors, including over and undernutrition, physical inactivity, and sleep, have a central role in maintaining mobility in later life, the pathways leading to physical disability in older adults are likely complex and involve consideration of a larger number of etiologic factors. environment and social relationships can serve as either risk or protective factors for aging adults. environmental factors across the lifespan interact with biology and contribute toward health outcomes [ ] . research shows that early life stressors can influence biological functioning, priming the stress system toward a level of heightened sensitivity increasing greater risk for later life health conditions and earlier mortality [ ] . as individual age, environmental factors, life experiences, and personal and financial resources can buffer or exacerbate healthrelated conditions. social relationships also influence health and well-being. limitations in social relationships can be experienced as social isolation and loneliness [ ] . of concern, approximately one fourth of adults, individuals aged years and older meet social isolation criteria and among individuals aged years and older, greater than % endorse loneliness [ ] . age-related life changes that increase susceptibility to social isolation and loneliness includes changes in health status limiting functioning and mobility; changes in family structure (divorce, childless); death of friends, family members, and spouse; auditory and visual changes reducing the ability to communicate and interact; and resource reductions including healthcare access and quality of care [ ] . there is also research evidence that socially isolated older adults are less physically active independent of any mobility limitations [ ] . however, whether or not declines in mobility mediate the well-established relationship between social isolation and all-cause mortality [ , ] remains unclear. minority older adults are at an even greater risk to the health consequences of environmental and social factors. higher frequency of negative environmental exposures, limited j o u r n a l p r e -p r o o f environmental resources, possible language limitations, and experiences of stigma and discrimination might be further contributing to increased risk of morbidity and mortality [ ] . despite this increased risk for poor health outcomes, access to medical care is often limited and the extended wait times to receive care may discourage healthcare utilization, particularly preventive health services among minority populations [ ] [ ] [ ] . thus, environmental and social factors represent an area where research and evidence-based strategies can contribute to improved health outcomes [ , , ] . older adults perceive mobility as essential to feeling whole and identify mobility assistance and adaptation as key to managing age-related changes [ ] . in fact, older adults who met just one of five established frailty phenotype criteria were more likely to also be depressed, suggesting frailty has both physical and psychological components [ ] . also noteworthy, psychological factors such as balance efficacy and falls efficacy have previously been found to be more important than physical factors (e.g., fall history, medical morbidity, and balance tests) in predicting future falls [ ] . theoretically, self-efficacy for specific tasks, mood, and behavior have a reciprocal influence on an older person's decision making and performance. for example, lower baseline self-efficacy for functional tasks predicted decreased walking performance and stair ascent among older women with osteoarthritis [ ] . falls efficacy, a measure of falls-specific selfefficacy, can be independently predicted by normal walking pace, anxiety, and depression [ ] . dizziness, another common mobility-related complaint of older adults, has been associated with lower falls efficacy and slower walking speed [ ] . these trends are consistent with other data j o u r n a l p r e -p r o o f showing fall history and female gender independently predict fear of falling [ ] and mobility device use [ ] . consistent with the data on the importance of psychosocial factors in mobility, a number of mobility-related clinical interventions are integrating falls-specific self-efficacy [ ], balance-specific [ ] and other psychological concepts into trials targeting frailty in older adults [ ] . further, these trials are also targeting motivation for physical activity [ ] , adherence to exercise programs [ ] , fall prevention [ ] , and interventions to reduce the fear of falling and improve balance such as yoga [ ] . protocols are emphasizing the need to tailor to older adult's preferences, personal choice, and providing social support [ ] . these factors should align with older adults' own attitudes and perceived needs [ ] , as well as older adults' perceived enablers and barriers to participation in strength and balance activities (barriers = risk of cardiac events, death, and hyper muscularity; enablers = potential improvement in the ability to complete daily activities, prevent deterioration /disability, and decreased risk and fear of falling) [ ] . in a month integrated care program that included problem-solving psychotherapy reported improvements in frailty were sustained at one year follow up [ ] . although these studies suggest promising results, the integrated biopsychosocial approach to mobility is still underutilized. poor nutrition may be a key factor that promotes metabolic syndrome and can exacerbate a decline in physical function and mobility. given the link between metabolic syndrome or obesity with the musculoskeletal decline among the older population, it is no surprise that dietary interventions that reduce bodyweight also improve health outcomes in older adults. dietary j o u r n a l p r e -p r o o f restriction (or caloric restriction), defined as a mild reduction of energy intake without malnutrition, delays aging in nearly all animal species tested so far [ ] . in addition to promoting longevity in various model organisms (e.g., yeast, worm, fly, mouse) [ , ] , dietary restriction had also been shown to be beneficial for enhancing physical function and mobility in older adults [ ] [ ] [ ] [ ] . furthermore, in overweight humans, caloric restriction has been shown to reduce several cardiac risk factors [ ] [ ] [ ] , improving insulin-sensitivity [ ] , and enhancing mitochondrial function [ ] . current challenges: despite health-promoting biological changes, there are two important concerns related to calorie restriction interventions in older adults. first, weight loss could accelerate aging-associated muscle loss and thereby have adverse effects on physical function [ , ] . second, most individuals have difficulty engaging in caloric restriction over the long-term and frequently regain weight that was lost [ ] . for these reasons, alternative innovative dietary approaches for reducing body weight, specifically body fat, in overweight, older adults at risk for the functional decline are currently being explored. innovations from geroscience: one alternative dietary approach that has been suggested to produce similar biological changes as calorie restriction that has received increasing interest from the scientific community is intermittent fasting or time-restricted eating (tre) [ ] . in contrast to traditional calorie restriction paradigms, there is typically no restriction to calorie consumption in tre during designated eating periods (typically - hours). in a recent review of the effects of intermittent fasting regimens, specifically tre and alternate-day fasting, we found that tre produced significant reductions in body fat without significant loss of lean tissue, suggesting it may be an effective intervention approach for overweight, older adults [ ] . another area of increasing scientific interest is understanding the role of dietary composition in impacting human physiology and physical performance. for example, the mediterranean diet, which consists of healthy fats, fiber, fish, and minimally processed, plantbased foods, has been shown to provide health benefits including improving cardiovascular function, glucose control and decreasing body weight among older adults [ ] [ ] [ ] . also, noteworthy, in some preclinical studies conducted in rodent models, the ketogenic diet has been shown to extend longevity and healthspan, [ [ ] improve memory and cognition, [ ] [ ] [ ] and improve endurance athletic performance [ , ] . based on such findings, the lowcarbohydrate, high-fat ketogenic diet has attracted increasing attention as a potential dietary intervention to promote healthy aging. future directions: to date, the impact of diet interventions on physical function and mobility among seniors with aging-associated morbidities is unknown. although some risk may be associated with lifestyle-based weight loss interventions in older adults, obesity, and sedentary lifestyle are known to predict the development of disability in otherwise healthy older adults [ , ] . however, randomized controlled studies are needed to demonstrate whether the benefits of these interventions outweigh the risks before implementing these interventions on a broad scale. an important primary focus of these interventions should be enhancing and/or maintaining fat-free mass, as high-quality muscle is the primary driver of metabolism and also directly impacts mobility and physical function [ , ] . notably, as multimorbidity is often a characteristic feature observed in older individuals with impairments in mobility, a geroscience approach will be instrumental in determining the long-term efficacy of nutrition-based interventions and addressing the potential challenges with aging-associated comorbidities. exercise provides benefits to all major body systems, including the nervous system. aerobic exercise, in particular, can enhance brain health by upregulating neurotrophic factors that improve nerve structure and function [ ] . to prevent functional decline, the american college of sports medicine (acsm) guidelines for older adults recommend a regular exercise program that includes a combination of endurance and resistance training [ ] . in support of these recommendations, low-intensity aerobic activity such as walking - days per week [ ] or going up and down a -stair staircase [ ] , have been shown to be protective against loss of mobility and functional decline [ ] [ ] [ ] . current challenges: while structured physical activity is a powerful tool to improve overall health in older adults, involvement in structured physical activity may be overwhelming for frail older adults who are home-bound and have poor physical performance. older adults may not be capable of participating in structured, institution-based physical activity programs with multiple visits to research sites due to poor health status and distant living locations. innovations from geroscience. our group has shown that a structured, moderate-intensity physical activity program compared with a health education program reduced the incidence of major mobility disability over . years among older adults at risk for disability [ ] . other studies have found that resistance training can reduce and delay age-related changes in functional mobility [ ] , improves leg strength [ ] , and prevents falls by improving transfer of weight and swooping motions in the elderly [ ] . reduction of sedentary behavior may be an alternative way to deliver a home-based and remotely supervised intervention to improve the functional status in older adults who cannot engage in center-based physical activity programs. for example, an intervention to reduce sedentary time over -weeks improved scores on the short physical performance battery (sppb) and self-reported moderate-to-vigorous physical activity (mvpa) levels in older men and women [ ] . such it could be a promising intervention to improve physical function in frail older adults in a home-based setting. strong positive associations between breaks in sedentary time with physical function in older adults have also recently been reported [ ] . challenges: remotely delivered interventions are more difficult to achieve long-term adherence to the intervention tasks. additionally, considering heterogenous levels of daily activity and sedentary time among individuals, it is challenging to set daily frequency of sedentary time reduction breaks and design the methods for prompting these breaks as well as an amount of steps to be reached daily. [ ] innovations from geroscience: thanks to new developments of well-accepted wearable technology in older adults [ ] , such as the fitbit alta device, activity and sedentary-behavior levels can be monitored and registered remotely, and importantly, users can be reminded automatically to transition from sitting to standing position and perform brief light-intensity activity such as leisurely walking [ ] . for example, participants using wearable technology aimed to achieve a minimum goal of % increase in daily posture breaks, and an additional , steps a day to baseline, which is considered clinically meaningful in a geriatric rehabilitation population [ ] . this novel and practical approach, is less physically strenuous, j o u r n a l p r e -p r o o f does not require frequent visits to research sites, and can be operated and monitored remotely by a research team. future directions: future randomized clinical trials are needed to test wearable technologies in a population of frail older adults with poor physical function, multi-morbidities, and live a far distance from research facilities. given the importance of physical activity and exercise for healthy aging, it is important to consider how these can be optimized to promote neural control of walking. the mode of activity/exercise may be important, and there may be adjuvant interventions that promote neural plasticity. innovations from geroscience. task-specific aerobic exercise that incorporates complex walking tasks and other activities of daily living may be especially helpful for mobility function [ ] . an example of these interventions is the use of non-invasive neuromodulation such as transcranial direct current stimulation (tdcs), a mild form of electrical stimulation that is safely delivered via electrode sponges placed on the scalp. tdcs does not directly activate brain neurons, but rather alters the neuronal membrane potential, which is believed to alter the likelihood of eliciting neuron activity (either increased or decreased likelihood, depending on the stimulation parameters) [ ] . when paired with task practice, excitatory tdcs might reinforce task-specific neural circuits, enhance learning, retention of new skills, and has been shown to benefit walking tasks in preliminary studies [ ] [ ] [ ] [ ] . cognitive interventions refer to a broad set of methods designed to improve or maintain cognitive functioning [ ] . because many forms of cognition (e.g., memory, reasoning, speed, executive functioning, attention, working memory) are change with age, and are associated with functional losses in later adulthood [ ] [ ] [ ] , the field of cognitive intervention research has been rather broad. methods of intervention have varied from cognitive training (e.g., providing elders with strategic instruction and practice/feedback in age-vulnerable cognitive domains i ), engagement [ ] (having elders engage in complex real-world or leisure activities, including video games) [ ] , quilting and digital photography [ ] , performing arts [ , ] interacting with technology [ , ] , to a wide variety of physical and nutritional strategies (e.g., cardiovascular and strength training, anti-inflammatory diets [ ] ). most of this research has sought to investigate whether interventions can improve cognition and/or cognitively demanding activities of daily living. innovations from geroscience. useful field of view training progressively and adaptively trains older individuals to improve the speed with which they make accurate perceptual judgments about targets presented in the center of the field of view, while also correctly noting the location of peripheral objects presented on a display [ ] . restrictions in useful field of view have been associated with problems of mobility [ ] , balance [ ] and increased risk of falling [ ] , although direct training benefits have not yet been widely reported. of relevance to the mobility domain, older drivers who received useful field of view training showed a roughly % reduction in five-year motor vehicle crash rates [ ] , presumably because of the improved ability to rapidly monitor a broad visual display and to divide attention between central and j o u r n a l p r e -p r o o f peripheral targets. the unifying feature of each of these domains of successful cognitive training is the focus on divided attention. in all cases, training included the feature of exposing elders to two tasks at once with one task usually representing a balance/gait or visual-perceptual challenge. generalization of training to mobility tasks seems to be associated with the improved ability to attend to multiple tasks at once, or perhaps to be resistant to distracting tasks by having greater control over attentional prioritization (i.e., reducing the effects of distraction, or improving the ability to exert controlled attentional processing over mobility-relevant tasks). the question of whether cognitive interventions might also improve mobility and physical functioning has received less attention, but a few areas of inquiry have yielded supportive findings. first, dual-task training has been shown to improve standing balance, gait, and to reduce fall risk [ , [ ] [ ] [ ] . the rationale for such studies is that balance and gait are thought to be under central (executive) control, and improving attentional capacity to concurrently conduct cognitive and motor challenges will improve the ability to maintain adequate mobility under distracting conditions, as distractions are thought to put elders at a high risk for falls. there are a number of hormonal interventions that have the potential to impact mobility and improve physical function. we focus on one promising compound, the neuropeptide oxytocin, which serves various adaptive and interrelated physiological, behavioral, and cognitive functions [ ] . as a hormone, oxytocin is released into the peripheral circulation and acts directly on multiple organ systems. for example, in humans, low plasma oxytocin levels were associated with increased prevalence of chronic pain, and acute (i.e., one-time) intranasal oxytocin administration decreased experimental pain sensitivity, increased pain inhibition, and j o u r n a l p r e -p r o o f journal pre-proof improved mood and positive affect. in addition, there is increasing evidence of improved wound healing and anti-inflammatory effects associated with oxytocin [ ] , promoting physical health. innovations from geroscience: the ability to administer oxytocin centrally via nasal spray [ , ] , with minimal and inconsistent side effects [ ] , has spurred research to explore the neuropeptide's therapeutic potential across functional domains, including physical health and in aging [ ] [ ] [ ] [ ] . going beyond its classic role in labor and lactation [ ] , oxytocin has been demonstrated to modulate higher-order cognitive processing [ ] , improve vasculature in the cardiovascular system, benefits weight control, and insulin sensitivity [ , ] . oxytocin has also been shown to play a crucial role in endogenous analgesia and has recently been discussed as a promising treatment for pain in older individuals [ ] . these analgesic mechanisms may be explained by oxytocin's role as both a neurotransmitter and a paracrine hormone and may be associated with brain-morphological processes. as a neurotransmitter, oxytocin may provide analgesia via widespread effects on the brain and spinal cord. in humans, emerging evidence supports an association between plasma oxytocin levels and brain volumes [ , ] . preliminary data from a -week intranasal oxytocin intervention in older men found increased regional gray matter volume following oxytocin but not placebo treatment, with this oxytocin-induced enlargement in brain volume was associated with improved processing speed [ ] . furthermore, animal models that administer repeated oxytocin treatment have documented brain changes driven by cell proliferation, differentiation, and dendritic complexity of new-born neurons in the hippocampus [ ] . findings in both models offer promise for future investigations into the potential of intranasal delivery of oxytocin to counteract cognitive decline and positively affect physical health in aging. additionally, data j o u r n a l p r e -p r o o f from an animal model that systematically administered oxytocin found that the administration enhanced muscle regeneration after injury through activation of stem cells and mapk/erk signaling [ ] . future directions: only one study to date has specifically examined the effects of intranasal oxytocin administration on physical health among older adults and found that -days of oxytocin spray was associated with less self-reported physical decline and reduced selfreported fatigue [ ] . the promising findings from these diverse emerging fields call for more systematic research on both acute and chronic oxytocin intervention towards physical function among older adults. examination of exogenous oxytocin's direct and mediated effects, and interaction with the endogenous oxytocin system (e.g., naturally circulating neuropeptide levels, oxytocin receptor gene polymorphisms and methylation levels [ , ] ), forms an interesting angle for future research on interventions promoting physical function and mobility in aging. in addition, there is growing support in the literature of sex dimorphism in the oxytocin system [ ] , including in aging [ ] , and evidence of sex-dimorphic effects of intranasally administered oxytocin on both brain [ , ] and behavior [ , , ] , including among older adults. in an age-heterogenous sample of generally healthy women and men, plasma oxytocin levels were higher in women than men, with young women showing the numerically highest levels and older men showing the numerically lowest plasma oxytocin levels [ ] . based on this emerging evidence, future research on the application of oxytocin's effects across different functional domains during aging will benefit from consideratin of sex-by-age variations. pharmacological interventions targeted at underlying mechanisms of mobility decline may also lead to improvements in mobility and physical function in older adults. for example, cell senescence characterized by a loss of cell proliferative capacity, increased metabolic activity, and resistance to apoptosis is a major contributing factor to the development of various agerelated conditions. thus, targeting the removal of senescent cells or suppressing the senescenceassociated secretory phenotype may be helpful in improving physical function [ ] . specifically, inhibition of cytoplasmic hsp (a chaperone protein needed for proper protein folding) induced by hsp inhibitors causes senescent cells to be more susceptible to apoptosis. other pharmacological agents aimed to help proper protein folding or remove misfolded protein aggregates may also delay the onset of age-related diseases and subsequently prevent or ameliorate physical functional decline from these sources. the idea that aging itself may be modified through a pharmaceutical intervention will be tested in the targeting aging with metformin (tame) proposal, the first clinical trial to examine an intervention to slow aging rather than to treat a specific age-related chronic disease in humans pharmacologically [ ] . the impetus for this trial is that metformin has been demonstrated to have protective effects against several agerelated diseases in humans. however, there does not appear to be a single biological mechanism targeted. rather metformin appears to have broad systemic effects, which can enhance insulin sensitivity and upregulate stress responses at the cellular level. further, targeting cognition pharmacologically to improve mobility or prevent further decline may be possible, given the brain's neurotransmitter systems shared between cognitive function and the circuits controlling gait. specifically, drugs targeting the cholinergic, j o u r n a l p r e -p r o o f dopaminergic and glutamatergic systems have been reported with various degrees of success in individuals with alzheimer's and parkinson's disease [ ] , but may be an additional option to explore in cognitively intact older adults with poor mobility. future directions: to date, there is very limited research focused on pharmacologically targeting aging for improving physical function. given the mosaic of aging processes and potential multi-factorial underlying mechanisms, a geroscience approach will be needed to test interventions with multi-functional properties that target the biopsychosocial contributors to aging processes. natural compounds may also represent an important source of potential new interventions for older individuals. similar to pharmaceutical agents, these compounds would likely be most effectively used as an adjunct treatment with lifestyle interventions, behavioral self-management programs, physical exercise, or cognitive interventions. current challenges: for the vast majority of these compounds, the findings have primarily been shown in preclinical models and have not yet been translated to humans, and/or few clinical trials have shown positive effects on mobility in older adults when biologically based approaches are used alone and not in combination with a behavioral intervention [ ] . innovations from geroscience: studies to date suggest some natural compounds may be effective adjuvants to lifestyle interventions. in this section, we will focus on one promising nutraceutical compound, nicotinamide riboside (nr), a form of vitamin b that stabilizes the nad metabolome (nad+, nadh, nadp+ and nadph), which in a homeostatic state, mediates transformations from food into energy and repair processes [ , ] . given the nad metabolome destabilizes with age [ ] , supplementation with nr has been shown to stabilize j o u r n a l p r e -p r o o f the nad metabolome in a variety of tissues [ ] . clinical studies have demonstrated excellent tolerabilty and safety of nr supplementation in middle-aged and older adults, and improved vascular function [ ] and reduced fat tissue [ ] following weeks of supplementation. future directions: the effects of nr supplementation alone on physical performance in older humans are unclear, and therefore future studies warrant investigations of longer-duration nr supplementation on physical performance, weight loss and cardiovascular function in humans [ , ] . much will be learned about the promise of preclinical findings to translate to humans, as well as their compatibility with other interventions, in the coming years. there are many promising complementary and alternative treatment modalities, including biofeedback, hypnosis, meditation, mindful exercise, massage and other types of body-work, acupuncture, and music therapy, that have the potential to improve mobility and physical function in older adults. here we will focus on the potential role of massage therapy (mt), which is a mind-body intervention that has been shown to improve muscle function and quality, preserve of neuromuscular function, improve sleep quality and psychological functioning [ , [ ] [ ] [ ] [ ] [ ] ; [ ] ; [ ] . additionally, a growing body of literature supports the use of mt to treat chronic musculoskeletal pain associated with aging [ ] [ ] [ ] [ ] . current challenges: while mt shows significant promise for improving factors associated with physical function and quality of life, there are important considerations for older adults, including access, attitudes, and approach. attitudes towards complementary health approaches, specifically mt, are often biased towards a luxury service instead of an actual medical intervention. also declines in mobility and independence may inhibit treatment seeking. innovations from geroscience: specific to biological processes in aging, mt has been shown to modify gene expression, protein synthesis, and inflammatory responses [ ] [ ] [ ] [ ] , as well as improve peak isometric torque recovery following intense exercise [ ] , and protect against loss of strength and fibrotic nerve and connective tissue changes associated with repetitive motion injuries [ ] . massage therapy has also been demonstrated to modulate inflammatory processes that may be protective in aging [ , ] . of particular relevance, recent preclinical studies using rodent models, demonstrated mt induced immunomodulatory changes (e.g., increased satellite cell number) comparable to those seen in younger animals without damaging muscle tissues. [ ] the beneficial effects of massage therapy appear to take place quickly, as a single -minute massage therapy session following exercise-induced muscle damage was found to be beneficial for reducing inflammation and promoting mitochondrial biogenesis [ ] . additionally, massage therapy is capable of altering proprioceptive feedback to the central nervous system [ , ] , a critical component for maintaining mobility in aging. adults have yet to be fully elucidated, it is likely that massage therapy can serve a vital role in helping older adults maintain mobility by reducing pain, improving muscle functioning, maintaining proprioceptive abilities, and altering negative inflammatory processes, while improving psychological functioning [ , , [ ] [ ] [ ] . although mt may need to be modified to accommodate older adults' needs, it appears to be a safe and effective intervention. given that mt acts upon multiple important pathways for mobility and independence, applying an integrated geroscience approach will improve our understanding of mt in addressing agerelated mobility and functional declines. there is now evidence to support a wide variety of intervention approaches to improve mobility and attenuate functional decline in older adults. both behavioral and biological interventions hold great promise for improving function and mobility and thereby extending healthspan and promoting wellness in functionally limited but healthy older adults. as noted previously, such interventions may enhance physical function directly, as well as indirectly through modulation of cognitive and socioemotional processes. these processes include depression, social stress, and anxiety, which all have high relevance in aging and may contribute to social isolation and reduced well-being among older adults. the utility of such interventions to produce desired outcomes is directly impacted by participant adherence to prescribed treatments, and even the most efficacious intervention can be ineffective if the patient fails to follow treatment recommendations. thus, it is very important to carefully evaluate the sustainability of such interventions, especially in light of research demonstrating that individuals who are not fully adherent to health interventions experience significantly fewer health benefits [ ] . a variety of factors can affect long-term adherence to health promotion behaviors, including the complexity of the required changes, the number of decision points needed to carry out such changes on a daily basis, and a number of environmental, socio-cultural, and psychological influences [ ] . this suggests the need for two approaches to enhance the effectiveness of behavioral and biologically-based interventions: ) continued refinement of strategies that can enhance the delivery of and adherence to such interventions, and ) development of novel intervention approaches (e.g., intermittent fasting and intermittent activity bouts) that have the potential to produce similar health benefits as traditional lifestyle approaches and also may be easier to sustain over the long-term. the role that technological advances may have in increasing the effectiveness of both traditional interventions, as well as more novel intervention approaches, is a topic of great interest. in the section below, we describe some of the key considerations in delivering digital and mobile health (mhealth) based interventions in older adults. personally-held devices, such as smartphones, smartwatches and fitness trackers, provide a ubiquitous infrastructure for researchers and clinicians to passively collect a moment-bymoment quantification of individuals' behavior in their own environment, or recently referred to as digital phenotyping. smartphones are considered the most common electronically held devices. pew research center (prc) conducted a survey about the ownership of smartphones in showing that % of americans and % of older adults own smartphones, usage doubling among americans and nearly quadrupling among older adults since [ , ] . smartwatches are also growing rapidly. the international data corporation (idc) worldwide quarterly wearable device tracker published that smartwatches accounted for . % of the wearable market in and is expected to rise to . % by [ ] . prc has published recently a survey showing that onein-five americans ( %) wear a smartwatch or a fitness tracker [ ] . a recent study by manini and colleagues [ ] about the perception of older adults ( + years) towards the use of smartwatch technology for assessing pain showed an overall positive view. data collected using smart devices fall under two main categories: active and passive data. the essential difference between these two types is the involvement of participants in reporting data. the active data is described as questions or surveys that a participant has to self-j o u r n a l p r e -p r o o f report at specific times. this data is commonly used for ecological momentary assessment (e.g., pain, mood, or fatigue). in contrast, passive data collection does not require participants to report any data. participants are only required to carry the smart device to be able to continuously collect data through built-in sensors. the type of passively collected data and the quality depend on the availability and modalities of sensors. the most common sensors available are: ) global positioning sensor (gps) that could be used to measure life-space mobility; which is a measure of the spatial size and frequency of interaction with the surrounding environment; ) accelerometer that could be used to track physical activity pattern and energy expenditure; ) microphone that could be used to collect voice samples to be used to extract vocal markers that can serve as a prognostic value for neurological disorders; and ) call and text logs that can convey information about the size and reciprocity of a person's social network and can also serve as a prognostic value for neurological and psychological disorders. the huge amount of data collected from personally held devices contain hidden, but useful knowledge about the behavior of an individual. fortunately, the advancement of machine learning techniques allowed us to tap into this data and extract patterns. in recent years, sensors embedded into wearable and personal devices such as smartphones have made it possible to develop many mhealth apps, e.g. for tracking physical activity, monitoring blood pressure and heart rate, medication reminders, and many more [ , ] . some mhealth apps additionally provide just in time (jit) interventions (figure ) , such as prompting physical activity based on inferred levels of activity or daily steps. a number of recent studies have utilized such mhealth tools in controlled trials to examine mhealth interventions, especially for chronic disease management [ ] . several studies have used mhealth intervention tools in cardiovascular and diabetes patients, including the pilot mobile atrial fibrillation (maf) [ ] trial (n = , cluster randomized design pilot study). as the first mhealth trial of atrial fibrillation patients, maf showed improved drug adherence and anticoagulant satisfaction versus the usual care. in a larger study, the heart failure ii (tim-hf ) trial [ ] (n = , randomized parallel-groups), utilized remote monitoring and demonstrated that it could reduce the percentage of days lost due to unplanned cardiovascular hospital admissions and all-cause mortality. in a remote monitoring study, giacomelli et al. [ ] showed that remote monitoring after hospitalization for heart failure in older adults had no impact on the primary end-point but it significantly improved patients' quality of life. physical activity promotion also has been examined in several mhealth trials, including the mactive [ ] trial which showed that tracking and texting intervention increased physical activity. amorim and colleagues [ ] carried out a randomized controlled trial by integrating mhealth, health coaching, and physical activity for patients sufferings from chronic low back pain, demonstrating feasibility and acceptance and a reduction in care-seeking after treatment discharge. other studies have examined mhealth interventions for promoting mental health in clinical trials, including using smartphone cognitive behavioral therapy for refractory depression [ ] and smartphone-delivered intervention in patients with a serious and persistent mental health condition, with the improvement shown among patients from racial minority groups [ ] . these recent intervention studies and especially controlled trials show promise for the potential scalability and acceptance of mhealth tools. an important but sometimes overlooked j o u r n a l p r e -p r o o f aspect of developing mhealth intervention tools is conducting formative usability evaluation research, besides evaluating efficacy in formal trials. tools must be designed to effectively communicate the proper information by being interactive, interoperable, engaging, and accessible for diverse audiences [ , ] . therefore, the following attributes should be considered during the development, adoption, and implementation of mhealth tools: ) ease of use; ) how the tool fits within the policies, practices, and technical infrastructure of existing health and social systems; and ) whether intended users can understand and apply the health information provided. performing needs analysis and audience analysis can help guide the design to achieve such objectives [ ] . in summary, while mhealth tools may enhance the delivery of some interventions, especially in chronic disease management, evidence regarding their effectiveness for geriatric conditions is still mixed [ , ] . additionally, most controlled trials have been carried out in high-income countries, and evidence on the effectiveness of such tools in lower-income countries is missing [ ] . finally, there is a lack of end-to-end systems for sharing jit intervention results with providers through existing electronic health record (ehr) systems. both humans and animals exhibit an age-dependent progressive decline in mobility [ ] [ ] [ ] [ ] . thus, mechanistic studies of age-related mobility impairment in pre-clinical models could advance our understanding of the fundamental mechanisms underlying disability. for example, there is much that can be learned from the study of the simple organism c. elegans. despite its simple anatomy, c. elegans is capable of multifaceted behaviors in response to diverse environmental and intrinsic cues, and exhibits an age-associated decline in locomotion [ , ] . the multitude of genetic tools available also makes c. elegans an invaluable model system for the study of cellular and molecular mechanisms underlying aging-related locomotor and j o u r n a l p r e -p r o o f movement decline [ ] . in c. elegans, the progressive deterioration of muscle occurs with age, which resembles human sarcopenia [ ] . importantly, the functional decline of motor neurons at the neural muscular junctions precedes the deterioration of muscle tissues during c. elegans aging [ ] , indicating an important role of motor neurons in the age-related mobility impairment. findings from pre-clinical models have led to the identification of important biological mechanisms related to the aging process including mitochondrial function and dynamics [ , ] , autophagy [ , ] , oxidative stress [ ] , chronic inflammation [ ] , muscle composition [ ] , hormonal factors [ ] , and neurodegeneration [ ] . moreover, preclinical studies have led to the transformative discovery that interventions targeting the fundamental biology of human aging have the potential to delay, if not prevent, the onset of aging-associated conditions [ ] [ ] [ ] [ ] [ ] . ultimately a strong translational geroscience approach is needed to understand the disease-mediated pathways associated with functional decline and identify promising interventions to maintain mobility and physical function (see figure ). as aging research becomes more information-based, statistics plays a critical role in almost all research topics discussed in the previous sections. for any given aging research project, statistical support is needed at almost all stages starting with the formulation of a scientific hypothesis, study design, data collection, data management and analysis, and conclusion making and ending with manuscript writing. often, the earlier a statistician is involved in an aging research project, the more productive the project will become. let us use a specific example to demonstrate how statistics can significantly help aging research. assume that a research project aims to investigate whether an intervention (e.g., a j o u r n a l p r e -p r o o f nutritional supplement) can improve older adults' mobility. to make the hypothesis more specific, we first need to determine major mobility measurements. according to webber [ ] , mobility can be measured in five dimensions (i.e., cognitive, psychosocial, physical, environmental, and financial), and there are many different ways to measure mobility in each dimension. if we are interested in all five dimensions and would like to develop a single mobility index or choose some important ones from all possible mobility measures, then some preliminary studies to collect data on these measures are needed. the data from these preliminary studies can be analyzed by statistical modeling and variable selection approaches, allowing us to come up with either a single mobility index or a relatively small number of mobility measures. these variables can then be used as the response variables of the original study. second, the sample size for the study needs to be properly calculated. to do this, researchers need to specify the smallest meaningful difference between the intervention and control groups for each response variable. the next step is to check whether all model assumptions of the related sample size formula are valid. if not, then a new formula needs to be derived, which could be challenging. for data collection, statisticians are vital in determining which study design is best, such as deciding between a double-blinded randomized study or other types of studies. these steps of study design are extremely important to make the collected data useful in testing the major scientific hypothesis. after data collection, much statistical expertise is required to analyze the data and make solid conclusions. during data analysis, proper statistical methods that clearly describe the observed data need to be chosen, all model assumptions should be verified, and develop new statistical methods when necessary. primary care physicians and geriatricians play an instrumental role in the identification of older adults who have or are at risk for impaired mobility. unfortunately, healthcare providers encounter several barriers to the proper evaluation and treatment of mobility issues in older adults. some of these barriers include insufficient knowledge in latest research findings in the field of geroscience, time constraints in busy clinics, lack of needed resources for treatment interventions, weak patient support systems, and even language barriers in some minority communities. despite these barriers, most patients can be quickly and efficiently screened for cognitive concerns and/or mobility issues with validated assessments, such as the "get up and go" test. when appropriate, providers should deliver succinct but impactful counseling on the importance of adopting a healthy diet, practicing regular physical exercises, and obtaining adequate sleep. the use of educational hand-outs can be very helpful for some patients. clinicians should also use available resources for the enhancement of mobility, such as referrals to physical /occupational therapy, ophthalmology, audiology, and massage therapy. there is a need for more educational programs for healthcare providers covering the latest research findings in the treatment of geriatric conditions including impaired mobility. optimal communication between clinical researchers and clinicians might facilitate the prompt implementation of efficacious new treatments. collaboration among academic investigators and community partners also has the potential to increase the relevance of the research and its potential for addressing public problems such as general health disparities [ ] and health problems more specific to seniors, such as limited mobility. such collaborations require (a) culturally sensitive, multidisciplinary academic research teams, (b) empowerment of community members through training them to assume leadership in implementing and disseminating research center-tested j o u r n a l p r e -p r o o f interventions and assisting in getting the institutional review board credentials for being equal research partners, (c) paying trained community member researchers as research professionals, (d) mobilizing community resources and partners (e.g., businesses and local officials) to make policy changes to reduce the social determinants of health (e.g., no/limited public transportation in target low-income black communities) that impede implementation and dissemination efforts. interventions shown to be efficacious in research centers are typically implemented and tested under controlled conditions with non-representative samples of motivated participants [ ] . there is a need to implement and disseminate efficacious interventions in communities where uncontrollable social determinants of health (e.g., poverty, race and racism) and associated health disparities negatively influence the length and quality of community members' lives. these communities are where seniors, racial/ethnic minorities, the poor, and/or the medically underserved (i.e., health disparity groups) often live. because of this, ideal implementation and dissemination sites in such communities are churches [ , ] and primary care centers [ ] . it is these sites that commonly serve the aforementioned groups, are stable community structures with physical resources (e.g., meeting spaces), and have human resources (e.g., pastors and physicians) who can influence members of health disparity groups to participate in efforts to implement and disseminate health promotion interventions. the empirically supported community-based participatory research (cbpr) approach [ ] is useful in implementing and disseminating efficacious interventions in communities in general and in racial/ethnic minority, poor, and/or medically underserved communities in particular. cbpr creates a paradigm shift from traditional research practices that have characterized academics as experts towards a collaborative research process in which academics are also learners [ ] . accordingly, the cbpr approach requires that community members be j o u r n a l p r e -p r o o f actively involved in all aspects of the research process, including the selection of the research topic and methodology, participant recruitment, research implementation, data collection, interpretation of study results, and dissemination of research findings [ , ] . the patient-centered culturally sensitive healthcare (pc-cshc) model [ ] , explains the linkages between provider cultural sensitivity and patients' health outcomes and is useful in guiding implementation and dissemination in community-based healthcare settings. notably, cultural sensitivity extends beyond cultural competence and enables patients to feel comfortable with, trusting of, and respected by providers and researchers, and involves recognizing and overcoming biases and stereotypes that these groups have towards to each other [ ] . the provider being culturally sensitive is one key aspect of the pc-cshc model and is a major factor in health promotion. further, patients must be allowed to determine what behaviors, methodologies, etc. enable them to feel comfort, trust and respect. the other key aspect of this model is patient and community empowerment. in accordance with the pc-cshc model, implementation and dissemination of research centertested interventions in community primary care sites that serve health disparity groups requiring that patients and community health workers are active partners with academic researchers. for example, patients should ideally be involved in focus groups and/or interviews to identify culturally sensitive strategies for making these efforts successful. community health workers, physicians, and other providers can then (a) implement these strategies and disseminate the target interventions, and (b) participate with researchers in town hall meetings to disseminate information to the community about the impact of these interventions. culturally diverse, multidisciplinary academic research teams can provide the training needed for physicians/providers and patients to be empowered, equitable partners in implementing and j o u r n a l p r e -p r o o f disseminating target interventions. such empowerment by academic researchers is particularly important for patients such as minority, senior, poor, and medically underserved patients with limited actual and/or perceived power to take charge of their health. patient empowerment is the appropriate response to the increasing national calls for social, health, and healthcare justice. can we really slow the decline in mobility that occurs during aging? and can function improve as we age? the good news is that the answer to both questions appears to be an emphatic yes. effective future interventions, however, will need to take into consideration factors across multiple domains, as well as the complex interaction among these factors. findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, can have a dramatic effect on an older person's mobility and function. additionally, several biological and behavioral factors have been identified as directly related to functional capacity. these are exciting times within the field of gerontology with novel discoveries happening across different fields of study that have direct implications for function and/or functional capacity. for example, the discoveries made within the biology of the aging realm have informed of the types of intervention targets that could truly make a difference in an older adult's functional capacity. furthermore, covid- has highlighted the importance of self-care and preventative medicine to promoting wellness and extend healthspan. covid- has also highlighted the clear need to protect our older population, particularly minority older adults, as there are clear biological and metabolic factors that increase older adults' susceptibility to this condition. additionally, covid- has greatly increased the adoption of virtual communication; j o u r n a l p r e -p r o o f thus, the acceptability of technologically based future interventions is likely to be much greater than prior to covid- . before translating interventions on a broad scale, however, their suitability and effectiveness across a number of domains are needed to help inform decision making. clearly, there is an important need to evaluate safety outcomes, first and foremost, with the next benchmark related to whether such interventions are sustainable. there is also the need to carefully determine the types of randomized clinical trials that are best suited to address particular questions, as well as the appropriate comparison groups. j o u r n a l p r e -p r o o f j o u r n a l p r e -p r o o f highlights • findings over the past decade have highlighted the complexity of walking and how targeting multiple systems, including the brain and sensory organs, as well as the environment in which a person lives, can have a dramatic effect on an older person's mobility and function. • behavioral interventions that incorporate complex walking tasks and other activities of daily living appear to be especially helpful for improving mobility function. • effective future interventions, however, will need to take into consideration factors across multiple domains, as well as the complex interaction among these factors. • before translating interventions on a broad scale, however, their suitability and effectiveness across a number of domains are needed to help inform decision making. active life expectancy geroscience: linking aging to chronic disease age-related change in mobility: perspectives from life course epidemiology and geroscience physiological geroscience: targeting function to increase healthspan and achieve optimal longevity translational geroscience: emphasizing function to achieve optimal longevity a framework for selection of blood-based biomarkers for geroscience-guided clinical trials: report from the tame united nations world populations prospects: the advances in geroscience: impact on healthspan and chronic disease successful aging: advancing the science of physical independence in older adults the impact of behavioral intervention on obesity mediated declines in mobility function: implications for longevity studies of illness in the aged. the index of adl: a standardized measure of biological and psychosocial function a guttman health scale for the aged role of gait speed in the assessment of older patients improvement in usual gait speed predicts better survival in older adults obesity, functional mobility and quality of life ability to walk / mile predicts subsequent disability, mortality, and health care costs association of mobility limitations with health care satisfaction and use of preventive care: a survey of medicare beneficiaries estimating transition probabilities in mobility and total costs for medicare beneficiaries association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability disability status, mortality, and leading causes of death in the united states community population active life expectancy for , caucasian men and women in three communities sedentary activity associated with metabolic syndrome independent of physical activity. diabetes care increasing prevalence of the metabolic syndrome among u.s. adults. diabetes care prevalence of the metabolic syndrome in us populations lumbar motoneurons of man: i) number and diameter histogram of alpha and gamma axons of ventral root macro emg in healthy subjects of different ages methods for estimating numbers of motor units in biceps-brachialis muscles and losses of motor units with aging physiological changes in ageing muscles the estimated numbers and relative sizes of thenar motor units as selected by multiple point stimulation in young and older adults motor unit number estimates in the tibialis anterior muscle of young, old, and very old men role of the nervous system in sarcopenia and muscle atrophy with aging: strength training as a countermeasure innervation and neuromuscular control in ageing skeletal muscle denervation drives mitochondrial dysfunction in skeletal muscle of octogenarians accumulation of severely atrophic myofibers marks the acceleration of sarcopenia in slow and fast twitch muscles failed reinnervation in aging skeletal muscle multimodal imaging of brain activity to investigate walking and mobility decline in older adults neural correlates of obstacle negotiation in older adults: an fnirs study. gait and posture neurocognitive aging and the compensation hypothesis automaticity of walking: functional significance, mechanisms, measurement and rehabilitation strategies the global burden of musculoskeletal pain-where to from here? global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries for countries, - : a systematic analysis for the global burden of disease study prevalence of chronic benign pain disorder among adults: a review of the literature movement-evoked pain: transforming the way we understand and measure pain physical performance and movement-evoked pain profiles in communitydwelling individuals at risk for knee osteoarthritis interrelated neuromuscular and clinical risk factors that contribute to falls multisite pain is associated with long-term patient-reported outcomes in older adults with persistent back pain persistent pain quality as a novel approach to assessing risk for disability in community-dwelling elders with chronic pain risk factors for restriction in activity associated with fear of falling among seniors within the community the course of limitations in activities over years in patients with knee and hip osteoarthritis with moderate functional limitations: risk factors for future functional decline. osteoarthritis cartilage profile of the elderly in physical therapy and its relation to functional disability reasons for functional decline despite reductions in knee pain: the multicenter osteoarthritis study chronic pain, perceived stress, and cellular aging: an exploratory study accelerated aging in adults with knee osteoarthritis pain: consideration for frequency, intensity, time, and total pain sites chronic pain is associated with a brain aging biomarker in communitydwelling older adults epigenetic aging is associated with clinical and experimental pain in community-dwelling older adults clinical neurophysiology of circadian rhythm sleep-wake disorders age-related changes in the circadian system unmasked by constant conditions. eneuro impact of sleep and circadian rhythms on addiction vulnerability in adolescents the role of the molecular clock in promoting skeletal muscle growth and protecting against sarcopenia a new face of sleep: the impact of post-learning sleep on recognition memory for face-name associations the aging clock: circadian rhythms and later life mitochondrial mechanisms of neuromuscular junction degeneration with aging. cells a cross-sectional study of muscle strength and mass in -to -yr-old men and women longitudinal muscle strength changes in older adults: influence of muscle mass, physical activity, and health muscle function decline and mitochondria changes in middle age precede sarcopenia in mice mfn deficiency links age-related sarcopenia and impaired autophagy to activation of an adaptive mitophagy pathway skeletal muscle mitochondria and aging: a review circadian rhythms and mitochondria: connecting the dots executive summary: heart disease and stroke statistics-- update: a report from the american heart association aortic stiffness and interstitial myocardial fibrosis by native t are independently associated with left ventricular remodeling in patients with dilated cardiomyopathy arterial-ventricular coupling with aging and disease concept of extremes in vascular aging enhancing recovery from sepsis: a review large cross-sectional study of presbycusis reveals rapid progressive decline in auditory temporal acuity who, prevention of blindness and deafness: estimates current concepts in age-related hearing loss: epidemiology and mechanistic pathways the role of hormones, cytokines and heat shock proteins during age-related muscle loss growth hormone in aging. the endocronology of aging growth hormone and insulin-like growth factor- (igf- ) and their influence on cognitive aging bone mineral status and bone loss over time in men with chronic systolic heart failure and their clinical and hormonal determinants serum levels of insulin-like growth factor-i (igf-i) and dehydroepiandrosterone sulfate (dhea-s), and their relationships with serum interleukin- , in the geriatric syndrome of frailty hospital diagnoses, medicare charges, and nursing home admissions in the year when older persons become severely disabled disability in older adults: evidence regarding significance, etiology, and risk morbidity and disability in older persons in the years prior to death functional transitions among the elderly: patterns, predictors, and related hospital use sarcopenic obesity and complex interventions with nutrition and exercise in community-dwelling older persons--a narrative review the state of us health, - : burden of diseases, injuries, and risk factors among us states does overall diet in midlife predict future aging phenotypes? a cohort study. the american journal of medicine the association between objectively measured sitting and standing with body composition: a pilot study using mri associations of physical activity and sedentary behavior with regional fat deposition reduced physical activity increases intermuscular adipose tissue in healthy young adults sedentary behavior, physical activity, and the metabolic syndrome among u.s. adults low muscle mass in older men: the role of lifestyle, diet and cardiovascular risk factors physical activity prevented functional decline among frail community-living elderly subjects in an international observational study obesity and mobility disability in the older adult decreased functional capacity and muscle strength in elderly women with metabolic syndrome prevalence of metabolic syndrome and its association with physical capacity, disability, and self-rated health among lifestyle interventions for elders (life) study participants sedentary and physically active behavior patterns among low-income african-american and white adults living in the southeastern united states the independent and combined associations of physical activity and sedentary behavior with obesity in adults: nhanes - sedentary time is associated with the metabolic syndrome in older adults with mobility limitations--the life study why sleep is important for health: a psychoneuroimmunology perspective prevalence of healthy sleep duration among adults--united states sleep and human aging frequent napping is associated with excessive daytime sleepiness, depression, pain, and nocturia in older adults: findings from the national sleep foundation ' sleep in america' poll longitudinal relationship between sleep deficiency and pain symptoms among community-dwelling older adults in japan and singapore cortical thickness mediates the association between self-reported pain and sleep quality in community-dwelling older adults chronic musculoskeletal pain moderates the association between sleep quality and dorsostriatal-sensorimotor resting state functional connectivity in community-dwelling older adults the national institute on aging health disparities research framework effects of stress throughout the lifespan on the brain, behaviour and cognition social isolation and loneliness in older adults: opportunities for the health care system associations between social isolation, loneliness, and objective physical activity in older men and women social isolation, loneliness, and all-cause mortality in older men and women social isolation, loneliness and health in old age: a scoping review where we live: health care in rural vs urban america differential access to care: the role of age, insurance, and income on race/ethnicity-related disparities in adult perforated appendix admission rates national dissemination of multiple evidence-based disease prevention programs: reach to vulnerable older adults ethnicity-and socio-economic status-related stresses in context: an integrative review and conceptual model determinants of adherence in time-restricted feeding in older adults: lessons from a pilot study older adults' perceptions of mobility: a metasynthesis of qualitative studies frailty phenotype: evidence of both physical and mental health components in community-dwelling early-old adults balance confidence and fear of falling avoidance behavior are most predictive of falling in older adults: prospective analysis self-efficacy, pain, and quadriceps capacity at baseline predict changes in mobility performance over years in women with knee osteoarthritis falls efficacy as a measure of fear of falling dizziness and its association with walking speed and falls efficacy among older men and women in an urban population falls and fear of falling: which comes first? a longitudinal prediction model suggests strategies for primary and secondary prevention mobility device use in older adults and incidence of falls and worry about falling: findings from the - national health and aging trends study effects of supervised slackline training on postural instability, freezing of gait, and falls efficacy in people with parkinson's disease a backward walking training program to improve balance and mobility in acute stroke: a pilot randomized controlled trial integrated primary and geriatric care for frail older adults in the community: implementation of a complex intervention into real life dietary carbohydrate restriction improves metabolic syndrome independent of weight loss one-year adherence to the otago exercise program with or without motivational interviewing in community-dwelling older adults walking can be more effective than balance training in fall prevention among community-dwelling older adults the effect of yoga on balance and fear of falling in older adults motivating older adults with cancer to keep moving: the implications of lifestyle interventions on physical activity attitudes and needs of residents in long-term care facilities regarding physical activity-a systematic review and synthesis of qualitative studies enablers and barriers to older people's participation in strength and balance activities: a review of reviews integrated care for geriatric frailty and sarcopenia: a randomized control trial the retardation of aging by caloric restriction: studies in rodents and primates dietary restriction and lifespan: lessons from invertebrate models long-term calorie restriction is highly effective in reducing the risk for atherosclerosis in humans calorie restriction or exercise: effects on coronary heart disease risk factors. a randomized, controlled trial caloric restriction alone and with exercise improves cvd risk in healthy nonobese individuals effect of calorie restriction with or without exercise on insulin sensitivity, beta-cell function, fat cell size, and ectopic lipid in overweight subjects calorie restriction increases muscle mitochondrial biogenesis in healthy humans weighty concerns: the growing prevalence of obesity among older adults the danger of weight loss in the elderly the future of obesity: new drugs versus lifestyle interventions flipping the metabolic switch: understanding and applying the health benefits of fasting health benefits of the mediterranean diet: metabolic and molecular mechanisms mediterranean dietary patterns and impaired physical function in older adults association between adherence to the mediterranean diet at midlife and healthy aging in a cohort of french adults the effects of the ketogenic diet on behavior and cognition ketogenic diet reduces midlife mortality and improves memory in aging mice a ketogenic diet improves cognition and has biochemical effects in prefrontal cortex that are dissociable from hippocampus physical activity and risk of cognitive impairment among older persons living in the community walking speed predicts health status and hospital costs for frail elderly male veterans aerobic exercise effects on cognitive and neural plasticity in older adults genomic comparison of the ants camponotus floridanus and harpegnathos saltator the effect of walking on lower body disability among older blacks and whites risk of functional decline among well elders maintaining mobility in late life. ii. smoking, alcohol consumption, physical activity, and body mass index effect of structured physical activity on prevention of major mobility disability in older adults: the life study randomized clinical trial resistance training for activity limitations in older adults with skeletal muscle function deficits: a systematic review effects of a fall prevention exercise program on muscle strength and balance of the old-old elderly is lower extremity strength gain associated with improvement in physical performance and disability in frail, community-dwelling elders? molecular transducers of physical activity consortium (motrpac): mapping the dynamic responses to exercise reducing sedentary behavior versus increasing moderate-to-vigorous intensity physical activity in older adults breaking-up sedentary time is associated with physical function in older adults intervening to reduce sedentary behavior in older adults -pilot results not just another walking program interventions to reduce sedentary behavior mobility after hospital discharge as a marker for -day readmission systematic review of functional training on muscle strength, physical functioning, and activities of daily living in older adults a technical guide to tdcs, and related non-invasive brain stimulation tools effects of noninvasive brain stimulation on cognitive function in healthy aging and alzheimer's disease: a systematic review and meta-analysis time-but not sleep-dependent consolidation of tdcs-enhanced visuomotor skills noninvasive cortical stimulation enhances motor skill acquisition over multiple days through an effect on consolidation enhancing working memory training with transcranial direct current stimulation cognitive interventions. handbook of the psychology of aging neuropsychology of aging characterizing and assessing cognitive aging. cognitive aging: progress in understanding and opportunities for action training versus engagement as paths to cognitive enrichment with aging computer and videogame interventions for older adults' cognitive and everyday functioning the impact of sustained engagement on cognitive function in older adults: the synapse project individualized piano instruction enhances executive functioning and working memory in older adults training older adults to use tablet computers: does it enhance cognitive function? gerontologist can acquired skill and technology mitigate age-related declines in learning rate? current and emerging trends in aging and work interventions to prevent age-related cognitive decline, mild cognitive impairment, and clinical alzheimer's-type dementia effects of cognitive training interventions with older adults: a randomized controlled trial useful field of view test wiifit plus balance test scores for the assessment of balance and mobility in older adults predictors of falling in older maryland drivers: a structural-equation model cognitive training decreases motor vehicle collision involvement of older drivers benefits of cognitive dual-task training on balance performance in healthy older adults effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trial standardization in the mspe: key tensions for learners, schools, and residency programs chronic oxytocin administration as a tool for investigation and treatment: a cross-disciplinary systematic review oxytocin alleviates the neuroendocrine and cytokine response to bacterial endotoxin in healthy men sniffing neuropeptides: a transnasal approach to the human brain evidence for intranasal oxytocin delivery to the brain: recent advances and future perspectives a review of safety, side-effects and subjective reactions to intranasal oxytocin in human research oxytocin and socioemotional aging: current knowledge and future trends oxytocin modulates meta-mood as a function of age and sex. front aging neurosci ageing and oxytocin: a call for extending human oxytocin research to ageing populations--a mini-review lifespan oxytocin signaling: maturation, flexibility, and stability in newborn, adolescent, and aged brain oxytocin control of maternal behavior. regulation by sex steroids and offspring stimuli oxytocin and vasopressin in the human brain: social neuropeptides for translational medicine treatment of obesity and diabetes using oxytocin or analogs in patients and mouse models musculoskeletal pain and brain morphology: oxytocin's potential as a treatment for chronic pain in aging. front aging neurosci oxytocin's fingerprint in personality traits and regional brain volume alterations of brain volumes in women with early life maltreatment and their associations with oxytocin associations between oxytocin receptor gene (oxtr) methylation, plasma oxytocin, and attachment across adulthood repeated treatment with oxytocin promotes hippocampal cell proliferation, dendritic maturation and affects socio-emotional behavior oxytocin is an age-specific circulating hormone that is necessary for muscle maintenance and regeneration effects of a -day oxytocin trial in older adults on health and well-being plasma oxytocin and vasopressin levels in young and older men and women: functional relationships with attachment and cognition current nutritional and pharmacological anti-aging interventions metformin as a tool to target aging pharmaceutical intervention mobility aging decline locomotion and posture in older adults metformin and aging: a review discoveries of nicotinamide riboside as a nutrient and conserved nrk genes establish a preiss-handler independent route to nad+ in fungi and humans nad+ metabolism in health and disease impairment of an endothelial nad(+)-h s signaling network is a reversible cause of nad(+) intermediates: the biology and therapeutic potential of nmn and nr chronic nicotinamide riboside supplementation is well-tolerated and elevates nad(+) in healthy middle-aged and older adults nicotinamide riboside supplementation alters body composition and skeletal muscle acetylcarnitine concentrations in healthy obese humans fat mobilization without weight loss is a potentially rapid response to nicotinamide riboside in obese people: it's time to test with exercise nicotinamide riboside-a missing piece in the puzzle of exercise therapy for older adults? the mechanisms of massage and effects on performance, muscle recovery and injury prevention fascial well-being: mechanotransduction in manual and movement therapies mechanotransduction and the regulation of protein synthesis in skeletal muscle mechanical strain stabilizes reconstituted collagen fibrils against enzymatic degradation by mammalian collagenase matrix metalloproteinase (mmp- ) manual therapy as an effective treatment for fibrosis in a rat model of upper extremity overuse injury effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women a randomised study of the effects of massage therapy compared to guided relaxation on well-being and stress perception among older adults massage therapy for pain-call to action nonpharmacologic therapies for low back pain: a systematic review for an american college of physicians clinical practice guideline massage therapy in chronic musculoskeletal pain managment: a scooping review of the literature noninvasive nonpharmacological treatment for chronic pain: a systematic review agency for healthcare research and quality massage timing affects postexercise muscle recovery and inflammation in a rabbit model could intermittent energy restriction and intermittent fasting reduce rates of cancer in obese, overweight, and normal-weight subjects? a summary of evidence a preliminary study of the effects of a single session of swedish massage on hypothalamic-pituitary-adrenal and immune function in normal individuals a preliminary study of the effects of repeated massage on hypothalamic-pituitary-adrenal and immune function in healthy individuals: a study of mechanisms of action and dosage the role of dna methylation in epigenetics of aging massage therapy attenuates inflammatory signaling after exercise-induced muscle damage the effect of foam rolling of the hamstrings on proprioception at the knee and hip joints effects of massage on muscular strength and proprioception after exercise-induced muscle damage the report on dietary reference intakes for calcium and vitamin d from the institute of medicine: what clinicians need to know massage therapy produces short-term improvements in balance, neurological, and cardiovascular measures in older persons the physiological and psychological effects of slow-stroke back massage and hand massage on relaxation in older people long-term adherence to health behavior change tech adoption climbs among older americans demographics of mobile device ownership and adoption in the united states idc forecasts steady double-digit growth for wearables as new capabilities and use cases expand the market opportunities. idc about one-in-five americans use a smart watch or fitness tracker perception of older adults toward smartwatch technology for assessing pain and related patient-reported outcomes: pilot study criteria for assessing the quality of mhealth apps: a systematic review a path to better-quality mhealth apps the impact of mhealth interventions: systematic review of systematic reviews mobile health technology for atrial fibrillation management integrating decision support, education, and patient involvement: maf app trial efficacy of telemedical interventional management in patients with heart failure (tim-hf ): a randomised, controlled, parallel-group, unmasked trial the effectiveness of remote monitoring of elderly patients after hospitalisation for heart failure: the renewing health european project healthy aging: the ultimate preventative medicine integrating mobile-health, health coaching, and physical activity to reduce the burden of chronic low back pain trial (impact): a pilot randomised controlled trial smartphone cognitive behavioral therapy as an adjunct to pharmacotherapy for refractory depression: randomized controlled trial hyperglycemia drives intestinal barrier dysfunction and risk for enteric infection online cancer communication: meeting the literacy, cultural and linguistic needs of diverse audiences evaluating health communication programs to enhance health care and health promotion unpacking mhealth interventions: a systematic review of behavior change techniques used in randomized controlled trials assessing mhealth effectiveness. digit health age-dependent changes in mobility and separation of the nematode caenorhabditis elegans identification by machine vision of the rate of motor activity decline as a lifespan predictor in c. elegans. neurobiology of aging drosophila as a model for age-related impairment in locomotor and other behaviors age-related change in mobility: perspectives from life course epidemiology and geroscience. the journals of gerontology series a, biological sciences and medical sciences age-dependent changes in mobility and separation of the nematode caenorhabditis elegans age-dependent changes and biomarkers of aging in caenorhabditis elegans stochastic and genetic factors influence tissue-specific decline in ageing c. elegans. nature functional aging in the nervous system contributes to age-dependent motor activity decline in c. elegans aberrant mitochondrial homeostasis in the skeletal muscle of sedentary older adults coordinated changes in mitochondrial function and biogenesis in healthy and diseased human skeletal muscle autophagy in the cellular energetic balance skeletal muscle autophagy and apoptosis during aging: effects of calorie restriction and life-long exercise autophagy, mitochondria and oxidative stress: cross-talk and redox signalling molecular inflammation: underpinnings of aging and age-related diseases effect of dietary restriction and exercise on lower extremity tissue compartments in obese, older women: a pilot study hypothalamic-pituitary-adrenal axis function and corticosterone receptor expression in behaviourally characterized young and aged long-evans rats aging, the central nervous system, and mobility mobility in older adults: a comprehensive framework health care use and barriers to care among latino immigrants in a new migration area. j health care poor underserved quality-of-care research: internal elegance and external relevance obesity interventions in african american faith-based organizations: a systematic review engaging black churches to address cancer health disparities: project church. front public health counseling psychologists and behavioral health: promoting mental and physical health outcomes. sage journals community-based participatory research conceptual model: community partner consultation and face validity the three r's: how community based participatory research strengthens the rigor community-based participatory research from the margin to the mainstream: are researchers prepared? circulation key: cord- -t bncpo authors: neto, leônidas oliveira; tavares, vagner deuel de oliveira; galvão-coelho, nicole leite; schuch, felipe barreto; lima, kenio costa title: aging and coronavirus: exploring complementary therapies to avoid inflammatory overload date: - - journal: front med (lausanne) doi: . /fmed. . sha: doc_id: cord_uid: t bncpo nan acute respiratory distress syndrome (ards) is the main cause of death in covid- patients ( , ) . in recent years the relationship between this respiratory syndrome and inflammatory system dysregulation has been discussed ( ) . patients with ards could present distinct endophenotypes with respect to immune alterations: hyper-or hypo-inflammatory profiles ( , ) . the identification of inflammatory endophenotypes of ards is important, as patients respond differently to clinical and hospital management ( ) . in patients with a hyper-inflammatory profile, a pro-inflammatory storm is observed in the human body, with elevated rates of biomarkers such as c reactive protein (crp) ( , ) and cytokines such as interleukins (il)- and tumoral necrosis factor (tnf)-α that are able to develop a systemic inflammatory response. the release of il- and tnf-α into the systemic circulation directly contributes to the increase in systemic inflammation levels and arteriosclerosis processes ( ) . people with chronic clinical comorbidities ( ) such as hypertension, diabetes ( ) , and kidney disease ( ) have a higher risk of becoming critically ill and dying from covid- . for this reason, the older age population has a higher risk of mortality by covid- , since they have many of these diseases ( , ) . it is interesting to highlight that both aging and chronic diseases are linked to an increase in levels of systemic inflammation, which could explain a potential common pathway between these factors and covid- . therefore, the acute and strong immune system dysregulation induced by the virus may be linked to ards and its complications, such as multiple organ failure, and finally lead to patient death ( ) , mainly in those with previous inflammatory allostatic overload ( , ) . in fact, people with covid- present high levels of systemic inflammatory biomarkers ( ) , and the detection of these forms part of the preliminary guidelines for the diagnosis and treatment of sars-cov- ( ) . accordingly, multiple experimental treatments with immune-suppressing or stimulating drugs have been tested, aiming to reduce the pro-inflammatory cascade and, thus, mortality ( ) ( ) ( ) . while the search for effective treatments and vaccines is the top priority, non-pharmacological complementary therapies targeting reductions in baseline inflammatory load, mainly in the oldest population, should receive some attention. during aging, a natural and progressive deterioration in cells and impairment in organ functions occur due to metabolic, immunological, neuroendocrine, or oxidative stress ( ) . at a molecular level, imbalance between the oxidant/antioxidant pathways ( ) could be explained by malfunction in inflammatory/antiinflammatory homeostatic mechanisms, which result in a chronic low-grade pro-inflammatory state known as inflammaging ( ). the inflammatory system is responsible for defending systemic functioning and repairing damages from infections and harmful environmental agents. aging is a process that all living organisms ages and corresponds to a reduction of defenses to the aggressor agents of living beings, and this we call immunosenescence. this process is gradual and differs between genders ( ) . at ∼ years of age, the first major reduction in immune functions occurs and occurs in a similar way between men and women. studies with covid- reveal that it is exactly in this age group that lethality doubles, from . to . %. around the early post- s, we have a new functional immune decline for men, which only occurs in the late s for women, which may partly explain the higher mortality of men worldwide ( ) . several studies report that, with aging, both the innate and adaptive immune response suffer changes both in their cellular composition and in their function ( , ) . in the case of covid- , the innate immune response in the elderly would be activated, and there would be no satisfactory passage of the innate immune response to adaptive, maintaining a chronic activation of the former and preventing the elimination of sars-cov ( , ) . in addition to maintaining the chronic immune response, which generates a chronic inflammatory state, there is an important decline in the performance of the adaptive system. yet, there is a reduction in the recognition of new antigens by adaptive immunity due to the reduction of naive cells and, moreover, a depletion of aging immune cells, which are already very stimulated and do not retain their functions. there are reports that immune cells of adaptive response also undergo changes in their functions and start to act as cells of the innate response ( ) . during the covid- pandemic, two of the proinflammatory proteins were elevated in severe patients ( ) , yet the inflammatory state may be associated with multiple diseases ( ) . in this sense, the consequences are systemic and affect the elderly especially, causing changes in body composition and an imbalance between availability and energy demand that can affect the quality of life and functionality of the elderly ( ) . in addition, the inflammation overload makes the elderly more susceptible to several other diseases, such as cardiovascular disease, diabetes, osteoporosis, and ostearthrosis ( ) . in this context, lifestyle and nutraceuticals arise as important prophylactic interventions to reduce the burden of baseline inflammation in older adults and consequently improve quality of life, mobility, cognition, mood, and metabolic and immune balances, especially during the pandemic. it is possible that covid- will be a long pandemic, with multiple infection waves ( ) ; therefore, these strategies are especially important since they can be adopted in the long term and under physical social isolation. the aim of this study is to discuss how diet and nutraceuticals and lifestyle as complementary therapies could help older adults during the covid- pandemic, reducing inflammaging. comfort foods are very palatable foods that are rich in saturated fats and carbohydrates, especially sugar, which can decrease stress and anxiety through activation of the dopaminergic pathways of the reward system ( , ) . in times of lockdown, a rise in the intake of comfort foods is likely, and this behavior tends to strengthen each time the reward system is activated ( ) . since comfort foods have a high caloric rate, they can lead to weight gain when the energy expenditure is lower than the caloric intake, resulting in obesity, which is recognized as an inflammatory disease ( ) . in order to avoid weight gain, which adds load to inflammaging through an increase in the synthesis of harmful adipocytokines by white adipose tissue ( ) , a diet should be prescribed by a specialist. for instance, some diets, such as the mediterranean diet, the low glycemic index diet, moderate carbohydrate intake, and vegetarian diets, should be adapted to the personal demands and preferences of older adults and prescribed in times of lockdown ( ) . however, diets with severe restriction should be avoided, as they could lead to impulsive food behaviors ( ) . besides adjustment in the diet, some specific nutrient supplementations can assist in health improvement, such as magnesium, zinc, s-adenosyl methionine, omega- , and vitamin d, which are important for good maintenance of cognitive and physiological mechanisms ( , ) . magnesium is fundamental for nervous system function and insulin sensitivity, helping in the prevention or management of diabetes mellitus type ii, characterized as a chronic and mild inflammatory disease ( , ) . zinc also contributes to improving insulin sensitivity ( ) and body metabolism ( ) . vitamin d, or more specifically, hydroxyvitamin d [ (oh) d], is an anti-inflammatory nutrient ( ) , and reduces the activation of the renin-angiotensin system, preventing hypertension ( ), besides its importance to bone and muscle, an inverse relationship is also observed between its levels and mortality risk in old adults ( ) . omega- has an important role in cognition and as an anti-inflammatory agent; thus, it seems effective against age-related mood disorder ( , ) . recently, -hydroxyvitamin d [ (oh)d] has been suggested as a nutraceutical alternative to reduce the risk of covid- infection due to improvement in the immune system, whereas vitamin d is pointed out as an adjunctive treatment in higher doses ( , ) . in addition, vitamin c could be an alternative to treat respiratory tract infections. also, one study indicated that administration of ∼ g/day of vitamin c for days may decrease mortality in patients with ards ( ). however, the vitamin c supplementation did not significantly improve organ dysfunction scores or alter biomarkers of inflammation and vascular injury. thus, controlled trials and large-population studies should be conducted to prove these hypotheses. moreover, it is important to highlight that the benefits of both diet and nutraceutical interventions are enhanced and the risks reduced when planned for a specific patient, through precisionbased approaches that consider nutritional macro/micronutrient deficiencies, levels of inflammatory cytokines, and genomic and microbiome analysis, among other factors ( ) . this individual analysis is mainly relevant to elderly adults who usually show imbalances in many micro-and macronutrient levels as a result of aging or pharmacological treatments. although some of these approaches are low-cost, unhappily, they are not always applied. therefore, their use should be stimulated to has to help reduce the number of deaths around the world, mainly during the pandemic ( ) . sedentary behaviors such as longer screen time and lower physical energy expenditure can aggravate physical and mental conditions ( ) , especially in this period of social isolation. therefore, reducing the time spent in sedentary behavior at home is of great importance for maintaining health during lockdown ( ) . furthermore, increasing the time spent engaging in exercise is essential. lifestyle therapy consists of adopting a health routine that includes a balanced diet, physical exercise, relaxation and meditation techniques, and good sleep ( , ) . a robust body of evidence has demonstrated the benefits of these modifications of lifestyle for mental health, mainly for mood symptoms ( ) ( ) ( ) ( ) , indicating that lifestyle therapy is an effective strategy for preventing and treating some mental disorders ( - ), including in old adults ( ) . it is natural that with aging, the frequency and intensity of physical activities will decrease ( ) . however, there are further reasons for encouraging an increase in activity levels, such as for improving cardiorespiratory fitness ( ) , which in turn reduces mortality risk ( ) , and poor health ( ) . furthermore, reducing sedentary behavior and engaging in exercise may increasing the production of systemic anti-inflammatory cytokines and help to combat inflammation ( , ) by increasing innate immune function ( ) and decreasing the chronic inflammation related to various diseases ( ) . considering the high rate of risk factors being present in older adults as a risk group ( ) , it is necessary to build tools directed at this group that aim to reduce sedentary behaviors and to keep them active during the covid- pandemic. as well as setting prescribed exercises and encouraging increased levels of daily physical activity, all movements should be stimulated, even simple routine activities such as those related to cleaning the house ( ) . with respect to exercises, to reduce sedentary behavior, we recommend the practice of modest exercises that are popularly known as jumping jacks, going up and down stairs, pushups, sit and get up, and balance exercises. these exercises are options that can fit well into the lockdown situation and can be done with home objects such as chairs and benches. however, all exercise should be supervised and prescribed by a trained professional, considering the individual, social, and economic aspects of the subject. however, it is necessary that this orientation occurs using distance-oriented tools, such as internet-based strategies like apps or video calls or mobile telephone messages. group classes can also improve motivation and social support, which in turn reduces psychological stress levels, helping in homeostatic balance ( ) . however, as some elderly adults have impaired motor skills, other alternatives have been used to reduce symptoms of mental disorders and reduction inflammation. for this, approaches with an integrative mind-body focus have been gaining ground in order to prevent or treat diseases such as chronic stress, anxiety, and depression ( ) , which are known to induce a mildly proinflammatory profile ( ) . these approaches use meditative practices as tools aimed at refining attention and promoting better emotional regulation and self-awareness ( ) . one of the main components of mindfulness-based activities is the regulation of attention ( ) . thus, attentional focus during the exercises proposed in mindfulness programs is directed to the observation of the experience of thoughts, body sensations, and emotions ( , ) . in addition, the practice of relaxation and meditation also has an effect on reducing inflammation ( ) . successful mind-body interventions in older adults have shown improvements in different aspects, such as pain control, sleep quality, attention, global cognition, and working memory ( ) . additionally, positive results were recently presented for the reduction of depressive symptoms through internet mindfulness therapy in this population ( ) . therefore, applying relaxation and meditation therapies is urgent, as these can improve mental and physical health in older people who are in isolation, following the guidelines of the who. social physical isolation due to covid- can bring serious risks to health if older adults continue with, or assume, a nonhealthy lifestyle, which includes a lack of physical activity and a diet low in nutrients and rich in comfort foods. therefore, strategies should be encouraged to promote and raise awareness among the older population about the application of lifestyle and nutraceutical tools. these interventions have great potential for insertion in public policies in different contexts due to their low cost, effectiveness, and simplicity. we are aware that it can be difficult to apply all of these suggestions, mainly in elderly adults, but every step is important and better than none. therefore, a healthy lifestyle should be encouraged as an intervention to prevent frailty among older people, and a multi-professional care system should act in this time of covid- to reduce risks and avoid damage related to inflammation overload in older adults. ln: conceptualization, project administration, and writingoriginal draft preparation. vt, ng-c, and fs: reviewing and editing. kl: conceptualization, project administration, and writing-original draft preparation. all authors contributed to the article and approved the submitted version. the authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. ng-c was supported by the capes foundation of the brazilian ministry of education (research fellowship . / - ) and the national science and technology institute for translational medicine (inct-tm fapesp / - ; cnpq / - ). a comprehensive literature review on the clinical presentation, and management of the pandemic coronavirus disease (covid- ) clinical features of patients infected with novel coronavirus in wuhan recent advances in understanding and treating acute respiratory distress syndrome latent class analysis of ards subphenotypes: analysis of data from two randomized controlled trials carolyn acute respiratory distress syndrome subphenotypes respond differently to randomized fluid management strategy the mercurial nature of neutrophils: still an enigma in ards? adipose tissue: immune function and alterations caused by obesity endocrine and metabolic link to coronavirus infection kidney disease is associated with in-hospital death of patients with covid- similarity in case fatality rates (cfr) of covid- /sars-cov- in italy and china clinical predictors of mortality due to covid- based on an analysis of data of patients from wuhan, china diagnosis and clinical management of severe acute respiratory syndrome coronavirus (sars-cov- ) infection: an operational recommendation of peking union medical college hospital (v . ): working group novel coronavirus, peking union medical colle interacting mediators of allostasis and allostatic load: towards an understanding of resilience in aging allostasis and allostatic load: expanding the discourse on stress and cardiovascular disease induction of pro-inflammatory cytokines (il- and il- ) and lung inflammation by coronavirus- (covi- or sars-cov- ): anti-inflammatory strategies associations between immune-suppressive and stimulating drugs and novel covid- -a systematic review of current evidence metronidazole a potential novel addition to the covid- treatment regimen the use of antiinflammatory drugs in the treatment of people with severe coronavirus disease (covid- ): the experience of clinical immunologists from china the role of oxidative stress in the aging process inflammation, genetic background and longevity clinical advances in sex-and gender-informed medicine to improve the health of all: a review the lethal sex gap: covid- . nikolich-Žugich j. the twilight of immunity: emerging concepts in aging of the immune system review-article chronic inflammation in the etiology of disease across the life span sestrins induce natural killer function in senescent-like cd + t cells dysregulation of immune response in patients with covid- in wuhan, china age and age-related diseases: role of inflammation triggers and cytokines aging, inflammation and the environment projecting the transmission dynamics of sars-cov- through the postpandemic period stress, eating and the reward system minireview: glucocorticoids -food intake, abdominal obesity, and wealthy nations in shaping the stress response: interplay of palatable food choices, glucocorticoids, insulin and abdominal obesity obesity & inflammation: the linking mechanism & the complications the endocrine function of adipose tissues in health and cardiometabolic disease overweight, obesity, and outcomes: fat mass and beyond nutritional medicine as mainstream in psychiatry adjunctive nutraceuticals for depression: a systematic review and meta-analyses magnesium in prevention and therapy a comprehensive review on zinc(ii) complexes as anti-diabetic agents: the advances, scientific gaps and prospects vitamin d and the immune system interplay of vitamin d, erythropoiesis, and the renin-angiotensin system vitamin d and ageing the antiinflammatory role of omega- polyunsaturated fatty acids metabolites in preclinical models of psychiatric, neurodegenerative, and neurological disorders the role of physical exercise and omega- fatty acids in depressive illness in the elderly evidence that vitamin d supplementation could reduce risk of influenza and covid- infections and deaths effect of vitamin c infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the citris-ali randomized clinical trial nutraceuticals for major depressive disorder-more is not merrier: an -week double-blind, randomised, controlled trial stress-mediated hormetic modulation of aging, wound healing, and angiogenesis in human cells physical activity can attenuate, but not eliminate, the negative relationships of high tv viewing with some chronic diseases: findings from a cohort of brazilian adults associations of moderate to vigorous physical activity and sedentary behavior with depressive and anxiety symptoms in self-isolating people during the covid- pandemic: a cross-sectional survey in brazil epa guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and position statement from the european psychiatric association (epa), supported by the international organization of physical therapists in mental the lancet psychiatry commission: a blueprint for protecting physical health in people with mental illness cardiorespiratory fitness in severe mental illness: a systematic review and meta-analysis aerobic exercise improves cognitive functioning in people with schizophrenia: a systematic review and meta-analysis exercise as medicine for mental and substance use disorders: a metareview of the benefits for neuropsychiatric and cognitive outcomes physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies physical activity and incident depression: a metaanalysis of prospective cohort studies quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise impact of physical inactivity on the world's major non-communicable diseases is physical activity or physical fitness more important in defining health benefits? pro-and antiinflammatory cytokine balance in strenuous exercise in humans the anti-inflammatory effect of exercise can exercise training improve immune function in the aged? reversing age-associated immunosenescence via exercise covid- and the consequences of isolating the elderly #traininginhome -training at home during the covid- (sars-cov ) pandemic: physical exercise and behavior-based approach resposta ao estresse: ii. resiliência e vulnerabilidade effects of yoga on depressive symptoms in people with mental disorders: a systematic review and meta-analysis is depression an inflammatory disorder? the clinical use of mindfulness meditation for the self-regulation of chronic pain mindfulness: a proposed operational definition full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness how does mindfulness meditation work? proposing mechanisms of action from a conceptual and neural perspective mindfulness meditation and the immune system: a systematic review of randomized controlled trials mindfulness-based stress reduction for chronic insomnia in adults older than years: a randomized, controlled, single-blind clinical trial internet mindfulness meditation intervention (immi) improves depression symptoms in older adults 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 © neto, tavares, galvão-coelho, schuch and lima. this is an openaccess article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -bc fj h authors: pekmezaris, renee; kozikowski, andrzej; pascarelli, briana; handrakis, john p.; chory, ashley; griffin, doug; bloom, ona title: participant-reported priorities and preferences for developing a home-based physical activity telemonitoring program for persons with tetraplegia: a qualitative analysis date: - - journal: spinal cord ser cases doi: . /s - - - sha: doc_id: cord_uid: bc fj h study design: focus group. objectives: the purpose of this qualitative study was to explore perceptions and priorities of persons with spinal cord injury (sci) for physical activity and to incorporate their feedback to inform future development of a physical activity program delivered via a telemonitoring platform. setting: new york. methods: qualitative data were collected from a purposive sample of adults with tetraplegia (n = ). two investigators led an audio-recorded focus group using a moderator’s guide. data were analyzed using a six-phase thematic analysis approach. results: the discussion focused on two major areas, which resulted in multiple derived themes and subthemes. the first theme centered on the daily life of persons with tetraplegia, including changes after sci, gain of function prioritization, and identification of psychosocial support systems that facilitate community reintegration after injury. the second theme centered on participant perceptions and recommendations for a physical activity program delivered via a telemonitoring platform. desired design features included variations in schedule, diverse activities, or exercises included in each class, and optional two-way video to enable social interactions with classmates. conclusions: participants favorably viewed the concept of a physical activity program delivered via a telemonitoring platform and contributed program design ideas. although this was a small sample size, challenges to obtaining physical activity expressed by participants were consistent with those identified previously in larger studies of persons with tetraplegia. therefore, we expect these concepts and their recommendations to be relevant to the greater sci community. approximately , persons in the us are living with traumatic spinal cord injury (sci) [ , ] . due to reduced mobility, persons with sci are at increased risk for developing obesity, muscle atrophy, osteoporosis, accelerated atherogenesis, type ii diabetes mellitus, and other medical consequences that increase the risk of stroke and coronary heart disease [ ] [ ] [ ] . this reduced mobility often has deleterious psychosocial effects that impact quality of life, including increased social isolation, reduced social participation, reduced exercise self-efficacy, and depression [ , ] . thus, there is a critical need for therapeutic strategies that reduce the risk of multiple medical and psychosocial consequences of sci. physical activity is a recommended therapeutic strategy to reduce risks of common medical consequences across diverse clinical populations [ , ] . physical activity reduces risks of coronary heart disease and diabetes, increases immunity and blood circulation, and decreases inflammation, fat, anxiety, pain, and improves mood and sleep [ ] [ ] [ ] [ ] . the american college of sports medicine recommends that able-bodied adults perform min of moderate-intensity aerobic exercise and participate in two or more days of muscle-strengthening exercise weekly [ ] . the latest physical activity guidelines for adults with sci recommend, "at least min of moderate to vigorousintensity aerobic exercise two times per week and three sets of strength exercise for each functioning muscle group, at moderate to vigorous intensity, two times per week" [ , ] . for cardiometabolic health benefits, it is recommended that adults with sci engage in at least min of moderate to vigorous-intensity aerobic exercise three times per week [ , ] . persons with sci and other disabilities are less likely to engage in regular physical activity, due to many modifiable barriers. these include: lack of knowledge about existing programs/safe exercises, insufficient programming, lack of transportation, cost, and scheduling issues [ ] . there are also other barriers, such as feeling too hot or cold outdoors or distance from an adaptive sports facility [ ] . in the general population, telemonitoring approaches to delivering physical activity are part of a highly successful commercial fitness industry. consumers are offered the ability to choose a program to engage in at home, with recorded or live classes, that can be delivered to a tv, tablet, phone, or computer via a commercial internet provider. compared to a gym membership, telemonitoring is convenient, scalable, and relatively low cost. regardless of the modality, telemonitoring physical activity programs often require minimal exercise equipment and are delivered at home on a personalized schedule. in addition to the physical health benefits, such as increased muscle strength and improved cardiovascular fitness, many physical activity instructors also engage actively in motivational strategies, to promote adherence and increase exercise self-efficacy [ ] . increasingly, telemonitoring enables a participant to experience self-efficacy in the following ways: ( ) mastery of experiences, the strongest predictor of self-efficacy, relate to actual performance when successfully meeting a challenging task. participants performing daily health behaviors and seeing progress, experience mastery. ( ) vicarious modeling (seeing others facing similar challenges and reaching their goals) will be achieved by viewing other participants of similar abilities attaining activity goals. ( ) social persuasion (verbal encouragement) is provided by the instructor. ( ) physiological factors, such as anxiety and distress, can be experienced by participants when they fail to meet activity goals; the instructor can interpret this as situational and not associated with overall success [ , ] . home-based physical activity delivered via telemonitoring may be a particularly useful option for persons with sci as a way to modify common environmental barriers to achieve the benefits of regular physical activity [ ] . to address these and other barriers, telehealth approaches are being increasingly studied in the context of sci [ ] . sweet and colleagues are starting an rct of an -week tele-rehab program for persons with paraplegia to measure changes in psychosocial variables related to exercise participation and quality of life [ ] . another study measured the effects of a home-based exercise program in persons with chronic sci, including outcome measures of metabolism, body composition, physical activity, energy intake, measures of health and wellbeing, resting metabolic rate, heart rate, and blood pressure, aerobic capacity, immune function, and adipose gene expression [ ] . encouraging results using telemonitoring have been obtained across physical health measures (i.e., wound care), as well as psychological health [ ] . there is a need to establish novel methods to facilitate regular physical activity for persons with sci [ ] . here, we report the results of a qualitative study of priorities and preferences for developing a home-based physical activity telemonitoring program for persons with tetraplegia. we consider this to be a first step towards optimizing feasibility and acceptability in a physical activity program for persons with sci [ ] . this is a qualitative study of adults with chronic (at least year from injury) tetraplegia who were recruited from the ny metropolitan area. the rationale for including only persons with tetraplegia was because, in general, this group has fewer opportunities for achieving physical activity in their daily life, lower reference values of cardiovascular fitness (relative vo peak), higher risk factors for cardiovascular disease, and lower life expectancy than persons with paraplegia. a short demonstration video developed by the study team was presented to participants to show the concept of a telemonitoring physical activity program led by a physical therapist for persons with tetraplegia. moderators explained that they envisioned that participants would join the class via a tablet with a split screen that showed themselves, the instructor, and classmates conducting exercises. moderators described that an instructor would monitor vital sign data (heart rate and blood oxygenation) of participants in real time via a pulse oximeter. before engaging in exercise, participants would be trained on proper equipment use. for safety, participants would be asked by the instructor every min during the intervention, to describe any symptoms of discomfort, including pain (musculoskeletal or other), fatigue, shortness of breath, or dizziness. frequency, duration, and type of proposed activities are based on the most recent guidelines on physical activity for persons with sci [ ] . the intervention presented was proposed to be delivered three times/week for min, with ≥ min of activity. the circuit training program proposed was based on evidence of strength and cardiorespiratory benefit in persons with sci [ ] . stretching, cardiovascular, and strengthening exercises would be tailored to participants' functional abilities. theraband, with open handgrips (loops), would be used to provide resistance for strength training [ ] . moderators explained that the program would consist of three repetitions of: (a) warm-up: a series of active (nonresisted) movements: shoulder lateral raises, flies, shoulder rolls, wide biceps curls, shoulder shrugs, triceps extensions to rear; (b) circuit exercise program: resistance followed by aerobic (arm spinning) exercises with rest periods as needed (~ s). resisted movements would include: set : seated rows, horizontal shoulder abduction, arm spinning/circles (aerobic exercise), set : shoulder internal rotation, shoulder external rotation, aerobic exercise, set : straight arm pulldowns, chest press, aerobic exercise [ ] . a -h focus group was conducted in january , led by two moderators previously unknown to participants. moderators used a moderator guide with open-ended questions and probes, related to a range of relevant topics including experiences with and priorities for benefits of physical activity before and after their injuries, technology use, and perceptions of important features that should be incorporated into a telemonitored physical activity program. the discussion was digitally recorded (using two recorders in case of technical failure), stored on an internal password protected server to ensure security, and transcribed professionally. transcripts were checked against the original recordings for accuracy. to optimize credibility, transferability, and dependability of results, we utilized analyst triangulation, peer debriefing, and conducted an audit trail of decisions made during the analysis and rationale. the transcript was analyzed by two researchers (a k and b p), to achieve triangulation to gain a more complex understanding of the data. a six-phase thematic analysis approach was utilized [ , ] . in the first phase, transcripts were reviewed independently multiple times to become familiar with the data. researchers documented initial theoretical and reflective thoughts, and potential codes and themes. in the second phase, researchers focused on data patterns and generated a comprehensive set of codes through inductive and deductive coding. two researchers documented their reasoning for coding blocks of text from the transcript of the focus group to explain how the data were perceived and examined. the third phase consisted of searching for themes after coding and codes were collated. in the fourth phase, themes were reviewed and refined. criteria for retaining themes were that they needed to be specific enough to be concrete, while broad enough to capture ideas. themes with sparse data were eliminated and those with large amounts of data were further divided into separate themes. in the fifth phase, team members met and discussed the finalization of theme names. in the sixth phase, the report was generated. participants were persons with tetraplegia (n = : males and females) who were wheelchair users for community mobility. the discussion explored challenges of living with tetraplegia, gain of function prioritization, social networks, and design recommendations for a telemonitored physical activity program. participants were asked to rank their gain of function prioritization on a seven-point scale, with one being most, and seven being least important, in the following areas: arm/ hand function, upper body/trunk strength and balance, bladder/bowel function, lived experiences of sexual function, elimination of chronic pain, sensation and mobility ("mobility could be anything that gets your body around in space") [ ] . most participants ranked either arm/hand function, sensation, or improvement of mobility as the most important. the next gain of function priorities ranked was upper body/trunk strength and balance, elimination of chronic pain, and sexual function. two major discussion themes emerged from a six-phase thematic analysis approach to the transcript. theme one: daily challenges pain several participants described challenges of performing activities of daily living (adls) while experiencing constant pain. the locations of pain symptoms varied by individual, including the back, neck, shoulders, and feet. multiple participants reported that pain symptoms were worse in the morning and did not resolve completely throughout the day. "right now, i feel like someone's kicking me in the back but that's normal for me, so it's just one of those things you kind of deal with…" "…i have chronic back pain that just will not go away. it's probablyif i say on a scale of one to ten, it's probably around a good eight most of the day…" "i'm in pain every day when i get home. i'm in bed by : because i can't even function." participants also discussed how pain impacted feelings of fatigue and strategies to cope with interruptions in sleep. "and you talk about getting exhausted during the day. i want to sleep every day by : . but i'm at work, so i can go in my office for a little while just to try to rest for a minute." multiple participants reported being athletic and active prior to their sci, had careers in physically enduring professions or participation in active sports including swimming, motocross, running, cycling, and skiing. "yeah, motor cross. yeah. so i used to ride-a lot of cycling, a lot of swimming. i had a home gym that i worked out in all the time. running-i was a terrible runner because my knees weren't that great. so i would run a little bit, but not that much. mostly cycling. i loved cycling. anything with wheels, i was there." "i was very free spirited, i'd say. we'll put it that way. but yeah, i sort of was very spontaneous and enjoyed flying by the seat of my pants and all that. it's like losing a little piece of you." as expected, the intensity and type of physical activity changed for most participants after injury. most focus group participants were not engaged in regular physical activity, outside of the exercises prescribed during physical therapy. for participants who were active, post-injury activities include using a stationary bike, thera-bands for resistance training, and free weights. "when i first came home, i was doing them every day. and then little by little, you're slacking off. but like i said, every day, once i get into bed, that's when i do the most thera-bands or weights or anything because i'll put a wrist [adaptor] on my arm. i'll go on my side and i'll do the left arm. then i get turned the other way, i'll do the right arm." "...everything from thera-bands like you were talking, to cuff weights. i use cuff weights as well that-most people use them on their ankles when they're running or exercising, but they also work great for quads around your arm. it's like a velcro weight. the rickshaw [wheelchair rehab exercise machine]…. it's a great machine for people in wheelchairs. and they have another machine there which is called the upper tone…it's kind of a home gym-type looking machine that's specifically designed for people in wheelchairs and people with limited hand function." variation in physical therapy and interactions with physical therapy personnel were discussed and perceived as impacting the post-injury rehabilitation process. "i've been to great therapists and i've been to not-sogreat therapists, and what they did clinically was not that different from each other. the difference was the therapists' behavior, the interaction." "i mean, it felt like it's a total package there. you get a lot of focused attention. youand theystart on the dime and they give you every second of that hour." participants discussed the critical role of social networks (family and friends) in community reintegration after injury. in addition, participants were motivated and inspired by interacting with peers with sci who demonstrated resilience. "…when you see people getting better, it helps. it makes you believe you can do the same thing too." the importance of self-efficacy to obtaining functional gains was also discussed, including the importance of maintaining both physical and emotional health. the feelings of well-being obtained from exercise were reported to reinforce the desire to continue exercising. "when i'm in a good mood, i feel i can conquer the world. but when i'm in a lousy moodlike today is not a great mood for meis i don't feel good about anything, and i don't want to do anything because i'm miserable. but then tomorrow i'll feel great and say i can pretty much take on the world and do anything i want and just let me do what i got to do." "yeah, inspirational. yeah, it would raise inspiration, want me to build more muscle on my end to want to feel better and know that i'm healthier and to keep going for whatever reason, whether it's for walking or not." "and i can tell you personally that i should probably be further along physically than i am… i think i plateaued and then went the other direction because of my own inability to push those things out of my mind…like if your head's not there, like in anything in life, but especially with sci rehab, it's hard enough knowing that this happened." participants discussed the importance of recognizing that goals and priorities may vary by individual and that each person will begin the program looking for a different outcome. for some, success may be defined as an improvement in mobility, whereas for others success may be defined as increased social interactions, motivation, or health maintenance. "i think everybody's priorities and everybody's goals are different." "so i mean, so i don't want to lose those [functions] any worse than they've been getting over the years because it's like almost limited to what i can kind of do…" "well, i guess it depends on somebody's lifestyle and age has a lot to do with it. so i would say some people are just looking to maintain themselves and stay healthy to be able to continue to do the activities that they currently do." "yeah, and just feeling better as well in daily activities." interaction with other classmates a strong recommendation was made to foster potential interactions among classmates in order to motivate and inspire one another. an additional recommendation was to include a feature to extend class times to allow for social interactions among classmates before or after exercise. some participants suggested that two-way viewing among classmates should be optional, so as to not discourage those who might feel uncomfortable. "i think it would be key to interact with not only the therapist, but with other patients. so i see jack on the one screen and he's struggling, i'm like come on. do one more. do one more. and we're all telling himme, alex-jack, come on. do one more. and he pulls through, so it gives that mental back." "so you said a -minute designed program, but maybe its min and we all log on min before. we could all-oh, maria*, how's that going, or chris*, how's that? so the social muscle to it instead of just working on arms and then logging off, like good old talk." "but to have the ability to [see others] should certainly be an option… but they should at least have the option to turn it off if they want i think, right?" participants suggested that it would be helpful for someone to orient a class member, assist with equipment needs and demonstrate specific exercises included in the program prior to session initiation. participants suggested that including a variety of exercises within each class would be desirable, in order to meet personal preferences and to address varying physical abilities. multiple participants suggested that three times per week would be the preferred frequency of classes, held at a variety of days and times to accommodate different schedules (e.g., weekday, weekend, and evening sessions). the goal of this focus group was to discuss experiences with physical activity and gather input from persons with tetraplegia to inform future design of a physical activity program delivered via telemonitoring that would be feasible, acceptable, and consistent with exercise guidelines for those with sci. a minor aspect of the discussion revealed that, in general, priorities for improvement included: arm/hand function, sensation, and improvement of mobility as being most important. in addition, upper body/trunk strength and balance, elimination of chronic pain, and improving lived experiences of sexual function were also ranked as important. data demonstrate that different modalities of exercise and physical activity have indeed been shown to improve aspects of physical capacity, health, and abilities to perform activities of daily living (e.g., functional wheelchair maneuvers and transfers) in persons with sci [ ] . participants perceived a home-based physical activity program as needed and important. intensity and type of physical activity performed before and after injury were discussed. participants identified family support, psychological state, and having a peer network (e.g., others with sci) as important factors for their overall recovery. participants regarded their input and feedback as critical for ensuring usability and feasibility, including the ability to make choices regarding whether a participant can be seen by classmates, types of exercises in a class, and timing of class delivery to suit multiple schedules. participants generally expressed enthusiasm for interacting with classmates, a desire for help from a caregiver or professional in initial set up, and comfort with a frequency of three times/week for classes and a duration of - min per class. participants perceived multiple potential benefits of a physical activity for persons with sci delivered via telemonitoring. participants had several practical suggestions to optimize design and delivery of such a program. clearly, a pilot study in this population testing this kind of intervention is needed. it is important that future studies incorporate feedback from participants on the design and implementation of a physical activity program. data generated during the focus group are not publicly available in order to protect privacy of participants. deidentified data can be made available upon request to the corresponding author. publisher's note: springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons license, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this license, visit http://creativecommons. org/licenses/by/ . /. annual statistical report for the spinal cord injury model systems public version traumatic spinal injury: global epidemiology and worldwide volume facts and figures at a glance facilitators and barriers to social and community participation following spinal cord injury social and community participation following spinal cord injury: a critical review position statement. part two: maintaining immune health position statement. part one: immune function and exercise reduction in trunk fat predicts cardiovascular exercise training-related reductions in c-reactive protein exercise and respiratory tract viral infections cardiovascular exercise training extends influenza vaccine seroprotection in sedentary older adults: the immune function intervention trial exercise, inflammation, and innate immunity american college of sports medicine position stand. quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise evidence-based scientific exercise guidelines for adults with spinal cord injury: an update and a new guideline development of scientific exercise guidelines for adults with spinal cord injury the development of evidence-informed physical activity guidelines for adults with spinal cord injury more than just a game: the public health impact of sport and physical activity for people with disabilities (the delisa lecture) functional and environmental factors are associated with sustained participation in adaptive sports self-efficacy: the exercise of control self-efficacy: the exercise of control self-efficacy mechanism in human agency correlates and determinants of physical activity in persons with spinal cord injury: a review using the international classification of functioning, disability and health as reference framework participation in physical activity in persons with spinal cord injury: a comprehensive perspective and insights into gender differences participation in sport in persons with spinal cord injury in switzerland telehealth for people with spinal cord injury: a narrative review circuit training provides cardiorespiratory and strength benefits in persons with paraplegia a comparison of circuit exercise training techniques for eliciting matched metabolic responses in persons with paraplegia using thematic analysis in psychology causes of death during the first years after spinal cord injury targeting recovery: priorities of the spinal cordinjured population exercise and health-related risks of physical deconditioning after spinal cord injury acknowledgements the authors appreciate the time, effort, and opinions of the focus group participants.funding a grant from the new york state spinal cord injury research board (to ob) and institutional funds supported this work. these funds were used to support sci-related research at our institution and did not influence the specific study in any way.authors' contributions rp, ak, jh, dg, and ob designed the study. rp and ak led development of the moderator guide, to which all authors made contributions. jh and dg developed the proposed physical activity program. rp, ak, jh, dg, and ob created the demo video of the proposed physical activity program. all the authors (rp, ak, jh, dg, ac, bp, and ob) were present for the focus group. rp and ak moderated the focus group. ak and bp analyzed the transcript and wrote the report. all the authors (rp, ak, jh, dg, ac, bp, and ob) contributed to interpreting the data and writing the manuscript. conflict of interest the authors declare that they have no conflict of interest.ethics study activities were deemed not human subject research by the local institutional irb research and therefore did not require irb review. key: cord- -tnfkzw authors: han, jia; wang, xueqiang; shen, xia; hu, jia; zhang, xin; tang, xin; wang, hong; luo, qinglu; jiang, ying; jiang, zheng; yang, lin; zhang, qi; bai, yiwen; wu, xubo title: on “translating covid- evidence to maximize physical therapists’ impact and public health response.” dean e, jones a, yu h.p-m., gosselink r, skinner m. [published online ahead of print june , ] phys ther. . doi: https://doi.org/ . /ptj/pzaa . implications for advancing therapy education, practice and public health in china date: - - journal: phys ther doi: . /ptj/pzaa sha: doc_id: cord_uid: tnfkzw nan given that china was the initial epicenter for the covid- pandemic, we read with particular interest the article by dean and colleagues. there is an urgent need for us to increase the number of physical therapist education programs in order to produce competent practitioners who are especially committed to promoting public health. programs at the baccalaureate level with "physical therapy" in the award title were we support structured bridging courses in which generic rehabilitation therapists can enroll to be upskilled to become qualified physical therapists, so that they meet international standards of practice across clinical settings from the critical care to community care. in chinese, the word for "crisis" has characters, 危机, "danger" and "opportunity." unquestionably, the pandemic is a global crisis; however, we see that there is unlimited opportunity for expediting further development of the physical therapy profession in china. identifying the challenges and solutions is a step in that direction. these include the lack of qualified physical therapists with advanced graduate degrees with academic positions who can conduct research relevant to china as well as teach evidence-informed professional physical therapy courses. to help relieve this demand, the ccptpd has considered sharing teaching resources (staff and teaching and learning materials). in addition, the pandemic has shed light on the paucity of attention that has been allocated to acute care and the cardiorespiratory curriculum. we have advised physical therapist academic programs to revise their curricula to better align with the urgent demand for physical therapy services in china in light of the pandemic. correspondingly, we have actively engaged with clinical placement providers to strengthen the cardiorespiratory component and to enhance students' cardiorespiratory clinical experience, especially in the critical care setting. another initiative is tele-physical therapy, which has been reported to be effective across a range of clinical settings and thus is being encouraged during the covid- pandemic. tele-physical therapy is now being considered for inclusion into our regularly revised physical therapy curricula. furthermore, we propose that online lectures and seminars translating covid- evidence to maximize physical therapists' impact and public health response coronavirus disease (covid- ): the need to maintain regular physical activity while taking precautions application of a contextual instructional framework in a continuing professional development training program for physiotherapists in rwanda physiotherapists during covid- : usual business in unusual times key: cord- -qvuand s authors: corbin, charles b. title: conceptual physical education: a course for the future date: - - journal: j sport health sci doi: . /j.jshs. . . sha: doc_id: cord_uid: qvuand s the conceptual physical education (cpe) innovation began in the mid- th century as an alternative approach to college-level, activity-only basic instruction classes. in addition to physical activity sessions, cpe courses (classes) use text material and classroom sessions to teach kinesiology concepts and principles of health-related fitness and health-enhancing physical activity. cpe courses are now offered in nearly all college programs as either required or electives classes. two decades later, the high school cpe innovation began, and kindergarten- programs followed. in this commentary, i argue that historian roberta park was correct in her assessment that physical education has the potential to be the renaissance field of the st century. scientific contributions of researchers in kinesiology will lead the way, but science-based cpe and companion fitness education (fe) programs that align with physical education content standards and fe benchmarks will play a significant role. cpe courses have been shown to be effective in promoting knowledge, attitudes, and out-of-school physical activity and have the potential to elevate physical education as we chart the course of our future. in corbin and cardinal cited historian roberta park, who suggested that physical education has the potential to become the renaissance field of the st century. her thorough historical account describes the emergence of physical education in the s and traces its development as a science-based profession. park notes that medicine was an emerging field during the s but became the renaissance field of the th century largely because of research that provided a scientific basis for medical education and the profession. i believe that park was correct in her suggestion that what was true of medicine in the th century can become true for physical education in the st century. we can become a renaissance profession, but not without changing our course. the purpose of this article is to articulate the importance of knowledge, especially higher-order knowledge, and conceptual physical education (cpe) as a program central to the delivery of knowledge and other aspects of physical literacy in the future. the dominant focus of th-century physical education in the us was formal activities imported from european countries (e.g., gymnastics and regimented exercise) . by mid- th century, physical education teacher preparation programs were established in the us, and in the association for the advancement of physical education was formed. the profession of physical education was becoming a force in american education. buoyed by research in psychology (e.g., hall) and education theory (e.g., dewey), leaders put forth theories of play, games, sport, and the -recreative‖ value of physical activity. through the early years of the th century the debate about how best to prepare physical educators and the nature of the content of school physical education programs continued. over time the -new physical education‖ of cassidy, nash, williams, wood, and others provided direction for programs of the s. expanded objectives for physical education programs such as leadership, teamwork, and sportspersonship based on uniquely american -democratic values‖ found their way into school programs. physical education became much less regimented, and sports and games became a significant part of the physical education curriculum. the european physical education of the th century morphed into the sports-dominated physical education of the th century. by the mid- s the science movement had begun and prompted park to suggest a new look for the st century. she details the new science within physical education (kinesiology) and documents the great strides that have been made in our multiple sub-disciplines. this excerpt characterizes her thoughts: there is a -great need for well-trained and dedicated professional practitioners in areas ranging from the health and fitness industry, to public school physical education, to exercise programs for older populations, to the management of recreational and sporting agencies, and much, much more. the attitude that prizes systematized knowledge, constant questioning, and the ability to forge logical links and see interdependencies, however, must infuse the work of the teacher, coach, and clinician as much as that of the exercise physiologist and biomechanist, sport psychologist, sport sociologist, and sport historian‖ (p. ) . the new science outlined by park sparked many changes within physical education and kinesiology and was an important factor in the emergence of cpe and fitness education (fe) programs. cpe originally referred to physical education programs (typically a semester-long class or shorter units in a class) that focused on teaching concepts, principles, self-management, and consumer skills to promote healthy lifestyles (e.g., regular physical activity, sound nutrition, making good consumer choices) and the outcomes associated with healthy lifestyle adoption (e.g., fitness, health, wellness). unique features of cpe include classroom sessions and the use of a textbook or text-based materials. knowledge gained in the classroom and from text materials is reinforced in physical activity sessions specifically planned for cpe. although not initially labeled as such, early cpe programs became known as fe programs because they were developed for use with fitness assessment. , as health-related fitness testing gained traction, the programs were expanded to help students understand the reasons for testing and to help them learn to effectively plan physical activity programs to build health-related fitness. more than years after the introduction of cpe, fe was formally included in the society of health and physical educators (shape america) fitness education framework as -a subcomponent of the total physical education program, focusing on helping students acquire knowledge and higher-order understanding of health-related physical fitness, the product, as well as habits of physical activity and other healthy lifestyles, the process, that lead to good health-related physical fitness, health and wellness‖ (p. ). in the years since their inception, cpe and fe programs have evolved significantly. some examples are used to illustrate. fitness for life is an example of a cpe program (e.g., text, classroom and activity sessions) that is also considered to be an fe program because of its extensive fitness-related content. however, over time, it has expanded to include content related to all physical education standards (see later sections). physical best is an fe program that focuses on health-related fitness content. because it does not use a student text or classroom sessions, it is considered to be an fe program, but not a cpe program. science of healthful living , uses text-based materials but does not use classroom sessions. its authors refer to it as a concepts-based physical education program. for the purposes of this article, concepts-based physical education programs will be included as cpe programs. cpe became widely adopted during an era of change. originally conceived as a physical education offering, college classes are now offered in departments with a variety of names (e.g., kinesiology, exercise science, sport science, health and human performance) and many course titles (e.g., fitness for life, personal fitness, concepts of fitness and wellness). regardless of the academic unit or class name, cpe captures the spirit of park's call for physical education to take its place as an enlightened or renaissance field. at the time of its introduction, cpe was not well received. however, the cpe innovation that began at the college level in the mid- th century became an offering, either as a required class or an elective, at virtually all institutions of higher learning , , . cpe -merges the practice and science of the field through a lecturelaboratory approach‖ (p. ). as cpe grew in popularity, the accompanying science movement provided evidence of the link between physical activity and public health. the epidemiological evidence helped to push performance-based youth fitness testing of the late s toward health-fitness testing by the end of the century. social movements (e.g., civil rights, rights for women, student rights) spurred change as students became active in affecting societal change. they fought for student choice in course and curriculum options. these movements aided the college cpe innovation because cpe provided an alternative to traditional required physical education classes. cpe classes offered a science-based personalized approach as an alternative for all students, especially for those who did not relate to the traditional sports-based physical education offerings. in addition, evidence of the effectiveness of cpe in promoting knowledge, attitudes, and physical activity behaviors provided support for its inclusion. cpe programs, and the evidence supporting them, have saved physical education requirements at many institutions since inception. many of the same factors that led to the college cpe innovation fueled the growth of both cpe and fe programs at the high school level. particularly influential were the growth of the science base within kinesiology and the associated public health approach to physical education. - knowledge in kinesiology expanded rapidly and provided a platform for advancing the profession of physical education. the shift from performancefitness to health-fitness testing occurred simultaneously with the science boom. practical considerations also contributed to the rationale and need for cpe programs. while kinesiology was accepted in the mainstream of science, physical education was gradually being marginalized in schools. survey data from the youth risk behavior surveillance system indicate that daily physical education attendance decreased from . % in to . % in . it has remained stable since , but attendance is well below what it was early in the s. facing the challenge of being sidelined or eliminated, many schools adopted cpe as an evidence-and standards-based option that helped protect physical education requirements. furthermore, those who advocated for cpe at the high school level pointed out that not all high school students go to college and that non-collegebound students deserve to participate in effective cpe programs. was the first high school cpe program. a number of others followed, including personal fitness for you, personal fitness: looking good/feeling good, and foundations of personal fitness. fitness for life ( th ed.) is the most widely used model. consistent with park's call for a scientific foundation for physical education, cpe programs are based on sound education theories that provide a foundation for building higher-order learning. promoting confidence, intrinsic motivation, and autonomy (social cognitive theory and self-determination theory); promoting the belief that these factors can help in overcoming barriers (health beliefs model); and providing information about moving through several stages of behavior change (trans-theoretical model) all set the stage for helping students achieve higher-order objectives in cpe. the program stairway to lifetime fitness, health and wellness, as illustrated in figure , provides a visual description that illustrates how theory meets practice in moving students from dependence (in elementary school) to independence and autonomy in middle and high school. central to the -stairway‖ metaphor is the notion that learning (achieving literacy) is vertical, not horizontal. early learning provides a foundation for later learning. accordingly, the stairway emphasizes the importance of addressing higher-order objectives in physical education through teaching for independent thinking and autonomy. as ennis and colleagues have demonstrated, conceptual learning at one grade level provides a foundation for learning in subsequent gradesor to put it another way, it helps students learn how to learn. at steps and (level of dependence) young students are dependent on us, the teachers. they typically lack fitness and physical activity knowledge and benefit from a direct teaching style. they participate as directed and benefit as the directed activities allow. at steps and (level of decision making) students begin to understand and apply concepts and principles and to use self-management skills (e.g., self-assessment, goal setting, self-monitoring, self-planning). they begin to analyze and evaluate their own behaviors. at steps and (level of independence) students become independent and autonomous ( fig. ) . they become problem-solvers capable of making decisions that can enhance their long-term fitness, health, and wellness. national physical education content standards provide a basis for establishing student objectives and outcomes, including higher-order objectives. the first national physical education content standards were published by the national association for sport and physical education (naspe, now shape america) in . the standards were revised in and again in . the current standards are shown in table . early cpe programs focused on the parts of health-related physical fitness, health-related fitness selfassessments and interpretation, the types of physical activities that promote health and health-related fitness, the fitt (frequency, intensity, time, type) formula for building fitness through physical activity, and steps in program planning. coverage of nutrition and stress management were also included, as were self-management skills (e.g., goal setting, self-monitoring, overcoming barriers). they focused primarily on standards that specifically identify knowledge, concepts, and principles as important student outcomes (standards and ) and the standard related to health-related fitness (standard ). cpe continues to provide its original fe function, but as suggested by mohnson, it now covers concepts and principles related to expanded sub-disciplinary content as well as all five physical education content standards. beyond content that focuses on exercise physiology concepts and principles, programs now typically include biomechanical and motor learning principles to help students in their efforts to demonstrate competency in motor skills and movement patterns (standards and ) and sociological and psychological concepts and principles that underlie the development of self-management skills and social emotional learning (standards and ). correlation tables have been created to show that programs comprehensively address standards and to indicate which materials and lesson plans address which standards. as noted earlier, in naspe/shape america developed a framework (with benchmarks) for fe for kindergarten- . the framework acknowledged the importance of teaching content commonly associated with cpe and fe programs and provided benchmarks for student achievements in these programs. many of the benchmarks (table ) were derived from longstanding cpe content. for this reason, many cpe programs met all, or most, of the fe framework benchmarks prior to the development of the framework. now, many cpe programs have expanded beyond the fe framework to include content from all physical education content standards. as we move forward, physical education standards and fe benchmarks will need to evolve consistently with the new knowledge that can serve our students in the future. in recent years the term physical literacy has gained traction. , the international physical literacy association (ipla) describes a physically literate person as one who has -the motivation, confidence, physical competence, knowledge and understanding to value and take responsibility for engagement in physical activities for life‖ (p. ). shape america has adopted this definition but operationalized it to refer to a physically literate person as one who meets national physical education content standards (table ). in a separate paper, i have expressed my concerns about the many different definitions of physical literacy and the use of the term. these concerns will not be revisited here. both the ipla definition and the shape america standards demonstrate that the development of knowledge is an important characteristic of physical literacy. as we move toward the future, i encourage physical educators to expand their view of knowledge development (especially higher-order knowledge) to include concepts central to current definitions of health literacy. health literacy, as defined by the institute of medicine (now the national academy of medicine), -is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions‖ (p. ). cpe is a program designed to help students to obtain, process, and understand information about physical activity and its health benefits. cpe content centers on providing the knowledge to assist students in making well-informed decisions about physical activity, nutrition, and stress management. as ennis aptly notes, content -transcends the physical, relying on a sound foundation of knowledge to guide and lead physical activity choices and participation across one's lifetime‖(p. ). she further emphasizes that -knowledge is at the heart of physical literacy‖ and that physical literacy -includes not only knowledge for performance but also the ability to apply knowledge and use knowledge for innovation‖ (p. ). cpe began at the high school level in the late s with a health-related fitness focus. the content was organized in several major strands as depicted in the first column of table . over time, the cpe content expanded based on user demand and alignment with standards and benchmarks (see the second column of table ). today's middle school cpe content is similar to early high school programs, with representative content indicated by asterisks alongside topics in table . lately, energy balance has also been an area of study in middle school cpe. the original model for high school cpe included an -week program (a one-semester class) that met in the classroom two days a week and in activity sessions three days a week. in the us, florida's required personal fitness class was implemented in the s using this model. as was the case when the florida cpe was implemented, the one-semester cpe class is often coupled with a second semester of a -required elective‖ to fulfill a one-year physical education requirement. various states and districts have followed this model, but other alternative schedules are common. for example, some high schools have integrated cpe classroom and activity sessions with traditional activity units, thus extending the class over a full school year. at the middle school level, the three-unit, nine-chapter fitness for life model (taking half a semester) has been widely adopted. in the half-semester plan, two textbook lessons are studied with classroom sessions and activity sessions. however, distributing units over different grade levels is a frequent alternative plan. portfolio sheets are used for recording student data. the science of healthful living curriculum is designed to increase middle school students' knowledge and interest in health-related science. it consists of lessons in units over grades , , and . , the curriculum, also referred to as -science in the gym‖ emphasizes a e system (engagement, exploration/experiment, explanation, elaboration, and evaluation) to integrate cognitive and physical tasks. students use workbooks and journals as a guide to learning tasks. research on the science for healthful living curriculum indicates that using workbooks is an effective way of promoting knowledge development in physical education. , fitness tests have been around since the s and were developed primarily to test youth fitness. the early skill-related fitness test batteries gradually gave way to health-related fitness tests beginning with the development of the american alliance for health physical education, recreation, and dance (aahperd, now shape america) health-related fitness test in . after years of debate about various fitness tests, fitnessgram ® created at the cooper institute for aerobics research (cooper institute), morphed from a fitness report into a full health-related test battery with computer-based fitness reports. critics have long suggested that tests by themselves do little to encourage fitness improvement and activity participation and may lead some youths to avoid engaging in physical education altogether. cpe programs were employed to address this concern. although there was no formal collaborative agreement, the fitnessgram ® . the help (h = health, e = everyone, l = lifetime, p = personal) philosophy that originated with fitness for life, by agreement, also became the philosophy of fitnessgram ® . the test items were included in fitness for life as self-assessments providing the basis for building a personal fitness profile in program planning. professional development sessions were conducted at the cooper institute for both fitnessgram ® and fitness for life to help teachers implement the programs and to prepare instructor trainers to conduct workshops to help teachers implement both programs. to fulfill the need for programs for k- , a variety of fe programs were developed. smart choice, included in the first fitnessgram ® test manual, was an early fe program. it included an award for keeping activity logs and meeting goals. in , it's your move activity booklets were created for elementary school students; and in , you stay active was published jointly by aahperd and the cooper institute. you stay active included teacher materials and student handouts for use in physical education to help students better understand why they were taking fitness tests and how fitness test scores can be used to set goals and aid in program planning. the cooper institute currently offers online instructional materials, called smart coach, for teachers. in fitnessgram ® became the health-related fitness test battery and fitness reporting system endorsed by shape america. aahperd's physical best health-related fitness test battery was converted to an educational program that supported fitnessgram ® . during the s, aahperd sponsored pre-convention instructor trainer sessions for physical best, fitnessgram ® , and fitness for life. physical best is currently -a program of resources and training for k- physical educators … to implement health-related fitness education, including curriculum development and health-related fitness activities‖ (p. ). physical best activity guides are available for elementary, middle school, and high school teachers. other programs-such as the president's youth fitness program (pyfp), which features fitnessgram ® test items. comprehensive school physical activity programs (cspap), which encourages before-, during-, and after-school physical activity. the active and healthy schools program, which encourages activities throughout the day and fitness for life: elementary school, school children have become quite effective in using sound management strategies , for keeping students active while promoting learning consistent with physical education content standards and fe benchmarks. these programs are often very well conducted by dedicated teachers. i do endorse the inclusion of activities that teach concepts and principles because they can help move students up the stairway to lifetime fitness, health, and wellness ( fig. ) and prepare students for secondary cpe programs. i also endorse whole-school or comprehensive school physical activity programs that create and foster healthy and active school cultures. the remainder of this article will focus on secondary school cpe rather on than elementary school programs. the formal exercise that characterized physical education in the th century gave way grudgingly to the -new physical education‖ in the th century. however, it was well into the s before the -american‖ model that emphasized sports and games became firmly established. by the model was dominant. data from the school health policies and practices study (shpps) reveal that team sports were the most frequently offered activities in secondary schools. basketball, volleyball, baseball/softball, football, and soccer were the top activities for both middle schools and high schools. dodgeball and kickball were also frequently included in programs. the team-sport approach of the s is still dominant now, at least in the us. table provides data from the shpps. the results look familiar. four of the team sports that ranked in the top five in are still in the top for both high schools and middle schools, and sports (mostly team sports) are among the most frequently offered physical education activities. it is important to point out that the data reflect the number of schools offering the activities-not the amount of time spent on the activities. still, the statistics indicate that the same sports activities are repeatedly offered from year to year in secondary school physical education. this can lead to the administrative policy of dumping-mixing lower-grade students in the same classes as upper-grade students, resulting in repeating the same instruction and same activities again for upper-grade students. see mccullick et al. and lounsbery et al. for more information about physical education and physical activity policies and common barriers to successful programming. contrast the activities most frequently taught in schools with the activities in which most adults participate (fig. ) . team sports that are dominant in school physical education rank well below activities such as individual sports, outdoor activities, and fitness activities. my own observations suggest that fitness activities, most common among adults, are often not available to all students in secondary schools. many high schools, for example, have fitness facilities; but elective resistance training classes using these facilities are open primarily to athletes. physical education classes, required or elective, often cannot use these facilities for classes for nonathletes. additional statistics are revealing. shpps data indicate that . % of middle schools and . % of high schools require students to take physical education as a graduation requirement or for promotion. at first glance, it would appear that most students are required to take secondary physical education. but the same survey data show that the percentage of schools that require physical education in each grade ranges from % to % for grades - and from % to % for grades - . the percentage of students taking physical education days a week is . %. as we plan physical education for the future, we should consider these questions. is it necessary to repeat the same activities over and over again, especially activities that are often not used after the school years? can all youth become proficient in all sports and activities? do they want to? would it be more productive to focus on activities that are more likely to be performed later in life? should students at least have a choice? how does repetition of the same activities contribute to all content standards and benchmarks? is the traditional sports-based model the best model for the future? dintersmithin his book what schools could be, quotes john dewey: -if we teach today's students as we taught yesterday's, we rob them of tomorrow‖(front matter). dintersmith  purpose-students attack challenges they know to be important, that make their world better.  essentials-students acquire the skills sets and minds sets needed in an increasingly innovative world.  agency-students own their learning, becoming self-directed, intrinsically motivated adults.  knowledge-what students learn is deep and retained, enabling them to create, to teach others. dintersmith does not address physical education, but his principles can be applied to -what physical education could be". certainly there are many outstanding teachers that currently apply the peak principles in their programs. however, a variety of statistics call into question the universal application of peak principles in secondary physical education. cpe has purpose. in cpe, students are challenged to learn concepts, principles, and self-management skills that can be used throughout life. results of project active teen indicate that students who took cpe as th-graders use the information years after high school graduation (see later section). cpe develops essential skills (e.g., self-management, consumer, performance) that are useful in the st-century world. cpe programs promote physical literacy that provides a foundation for later innovative learning. cpe builds agency. as shown in fig. , students learn to become intrinsically motivated independent (autonomous) problem solvers and decision makers while in school and in later life. cpe enhances knowledge. as park indicated decades ago, the science base (kinesiology) is significant and growing. cpe focuses on higher-order objectives, enabling students to learn to learn. this enables them to continue their learning throughout life. green labels the -pe effect‖ as physical education's ability to promote lifelong participation in physical activity. he further indicates that despite the belief that physical education produces a -pe effect‖, there remains a dearth of evidence to support this supposition. green states that physical educators often -take-for-granted‖ the positive effects of physical education programs (p. ) and cites the need for more longitudinal research into the pe effect. the evidence for cpe is described in this section, including the longitudinal research that green recommends. the early research related to cpe was conducted at the college level and provided evidence of the effectiveness of programs in building knowledge, attitudes, and active behaviors. researchers have noted the drop in regular physical activity as teens transition to adulthood , . but can physical education stop the drop? is there a pe effect? longitudinal studies suggest that there is. project active teen (pat) began in . high school th-graders took a yearlong cpe course using the fitness for life model. students used a textbook and had classroom sessions one day a week. they participated in activity sessions that focused on health-related fitness and the activity sessions were coordinated with classroom content as well as traditional physical education activities. teachers participated in regular professional development sessions that provided training in cpe content and methods, and detailed lesson-plan notebooks were provided. over the years of the study, three different progress reports were published. the first study, pat , assessed activity patterns of participants as juniors and seniors in high school . results indicated that students who took cpe in the th grade had lower levels of inactivity and were more likely to meet physical activity guidelines than both those who took traditional physical education (tpe) and a national sample of age-matched peers. the second study, pat , found similar results several years after participants graduated from high school cpe. the third study, pat , was conducted years after the cpe students graduated from high school. as with the first studies, results indicated that the cpe students were more active and less likely to be inactive than national peers and maintained high levels of physical activity years after graduation. questionnaire data showed that - % of respondents indicated that they remembered content from the class, % indicated that they still used the information, % indicated that they found the class useful after graduation, and % indicated that they currently consider themselves to be well informed about physical fitness and physical activity‖ (p. ). in the pat studies, tests for statistical differences were conducted. all of the significant differences favored those who took cpe. the authors of pat suggest that cpe -can be a vital part of a total quality physical education program that promotes lifelong physical activity and complements quality traditional physical education programs‖ (p. ). ennis, chen, and colleagues , , created a middle school cpe program that was used in a multi-year, federally funded intervention study (science of healthy living, shl). students in grade - in the intervention schools participated in a curriculum based on health, fitness, and nutrition that consisted of lessons in two units and associated physical activity sessions. the results were similar to those for the pat project. two years after the initiation of the study, participants in the shl group had higher out-of-school physical activity levels than the participants taking tpe. they also scored better on knowledge tests. research indicates that secondary school students often lack knowledge and/or hold misconceptions concerning healthy behaviors (e.g., physical activity, physical fitness, nutrition) [ ] [ ] [ ] . other studies document a positive relationship between fitness knowledge and participation in physical activity [ ] [ ] [ ] [ ] . there is also evidence that cpe programs can improve physical fitness and physical activity knowledge [ ] [ ] [ ] [ ] . furthermore, research has shown that knowledge from lower grade levels enhances learning of knowledge at later grade levels, which is evidence of vertical learning . based on the evidence, wang and chen offer a hypothesis that knowledge is a pathway to motivation for physical activity and ultimately to increased out-of-school physical activity. collectively, the evidence is clear: fitness knowledge-and the resulting knowledge improvement-is an important benefit that results from a well-delivered secondary cpe program. these results support the value of knowledge, especially higher-order knowledge, as a powerful factor that can be the glue that cements together the many benefits of physical education. as we move to the future, a strong case can be made for including cpe as a foundation physical education course in secondary schools. cpe programs are based on a sound philosophy (the help philosophy), a whole-person orientation, and sound learning theory. cpe program objectives align with national physical education content standards (physical literacy) and fe benchmarks. they address higher-order objectives that are consistent with the peak principles. cpe programs also address school reentry considerations that were very important during the corona virus pandemic. in addition, cpe has the support of the national academy of kinesiology and members of the medical community. cpe program content is based on kinesiology's sub-disciplinary sciences that park championed as the basis for moving physical education forward in the st century. most importantly, cpe programs work. the evidence is considerable and growing (see previous section). and there is more. in addition to the factors described above, advocates suggest that cpe provides academic connections that benefit students in other subject matter areas (e.g., math, science, english language arts); provides formative and summative assessment tools, including student-centered assessments in the cognitive, affective, and physical domains; and enhances teacher self-esteem and program reputation. , a quality physical education experience could look like the following for k- education. after completing a quality elementary school experience that includes fe, middle school students complete cpe units that provide them with a foundation for entry into a one-semester or one-year high school cpe program. the high school cpe experience, in turn, provides a foundation for practicing lifelong healthy lifestyles (e.g., active living, eating well); for becoming a good fitness, health, and wellness consumer; and for making informed decisions about additional quality physical education and later life experiences. the cpe content is streamlined and coherent from elementary school to high school with a vertical sequence. some of the opportunities for expanding physical education beyond the cpe foundation are listed in fig. , and the sections below illustrate the diverse and adaptive cpe programming for different school settings and situations as demanded for a stcentury education. as mccullick et al. have shown in their study of school policies, there is a lack of legislative support for physical education requirements. the lack of support is one reason why most teens are not enrolled in physical education in secondary schools. when physical education is required, it is typically for a limited time (one or two years in high school). enrollment is most prevalent among th graders, and by grades and , fewer than % of students are enrolled. middle school teens are more likely to be enrolled than those in high school, but less than one-third of all students are enrolled in grades - . cpe electives offer students opportunities to continue physical education after the foundation stage to keep learning and maintain in-school physical activity and can be an effective method for increasing enrollment in elective physical education. research has shown that students who have completed cpe have a good knowledge base, as well as self-management, consumer, and decision-making skills. they can use these skills to make their own decisions about elective options. if we teach students to make good decisions, we must allow them to make their own choices. in a school that requires one year of high school physical education, a one-semester cpe course could be followed by a required elective course. students choose the activities that they want to pursue. for this to be a legitimate option, schools must offer what students want to take-not what teachers want to teach. if students want yoga, tai chi, resistance training, self-defense, and dance, we must be prepared to offer these activities and be prepared to teach them. in schools with no requirement, we must offer attractive options that will entice students to take elective physical education. we must also consider ways to reduce barriers to participation. there are obstacles to the introduction of new offerings in secondary schools that are often not easy to overcome. nevertheless, several options are proposed here. the work of teachers in the san francisco unified school district (sfusd) to create an advanced cpe class is one example of how change is possible. it goes without saying that professional development opportunities will be necessary to help physical education teachers implement the proposed options. elective cpe. in schools that do not required physical education, a cpe class can be offered as an elective option. if the option is offered, interested students will take advantage of it. advanced cpe. advanced cpe can also be an elective option. for example, sfusd has a high school cpe requirement for all students . upon completion, students can continue cpe by electing to take an advanced class (fit for life ). this sfusd class is unique in that it meets university of california admission requirements for electives . the class expands on the content included in the required cpe class. another advanced option is an introduction to kinesiology class. offering an introduction to kinesiology class as a science course is defensible and opens doors for students who want careers in fitness, health, wellness, and allied health occupations. honors cpe. irwin and colleagues recommend that honors classes be offered in physical education. they describe honors classes as courses designed for high-achieving students that include greater depth of coverage . irwin et al. maintain that physical education is a legitimate education domain, and it is appropriate that honors classes be available just as they are in other academic areas. advanced cpe and introduction to kinesiology classes are excellent options for honor classes at the secondary level. advanced placement cpe. advanced placement (ap) classes offer students the opportunity to pursue advanced study in an academic area and allow students to earn college credit in advance of college enrollment. as irwin et al. indicate, -our profession is undergoing a critical dialogue to initiate a much-needed paradigm shift or rebranding of who we are and how society regards us. there is work to be done if we are to increase respect for what we do. we all know that our content can be exceptionally rigorous and just as important to student success as other academic content areas. ap classes can also provide opportunities for students who have a passion for our subject matter to challenge themselves. therefore, we are proposing that it is time to begin the process of creating and launching an ap course focused on our subject matter‖ (p. ). cpe and introduction to kinesiology courses provide good ap options in physical education. in describing what school could be, dintersmith places great emphasis on project-based learning using peak principles. he describes project-based classes in the schools that he visited and suggests that innovative project-based classes can be part of an effective st-century educational system. project-based learning is often structured so that groups of students work together on a specific project (e.g., building a robot in science class). however, students can also work on projects individually. key elements are innovation, student choice and decision-making, the use of st-century skills, and, most importantly, a relevant reason or goal that drives the project. cpe classes are, in many ways, project-based. students gain higher-order knowledge and decisionmaking skills driven by the opportunity to create their own lifetime program plan. the outcome can be student portfolios that are exhibits of a healthy-living project based on personal needs and interests. beyond cpe, other project-based physical education opportunities can be offered. sport education classes are, in my view, projectbased classes. elective sport education classes in a variety of activities are consistent with peak principles and allow students (in groups) to play many different roles in sport and physical activity settings. likewise, adventure/outdoor education classes have potential as project-based classes, with students doing the planning and organizing. the health-and-fitness club model , can also provide opportunities for project-based learning when students doing the planning, organizing, and administering. this option can be especially rich when students are offered the opportunity to apply their special talents in carrying out a project. for example, student musicians can create music (and background music) for exercise routines, student dancers can choreograph, student artists can create art, and students with computer and other technical skills can create active exergames and apps that encourage active living. schools have been reluctant to offer fully online physical education courses partly because of concerns about how to monitor physical activities and partly because of a lack of digital skills and resources for offering such classes. in , shape america published guidelines for k- online physical education . the guidelines offer direction for distance/remote learning of many types (e.g., blended learning, fully online learning, synchronous learning, asynchronous learning). as more and more states and school systems mandate classes in all academic areas, online physical education has become more widespread . cpe classes have been the more frequently offered than tpe because cpe's content is more easily adapted to an online format due to its knowledge-centered approach to physical activity promotion. the corona virus disease (covid- ) pandemic amplified the value of online learning, especially through cpe. teachers and school districts scrambled to provide remote physical education as schools closed. physical education teachers were tasked with providing alternatives to face-to-face learning for students. more than a few teachers and administrators contacted me to get help with materials and training (e.g., webinars, granting access to resources). those who had already been conducting cpe courses made an easy transition when remote learning became imperative. those who had not made the transition embraced cpe because it was a defensible alternative that administrators could accept. all of the benefits of cpe described in this paper have been used to support it during the pandemic. however, questions remain: if cpe is defensible as the -go to‖ program during the pandemic, why has it not been more universally implemented? will it continue to be implemented post-pandemic? as schools adopt online programs, we must answer the following question: -how do we know that students are active in their remote classes?‖ the answer is: -we don't.‖ face-to-face classes are much better for teaching skills and monitoring physical activity. however, video, activity monitors, and other creative options can help us when remote learning is the only option. in the meantime, student activity logs and reported activities on portfolio sheets can be used. students can design their own activity plans and perform them. no doubt, some may not actually do what they describe in their logs. however, students would learn how to plan and what to include in a program. concepts of personal responsibility can be discussed to help students develop ownership of content. they can learn what to do later in life if they choose to do so. a positive outcome with online cpe is the ability of students to do activities in a non-threatening environment, with none of the baggage of locker room bullying, embarrassing shower room events, and lack of time for personal grooming. for some, online programs can be a good option. on the negative side, we have work to do relating to testing and ensuring that the students enrolled in online classes are actually doing the work. using hybrid options that require students to do some activities face to face, especially assessments, would go a long way in solving this problem. the covid- pandemic also helped expose the fact that not all students have equal access to the internet and to the computer tools necessary to take advantage of online classes. for example, % of k- students have no internet access, % have no access to a home computer, and as many as % face barriers to connectivity . equality options are necessary to make sure that all students have an opportunity to learn remotely. while there is much more that needs to be done in this regard, when access is available, cpe programs provide digital texts and student resources that can facilitate online learning. print materials can be distributed by mail, delivered, or picked up from the school, thus assuring that all students can have access to at least some of the same experiences. the pandemic also has made obvious the lack of equity in providing resources for teaching in physical education. schools that transitioned to the cpe approach often had large class sizes (sometimes or more) and lacked computers, whiteboards, and other digital tools available to teachers in other subjects. texts, student resources, and teacher resources are also required. while physical education programs often have limited budgets, it should be noted that text materials and student/teacher resources for cpe programs are less expensive than purchasing typical sports equipment. it is my contention that cpe provides us with the ammunition to demand instructional equity (e.g., resources). -how you do it‖ matters when delivering a course of instruction. cpe offers many tools for use by professionals as they facilitate student learning. knowing how to use the tools is as important as selecting the appropriate tool for meeting a specific learning objective. some important factors relating to delivery are listed and briefly described in table . as noted in section , cpe is differentiated from other fe programs by its use of classroom sessions and text materials. why classroom sessions? different objectives require the use of different methods. when providing instruction with knowledge as the goal, the classroom offers opportunities for best practices for doing presentations (white boards, computers, vetted text materials, videos) and encouraging student discussions. blocks of time are available for in-depth study of content. because conceptual material is covered in the classroom, students avoid standing and listening during activity. textbooks and text materials provide opportunities to learn in all educational settings: in the classroom (texts), in activity sessions (portfolio sheets or workbooks), out of school (e.g., readings, assignments), and online (digital materials). effective middle school programs have used both textbooks and text-based materials (workbooks, portfolio sheets-print and digital), and effective high school programs have used textbooks (print and digital). one new innovation is interactive web text (iwt), which resides on the web and allows text material to be used on all digital devices (e.g., phones, tablets, computers) and virtually anywhere that an internet connection can be made . this is important in situations where students have a variety of digital devices. however, as noted earlier, for all students to benefit they must have access to digital devices and the internet. when teachers implement cpe, the most common question they ask is: -how can i justify having students sit in a classroom when so many students fail to meet national physical activity guidelines?‖ i offer the following answer, using an excerpt from a previous publication: -an overarching goal of physical education programs is to promote lifelong physical activity. to be sure, taking time from physical activity to be in a classroom reduces physical activity on those days. however, cpe is not meant to be all of physical education, rather it is one part of physical education conducted for a limited time period with a limited number of classroom days. the time spent in cpe yields more physical activity later in high school and later in life, more than compensating for the time lost in physical activity while the student is in the classroom. if, in cpe, we can teach students selfmanagement and consumer skills that will help them to be active for a lifetime, the limited classroom time in cpe seems well worth it. the research supports this idea.‖(p. ). one of the reasons for the low numbers of students taking physical education in secondary schools is exemptions (allowing alternative school activities to count for physical education credit). proponents of alternatives for fulfilling physical education requirements (e.g., band, jr. rotc, athletics) argue that these alternative programs provide activity and therefore are equal to physical education and are acceptable substitutes. physical educators argue that these alternative programs do not meet the criteria for quality physical education such those outlined in this article. regardless of the amount of activity students get in alternative programs, exempted activities such as band, jr. rotc, and athletics do not meet physical education standards and physical literacy requirements. to fulfill a physical education requirement, an online cpe module can be an option. the online module provides the content for meeting all of the requirements for quality physical education (all standards) while allowing alternative activities to count toward physical activity requirements for the class. physical education teachers conduct the online portion of the class and count students as enrolled. to meet the requirements for the cpe portion of the course, additional activities can be assigned to supplement the alternative programs that often provide relatively low amounts of activity . history has shown that for there are steps that can be taken to provide a pathway to success when implementing a cpe program. three very important steps can be taken to ensure teacher commitment and administrative support, provide teachers with professional development opportunities, and ensure the inclusion of all students. teacher commitment and administrative support. for any program to be effective, teachers must be committed to it. a program such as cpe typically requires teachers to attend professional development sessions and to do extra planning and grading. for some, commitment can be difficult, especially for teachers who are also athletic coaches. research indicates that when roles of coach and teacher conflict in terms of time and resources, priority is often given to the "athletics" portion of the job . i readily recognized the many coaches are also quality physical education teachers or teachers of other subjects. however, the primary responsibility of teachers is to fulfilling their duties as teacher, in this case committing to carrying out a quality cpe program. administrative support is also essential. based on my observations, too often the head of the physical education department is also the athletic director or the coach of a major sport. if innovative programs such as cpe are to be effectively implemented, it is my view that the department head should be a physical educator who does not have a coaching or other extracurricular assignment. her/his/their assignment is to administer and direct quality physical education programs. part of the administrative assignment must be holding teachers in the program accountable and making sure that they give a priority commitment to the teaching assignment for which the majority of the person's salary is paid. professional development. for those new to cpe, professional development is essential. teachers need updates on new information, including cpe content, methods, assessments, and technology. my surveys from the state conventions that i have keynoted indicate that few secondary school physical educators attend state conventions, often opting for coaching meetings instead. if cpe (and all of physical education for that matter) is to move forward, it is essential that secondary physical educators attend state conventions and other physical education professional development meetings. for students enrolled in physical education teacher education (pete) programs, a special course designed specifically to help them implement cpe should be offered. recommended content for teacher professional development and pete courses includes cpe instruction methods, content knowledge instruction, methods for overcoming barriers to success (e.g., teacher resistance, teacher workload, coach/teacher role conflict, and student resistance) . commitment to inclusion. the help philosophy emphasizes physical education for everyone and allows students to plan personal programs. to be consistent with this philosophy, programs must offer options for all students. cpe programs, for example, are planned using the universal design for learning framework . the framework helps to -improve and optimize teaching and learning for all people based on scientific insights into how humans learn‖ (p. ). in addition, programs and program planners can commit to diversity, equity, and inclusion consistent with statements such as the following from the american college of sports medicine (acsm): -we implore every human to go about their responsibilities and every other aspect of their daily lives, making decisions with social justice in their hearts and minds. the future of a pluralistic and just world depends on it!‖ (p. ). park notes that, as physical education develops in the future, -it may be useful to remember that medicine, an ancient and honored profession that many contend is the most valuable and venerated of the th century, was in a general state of disarray at the end of the th century‖(p. ). like medicine, the field of kinesiology was in disarray in the mid- th century but has made great strides in this century. a robust scientific base has been established, including, but not limited to, evidence that regular physical activity not only enhances fitness and performance but also reduces risk of chronic diseases and conditions (e.g., heart disease, diabetes, some cancers, osteoporosis, obesity). the covid- pandemic accentuated the fact that risk of serious complications and death from the virus are substantially higher among those with hypokinetic conditions. other benefits of physical activity (chronic and acute) include enhanced cognitive function, mental health, and wellness. we also have learned much about the science of human performance (mechanical, physiological, psychological, and sociological) and the science of physical education (sport) pedagogy. those of us who did our undergraduate study in health and physical education in the s did not benefit from the science now available to current and future teachers. texts in many of the subdisciplines did not become available until years later. scientific societies and many important journals were just being founded. earlier generations, however, did lay the groundwork for the dissemination of the new science. the modern profession of physical education, if built on a sound disciplinary foundation, has the opportunity to make strides similar to those made by medicine in the last century. it is interesting that the word doctor is derived from the latin word for teacher, docēre. physical educators do not practice medicine, but they teach. like medical doctors, it is important that they have a strong science background and the ability to pass what they know on to their students. cpe provides an effective platform for them to do so. in my years as an educator and researcher, and especially my years as an advocate for cpe, i have often been criticized and labeled as an opponent of skill learning and other worthy physical education objectives. i have also been accused of wanting to take the -physical‖ out of physical education. to be clear, while i do advocate for cpe as important component of a total quality physical education program, i also support participation in physical activities of all kinds. i support all of the objectives of physical education. i applaud quality skills instruction and instructional methods that foster moderate to vigorous physical activity (mvpa) in physical education. i believe in the importance of social-emotional learning programs that foster diversity and social justice. i endorse programs that help students to find meaning and enjoyment in movement and sport. there is room for them all. cpe is not an opponent of these efforts; it is an important partner. cpe programs that emphasize a knowledge base and that are consistent with peak principles do not distract from other programs-they complement them. students who have -learned to learn‖ are not only more likely to use what they have learned-they can generate their own new knowledge that will guide them in the future. as ennis suggests, engaging -students in a quest for knowledge about the effects of exercise on their bodies requires coordinated efforts by scientists and practitioners to build from kinesiology to society‖ (p. ) . as outlined in this article, there are many reasons for including cpe as part of a quality physical education program. simply put, if secondary physical education is to thrive in the future, we can and should make knowledge-based cpe programs a central component. if we are to become the renaissance profession of the st century, we must be strong in our trust in our science (knowledge) and strong in our conviction to chart a new course for the future based on our science. the advice of robert kennedy can guide us: -some people see things as they are and say why? i dream things that never were and say, why not?‖ table . physical education content standards and fitness education benchmarks. national physical education content standards fitness education instructional framework a standard : the physically literate individual demonstrates competency in a variety of motor skills and movement patterns. standard : the physically literate individual applies knowledge of concepts, principles, strategies and tactics related to movement and performance. standard : the physically literate individual demonstrates the knowledge and skills to achieve and maintain a health-enhancing level of physical activity and fitness. standard : the physically literate individual exhibits responsible personal and social behavior that respects self and others. standard : the physically literate individual recognizes the value of physical activity for health, enjoyment, challenge, self-expression and/or social interaction. technique: demonstrate competency in techniques needed to perform a variety of moderate to vigorous physical activities. knowledge: demonstrate understanding of fitness concepts, principles, strategies and individual differences. physical activity: participate regularly in fitnessenhancing physical activity. health-related fitness: achieve and maintain a health-enhancing level of health-related fitness. responsible personal and social behaviors: exhibit responsible personal and social behaviors in physical activity settings. values and advocates: values fitness-enhancing physical activity for disease prevention, enjoyment, challenge, self-expression, selfefficacy and/or social interaction. nutrition: strive to maintain healthy diet through knowledge, planning and regular monitoring. consumerism: access and evaluate fitness information, facilities, products, and services. a some fitness education instructional benchmarks were edited for brevity. based on school health policies and programs study (shpps) data . table . factors relating to effective delivery of conceptual physical education (cpe). in a mastery environment, the teacher reinforces efforts toward achieving specific learning goals. consistent with the help philosophy, there is an emphasis on the individual (personal learning). students learn and use selfmanagement skills to make personal decisions related to class content. in cpe, fitness assessments are self-assessments and are used as a basis for personal program planning. criterion-referenced, health-based fitness standards provide the basis for personal rather than comparative assessments. additional established assessment guidelines (e.g., confidentiality, not using fitness scores for grading) are adhered to. portfolios (print or digital) that include fitness and physical activity profiles provide evidence of student accomplishment. instruction focuses on higher-order objects as student's advance. students in cpe use previously learned information as a basis for future learning (vertical learning). some repetition is planned to foster mastery. horizontal learning, such as repeating instruction in the same activities, is contraindicated. when committing to a cpe model and adopting materials to carry out program goals, fidelity is important. staying on task is important for program success. note: the corona virus pandemic accentuated inequities when many schools used online platforms for remote learning. fig. conceptual physical education: the anatomy of an innovation the second years: or, can physical education become the renaissance field of the st century? knowledge, transfer, and innovation in physical literacy curricula exercise for a lifetime: an educational effort recreation and dance. health related physical fitness test manual the history of fitnessgram instructional framework for fitness education in physical education fitness for life society of health and physical educators effects of a concept-based physical education on middle-school students' knowledge, motivation, and out-of-school physical activity ‖ more than editions, and a half-century of effort! -an interview with dr. charles b. (chuck) corbin historical perspective and current status of the physical education graduation requirement at american -year colleges and universities the progression and characteristics of conceptually based fitness/wellness courses at american universities and colleges youth fitness, exercise and health: there is much to be done commentary on -children and fitness: a public health perspective health-based physical education the pill not taken: revisiting physical education teacher effectiveness in a public health context impact on schools: implications for curriculum physical education and its role in school health promotion a commentary on children and fitness: a public health perspective physical education's role in public health children and fitness: a public health perspective school physical education: secondary analysis of the school health policies programs study viral hepatitis, std, and tb prevention. trends in the prevalence of physical activity and sedentary behaviors national yrbs:  . available at conceptual physical education: a secondary innovation fitness for life personal fitness and you personal fitness: looking good-feeling good foundations of personal fitness fitness for life: middle school a state level update on secondary physical education policies (abstract) teaching physical lifeskills: practical ideas on health-related fitness aptidao fisica e saude nos programas de educacao fisica: desenvolvimentos recentes e tendencias internacionais fitness for life: physical education concepts fitness for life fitness for life canada: preparing teens for healthy, active lifestyles a dozen reasons for including conceptual physical education in a secondary program educating students for a lifetime of physical activity: enhancing mindfulness, motivation, and meaning moving into the future: national standards for physical education, a guide to content and assessment. reston, va: national association for sport and physical education va: national association for sport and physical education; . . society of health and physical educators. national standards and grade level outcomes for k- physical education concepts of physical education: what every student needs to know fitness for life: teacher's guide physical literacy, physical activity and health: toward an evidence-informed conceptual model implications of physical literacy for research and practice: a commentary international physical literacy association institute of medicine. health literacy: a prescription to end confusion ninth graders' energy balance knowledge and physical activity aehavior: an expectancyvalue perspective impact of education reforms: the quality of florida's high school physical education programs the science of healthful living learning science-based fitness knowledge in constructivist physical education impact of teacher value orientations on student learning in physical education american association for health, physical education, and recreation. youth fitness test manual american assc for health, physical education and recreation texas youth fitness study: a commentary presidential youth fitness program. presidential youth fitness program comprehensive school physical activity programs active and healthy schools fitness for life elementary school: guide for wellness coordinators the spark programs: a public health model of physical education dynamic physical education for elementary school children human kinetics; center for disease control and prevention. results from the school health policies and practices study an analysis of state physical education policies in physical education school physical activity policy what schools could be mission impossible? reflecting upon the relationship between physical education, youth sport and lifelong participation college physical education: an unrecognized agent of change in combating inactivity-related diseases gender differences in chronic disease risk behaviors through the transition out of high school tracking pedometer-determined physical activity: a -year follow-up study can conceptual physical education promote physically active lifestyles? physical activity participation of high school graduates following exposure to conceptual or traditional physical education effectiveness of secondary school conceptual physical education: a -year longitudinal study urban minority ninth-grade students' healthrelated fitness knowledge physical activity and fitness knowledge: how much - grade students know? physical activity and fitness knowledge in middle school physical education (abstract) fitness knowledge, cardiorespiratory endurance and body composition of high school students to move more and sit less: does physical activity/fitness knowledge matter in youth? determinants of exercise among children: ii. a longitudinal analysis health-related fitness knowledge and physical activity of high school students the effects of conceptually based physical education programs on attitudes and exercise habits of college alumni after to years of follow-up changes in healthy behaviour knowledge of rural pupils effects of florida's personal fitness course on cognitive, attitudinal and physical fitness measures of secondary students: a pilot study does cardiorespiratory fitness knowledge carry over in middle school students? two pathways underlying the effects of physical education on out-of school physical activity society of health and physical educators. school reentry considerations: k- physical education, health education, and physical activity american academy of physical education (currently the national academy of kinesiology). conceptual physical education. a position statement shape of the nation: status of physical education in the usa physical education website advanced-placement physical education: an opportunity to act a complete guide to sport education motivating middle school students: a health-club approach society of health and physical educators. guidelines for k- online physical education fitness for life: middle school interactive web text more than million children lack internet access at home for online learning jrotc as a substitute for pe: really? the udl guidelines physical education curriculum priorities: evidence for education and skillfulness speech at the university of kansas my thanks to ang chen, pam kulinna, bryan mccullick, and hans van der mars for their reviews of early versions of this manuscript. their time commitment and constructive comments are sincerely appreciated. the author declares that he has no competing interests. key: cord- - rohvqp authors: lee, alan title: covid- and the advancement of digital physical therapist practice and telehealth date: - - journal: phys ther doi: . /ptj/pzaa sha: doc_id: cord_uid: rohvqp nan during the covid- pandemic, each day challenges us with sobering realities in economy, health care, and politics in our society. the global pandemic has thrust the physical therapy profession and our society into digital physical therapist practice and telehealth. in light of the uncertainty with covid- , physical therapists are required to socially distance themselves at least feet apart in health care institutions, and patients and clients cannot access necessary physical therapy services in the community due to shelter-in-place and stay-at-home restrictions. furthermore, this unique situation magnifies the challenges and opportunities in digital practice, as practitioners may lack the necessary telehealth competencies identified in the literature. , therefore, it is especially important for physical therapy practitioners to consider key recommendations for safe and effective digital practice delivery. the purpose of this point of view is to identify recommendations on digital physical therapist practice and offer future directions in advancing digital practice and telehealth in the physical therapy profession in the wake of covid- . a joint digital physical therapy practice task force of the world confederation for finally, the task force agreed on service user as the term for actual or potential recipient of physical therapy services and defined in-person care as a situation in which both the provider and service user are in the same location at the same time. the task force described the advantages, limitations, current evidence, regulatory issues, academic implications, and recommendations for future opportunities in digital physical therapist practice prior to covid- . the advantages of digital practice were differentiated for service user, provider, and society. the common benefit for all stakeholders includes improved access to telehealth physical therapy services by building a strong relationship between service user and provider in order to deliver highquality and safe physical therapist practice via telehealth. covid- presents digital practice opportunities for improved access, high quality, and safety in physical therapy services for both service user and provider when deemed medically necessary. in fact, both telehealth and e-visits have been approved by the center for medicare and medicaid services (cms) in the united states during the covid- crisis on a temporarily basis. cms noted that telehealth services provided by interactive audio and video telecommunications systems permit real-time communication between end-to-end users, whereas e-visits are non-face-to-face, patient-initiated digital communications requiring a clinical decision that otherwise typically would have been provided in the office. however, specific federal and state payer guidelines, regulatory hurdles, and patient privacy barriers persist, requiring permanent fixes from cms on telehealth and e-visits. for example, health care providers on the front lines of covid- have identified that some older adults prefer telephone use to digital telecommunication interactions because of a lack of technology understanding and training. in order to address this immediate crisis and patient preferences, keesara and colleagues recommend expansion of telehealth broadly to include digital tools-beyond interactive audio and video-that offer -bit end-to-end encryption, including telephone services. other limitations include inadequate technology training, limited knowledge translation, and regulatory barriers that can stifle innovation and impede progress for service users and providers. dialogue among physical therapy practitioners, telemedicine providers, and payers can result in timely collaborative practice based on current evidence and societal needs in health care. with shelter-in-place and stay-at-home restrictions, digital practice is supported as the way forward, with many countries worldwide formally recognizing the benefits and value of using digital modes of care delivery. the body of evidence in relation to telerehabilitation is limited, however. telerehabilitation tends to require more provider time for consultations, and it is unclear whether telerehabilitation improves access to beneficial services. with paucity of definitive evidence in the wake of covid- , the joint task force believed it is not possible to recommend conditionspecific digital practice standards. hence, guiding principles should be reviewed by the physical therapy profession until such evidence is available. the task force developed each principle based on current practice, research, and regulatory considerations that may evolve over time (figure) . in summary, the guiding principles require strong provider-patient relationship, valid and reliable evidence, and the conduct of research to show whether telerehabilitation has greater benefit than potential risks for digital physical therapist practice. recently, wcpt identified resources including a tool kit for digital practice implementation, and wcpt recommendations have been translated in spanish for proper guidance in various member countries. in addition, the federation of state boards of physical therapy (fsbpt) provided jurisdiction telehealth laws and guidance for physical therapy providers in the united states. due to covid- , some of the regulatory issues have been waived at federal and state levels-including licensure, copays, and deductibles and expanded digital services with remote patient monitoring in the united states. because regulatory requirements are dependent upon factors in the legislative framework that exist globally, the best guidance is for providers to be informed of the legal framework that exists in each of their own jurisdictions and to be aware that, in some countries, providers have to take into account the jurisdiction of the service user's country. the task force identified global regulations in the digital landscape for australia, canada, the united kingdom, and the united states prior to covid- . moving forward, potential regulatory changes must be identified for individual countries in real time. therefore, practitioners should develop guidelines for selecting the ideal technology for the potential service user, risk management strategies, and competency training for digital physical therapist practice in emergent and nonemergent situations. prior to covid- , the implications of digital physical therapist practice for physical therapist education were investigated. although digital practice competency might prepare future providers for demands in primary care and might improve access to care in high-demand areas, the task force identified a lack of national digital practice answers to these questions must be addressed now in order to advance in digital physical therapist practice and telehealth. overall, the task force recognizes that the role of physical therapists must be advanced by informed practitioners in collaboration with physical therapy professional and international associations, accredited academic and research institutions, and patient advocacy groups. the time is now for the physical therapy profession to learn from the past and define its societal identity at large, because those who cannot remember the past are condemned to repeat it-even in the digital age. covid- -navigating the uncharted competencies required for nursing telehealth activities: a delphi-study it's not just facetime: core competencies for the medical virtualist world confederation for physical therapy and the international network of physiotherapy regulatory authorities. the report of the wcpt/inptra digital physical therapy american telemedicine association's principles for delivering telerehabilitation services apta covid- resources lessons from the front lines-cms covid- covid- and health care's digital revolution the current state of telehealth evidence: a rapid review telehealth tool kit. how to use telehealth for your patientsduring covid- spanish version of the digital practice survey report jurisdiction telehealth laws/guidance for pts and ptas preparing the healthcare workforce to deliver the digital future technology in rehabilitation: ethical and curricular implications for physical therapist education the great influenza: the epic story of the deadliest plague in history the authors thank richard woolf, pt, dpt, and leslie adrian, pt, dpt, mpa.keywords: covid- , telehealth, telemedicine, telerehabilitation, digital practice, technology accepted: april , submitted: april , key: cord- -r xgnz authors: yaacoub, jean-paul a.; salman, ola; noura, hassan n.; kaaniche, nesrine; chehab, ali; malli, mohamad title: cyber-physical systems security: limitations, issues and future trends date: - - journal: microprocess microsyst doi: . /j.micpro. . sha: doc_id: cord_uid: r xgnz typically, cyber-physical systems (cps) involve various interconnected systems, which can monitor and manipulate real objects and processes. they are closely related to internet of things (iot) systems, except that cps focuses on the interaction between physical, networking and computation processes. their integration with iot led to a new cps aspect, the internet of cyber-physical things (iocpt). the fast and significant evolution of cps affects various aspects in people’s way of life and enables a wider range of services and applications including e-health, smart homes, e-commerce, etc. however, interconnecting the cyber and physical worlds gives rise to new dangerous security challenges. consequently, cps security has attracted the attention of both researchers and industries. this paper surveys the main aspects of cps and the corresponding applications, technologies, and standards. moreover, cps security vulnerabilities, threats and attacks are reviewed, while the key issues and challenges are identified. additionally, the existing security measures are presented and analyzed while identifying their main limitations. finally, several suggestions and recommendations are proposed benefiting from the lessons learned throughout this comprehensive review. cyber physical systems (cps) are designated as essential components of the industrial internet of things (iiot), and they are supposed to play a key role in industry v . . cps enables smart applications and services to operate accurately and in real-time. they are based on the integration of cyber and physical systems, which exchange various types of data and sensitive information in a real-time manner [ ] . the development of cps is being carried out by researchers and manufacturers alike [ ] . given that cps and industry v . offer a significant economic potential [ ] , the german gross value will be boosted by a cumulative of billion euros by upon the introduction of cps into industry v . [ ] . a cps is identified as a network of embedded systems that interact with physical input and output. in other words, cps consists of the combination of various interconnected systems with the ability to monitor and manipulate real iotrelated objects and processes. cps includes three main central components: sensors, aggregators and actuators. moreover, cps systems can sense the surrounding environment, with the ability to adapt and control the physical world [ ] . this is mainly attributed to their flexibility and capability to change the run-time of system(s) process(es) through the use of realtime computing [ ] . in fact, cps systems are being used in multiple domains (see fig. ), and embedded in different systems such as power transmission systems, communication systems, agricultural/ecological systems, military systems [ ] , [ ] , and autonomous systems (drones, robotics, autonomous cars, etc.) [ ] , [ ] . that, in addition to medical care domains to enhance the medical services [ ] . moreover, cps can be used in supply chain management to enable echo-friendly, transient, cost efficient, and safe manufacturing process. despite their numerous advantages, cps systems are prone to various cyber and/or physical security threats, attacks and challenges. this is due to their heterogeneous nature, their reliance on private and sensitive data, and their large scale deployment. as such, intentional or accidental exposures of these systems can result into catastrophic effects, which makes it critical to put in place robust security measures. however, this could lead to unacceptable network overhead, especially in terms of latency. also, zero-day vulnerabilities should be minimized with constant software, applications and operating system updates. recently, several research works addressed the different security aspects of cps: the different cps security goals were listed and discussed in [ ] , [ ] , [ ] , [ ] ; maintaining cps security was presented in [ ] ; cps security challenges and issues were presented in [ ] , [ ] ; some of the security issues were reviewed, including big data security [ ] , [ ] , iot storage issues [ ] , and operating system vulnerabilities [ ] ; several security and privacy solutions using cryptographic algorithms and protocols were discussed in [ ] , [ ] . however, none of the existing works presented a comprehensive view of cps security in terms of threats, vulnerabilities, and attacks based on the targeted domain (cyber, physical, or hybrid). hence, this paper presents a detailed overview of the existing cyber, physical and hybrid attacks, and their security solutions including cryptographic and non-cryptographic ones. • cyber-physical attacks are presented in relation to the targeted cyber and/or physical system/device, and the corresponding vulnerabilities of each such domain. • risk assessment: a qualitative risk assessment method is presented to evaluate the risk and exposure levels for each cps system, while proposing suitable security countermeasures. • security measures and their limitations are discussed and analyzed, including recent cryptographic and noncryptographic solutions. • forensics solutions are also presented and discussed about securely extracting evidence and thus, to improve forensics investigations. • lessons: various lessons are learnt throughout this survey including how to protect real-time data/information communication among resource-constrained cps devices, and how to achieve protection of cps security goals such as confidentiality, integrity, availability and authentication. • suggestions & recommendations are presented about how to mitigate and overcome various cyber, physical and hybrid threats, vulnerabilities, attacks, challenges and issues for a safe cps environment. aside from the introduction, this paper is divided into six main sections as follows. section ii presents some background about cps including their layers, components, and models. section iii discusses and details the key cps threats, attacks and vulnerabilities in addition to listing and describing several real-case cps attacks, and the main persistent challenges and issues. section v assesses and evaluates the risks associated with cps security attacks, especially in a qualitative risk assessment manner. section v presents and analyzes the main cps security solutions including cryptographic, noncryptographic, and forensics ones. section vi highlights the lessons learnt throughout this study. section vii provides key suggestions and recommendations for a safe and secure cps environment. section viii concludes the presented work. in this section, we present the cps architecture, its main layers and components, as well as the main cps models. the architecture of cps systems consists of different layers and components, which rely on different communication protocols and technologies to communicate among each other across the different layers. ) cps layers: the cps architecture consists of three main layers, the perception layer, transmission layer, and application layer, which are presented and described in fig. . the analysis of the security issues at the various cps layers is based on the work in [ ] . • perception layer: it is also known as either the recognition or the sensing layer [ ] . it includes equipment such as sensors, actuators, aggregators, radio-frequency identification (rfid) tags, global positioning systems (gps) along with various other devices. these devices collect real-time data in order to monitor, track and interpret the physical world [ ] . examples of such collected data include electrical consumption, heat, location, chemistry, and biology, in addition to sound and light signals [ ] , depending on the sensors' type [ ] . these sensors generate real-time data within wide and local network domains, before being aggregated and analyzed by the application layer. moreover, securing actuators depends on authorized sources to ensure that both feedback and control commands are error-free and protected [ ] . generally, increasing the security level requires an endto-end encryption scheme at each layer [ ] . therefore, heavyweight computations and large memory requirements would be introduced [ ] . in this context, there is a need for the design of efficient and lightweight security protocols, which take into consideration the devices capabilities and the security requirements. • transmission layer: it is also known as the transport layer or network layer, and it is the second cps layer [ ] . this layer interchanges and processes data between the perception and application layers. data transmission and interaction is achieved through the internet for this purpose, various protocols are used to address the increase in the number of internet-connected devices, such as the internet protocol version (ipv ) [ ] . this layer also ensures data routing and transmission using cloud computing platforms, routing devices, switching and internet gateways, firewalls and intrusion detection/prevention systems (ids/ips) [ ] , [ ] . before outsourcing data contents, it is essential to secure their transmission to prevent intrusions and malicious attacks including malware, malicious code injection [ ] , denial of service/distributed denial of service (dos/ddos), eavesdropping, and unauthorised access attacks [ ] . this introduces a challenge, especially for resource-constrained devices due to the imposed overhead in terms of the required processing and power resources [ ] . • application layer: it is the third and most interactive layer. it processes the received information from the data transmission layer and issues commands, which are executed by the physical units including sensors and actuators [ ] . this is done by implementing complex decision-making algorithms based on the aggregated data [ ] . moreover, this layer receives and processes information from the perception layer before determining the rightly invoked automated actions [ ] . in fact, cloud computing, middleware, and data mining algorithms are used to manage the data at this layer [ ] . protecting and preserving privacy requires protecting private data from being leaked. the most known protective approaches include anonymization, data masking (camouflage) [ ] , [ ] , privacy-preserving, and secret sharing [ ] . moreover, this layer also requires a strong multi-factor authentication process to prevent unauthorised access and escalation of privilege [ ] . due to the increase in the number of internet-connected devices, the size of the generated data has become a significant issue [ ] . therefore, securing big data calls for efficient protection techniques to process huge amounts of data in a timely and efficient manner [ ] . ) cps components: cps components are used for sensing information [ ] , or for controlling signals (fig. ) . in this regard, cps components are classified into two main categories: sensing components (sc) that collect and sense information, and controlling components (cc) that monitor and control signals. • sensing components: are primarily located at the perception layer and consist of sensors that collect data/information and forward them to aggregators. then, this data/information is sent to the actuators for further analysis to ensure accurate decision making. in the following, we list the main cps sensing components. -sensors: collect and record real-world data following a correlation process named "calibration", to assess the correctness of the collected data [ ] . sensing data is essential since the decisions that will be made are based on the analysis of this data. -aggregators: are primarily located at the transmission layer (i.e routers, switches and gateways) to process the received data/information from sensors, before issuing the corresponding decision(s). in fact, data aggregation is based on the collected information about a specific target, where this information is gathered and summarized following a statistical analysis. online analytical processing (olap) is a prime data aggregation type used as an online reporting mechanism for processing information [ ] . -actuators: are located at the application layer to make the information visible to the surrounding environment based on the decisions made by the aggregators. since actuators highly depend on other network nodes, then each action performed by the cps relies on an earlier data aggregation sequence [ ] . also in terms of operations, actuators process electrical signals as input and generate physical actions as output [ ] . • controlling components: are used to control signals and they play a key role in signal control, monitoring and management to achieve higher levels of accuracy and protection against malicious attacks or accidents, mainly signal jamming, noise and interference. as a result, the reliance on programmable logic controllers (plcs) and distributed control system (dcss) along with their components (i.e programmable automation controller (pac) [ ] , operational technology/information tech-nology (ot/it) [ ] , control loop/server [ ] , and human-machine interface (hmi)/graphical user interface (gui) [ ] ) has become highly essential. next, we list the different types of control systems that are used in cps systems: • programmable logic controllers (plc): were initially developed to replace hard-wired relays, and are considered as industrial digital computers that control the manufacturing processes such as robotic devices performance and/or fault diagnosis processing; hence achieving better flexibility and resiliency. • distributed control systems (dcs): are computerized control systems that allow the autonomous controllers' distribution throughout the system using a central operator supervisory control. as a result of the remote monitoring and supervision process, the dcs's reliability is increased, whilst its installation cost is reduced. in some cases, dcs can be similar to supervisory control and data acquisition (scada) systems. • remote terminal units (rtu): or "remote telemetry unit" [ ] , are electronic devices controlled by a microprocessor such as the master terminal unit (mtu) [ ] . unlike the plc, they do not support any control loop nor control algorithm(s). thus, making them more suitable for wireless communications over wider geographical telemetry areas. rtu's main task is to interface scada to the physical object(s) using a supervisory messaging system that controls these objects through the system's transmission of telemetry data. in fact, both rtus and plcs use a small computerized "artificial brain" (central processing unit (cpu)) to process inputs and outputs from sensing devices and pumping equip-ment [ ] ; hence using ieds (intelligent electronic devices) to transmit data flow or trigger an alarm in case of any intrusion. table i presents a comparison of the common points and differences between plcs and rtus. concerning the relation between components and layers, it can be seen that sensing components are mainly deployed at the perception and transmission layers, while the controlling components are deployed at the application layer. cps models can be divided into three main types: • timed actor cps: this model focuses on the functional aspects based on behaviour and correctness, along with the non-functional aspects that are based on performance and timing. a theory was introduced in [ ] with a functional and classical refinement that restricts certain behaviour set, improving efficiency while reducing complexity. the main focus is on the refinement based on the "earlier-the-better" principle since it offers the ability to identify deterministic abstractions of non-deterministic systems [ ] . in fact, these time-deterministic models are less prone to state explosion problems, with the ability to derive analytical bounds easier [ ] . • event-based cps: in such models, an event must be sensed and detected by the proper cps components, before the actuation decisions are made. however, individual component timing constraints vary depending on the non-deterministic system delay, which is caused by the different cps actions including sensing, actuating, communication and computing [ ] . in [ ] , hu et al. stated that time constraints can be handled through the use of an event-based approach, which uses cps events to ensure the system's communication, computation, and control processes. this allows the cps to be more suitable and more useful for spatio-temporal information. • lattice-based event model in [ ] , the cps events are represented according to the event type, along with the internal and external event attributes. if these events are combined, they can be used to define a spatio-temporal property of any given event, while also identifying all the components that were observing the event. • hybrid-based cps model hybrid cps systems are heterogeneous systems that are made up of two distinct interactive system types, continuous state (physical dynamic systems) and discrete-state (discrete computing systems) [ ] , [ ] . both development and evolution depend on the response of discrete transient events represented by finite state machines, and the the dynamic behaviour represented by differential/difference equation(s) [ ] . unlike other cps models, hybrid cps is interconnected via a network, which makes it prone to delays. moreover, hybrid cps systems do not support any hierarchical modeling, and are not suitable for modeling concurrent systems. hence, hybrid systems modeling challenges caused by cps were discussed by benveniste et al. in [ ] . in fact, cps system network latency issues were addressed and solved by kumar et al. using a real-time hybrid authentication method [ ] , while a configurable real-time hybrid structural testing for cps was presented by tidwell et al. in [ ] . finally, an event driven monitoring of cps based on hybrid automata was presented by jianhui in [ ] . in a similar manner to most networking systems, security services were not incorporated into cps systems by design, leaving the door open for various vulnerabilities and threats to be leveraged by attackers to launch security attacks. this is also due to the heterogeneous nature of cps devices since they operate in different iot domains and communicate using different technologies and protocols. cps security threats can be classified as cyber or physical threats, as explained below, and if combined, these can result into cyber-physical threats. ) cyber threats: the main attention on industrial iot security was highly focused on cyber threats rather than physical threats for many reasons, as cited in [ ] . this includes the electrical grid evolution into an advanced metering infrastructure (ami), which resulted into the rise of newly unknown cyber threats aside from scada vulnerabilities [ ] , [ ] , [ ] . electronic attacks are now easier to launch from any device, unlike physical attacks that require physical presence and physical tools. moreover, the smart meter interfacing and interconnection with other meters in the near-me area network (nan) and home area network (han) increase its exposure to various remote threats. finally, electronic attacks are difficult to mitigate and overcome in the absence of the right prevention and defensive countermeasures. for further details on cyber threat intelligence, a brief survey of cps security approaches was presented in [ ] . for further information about cyber security threats, more details can be found in [ ] , [ ] . since cyber security is not limited to a single aspect, it can be considered from different perspectives, such as: • centring information: which requires protecting the data flow during the storage phase, transmission phase, and even the processing phase. • oriented function: which requires integrating the cyberphysical components in the overall cps. • oriented threat: which impacts data confidentiality, integrity, availability, and accountability [ ] . the above issues make cps systems prone to: • wireless exploitation: it requires knowledge of the system's structure and thus, exploiting its wireless capabilities to gain remote access or control over a system or possibly disrupt the system's operations. this causes collision and/or loss of control [ ] . • jamming: in this case, attackers usually aim at changing the device's state and the expected operations to cause sold with plc-like features digital computers designed for output arrangements and multiple inputs electronic device controlled by a microprocessor automates electro-mechanical processes interfaces scada physical objects physical media with process, relays, motion control and networking uses supervisory system messages to control objects does support control loops and algorithms does not support control loops and algorithms immune to electrical noise, resistant to vibration low to null immunity against electrical noise and vibration suitable for local geographical areas suitable for wider geographical telemetry areas mainly iec standards wired/wireless communications damage by launching waves of de-authentication or wireless jamming signals, which would result into denial of device and system services [ ] . • reconnaissance: an example of such a threat is where intelligence agencies continuously perform operations targeting a nation's computational intelligence (ci) and industrial control system (ics) mainly through a malware spread [ ] . this results in violating data confidentiality due to the limitation of traditional defenses [ ] , [ ] . • remote access: this is mainly done by trying to gain remote access to the cps infrastructure, for example, causing disturbances, financial losses, blackouts, as well as industrial data theft and industrial espionage [ ] . moreover, havex trojans are among the most dangerous malware against icss, as they can be weaponized and used as part of cyber-warfare campaign management against a nation's cps [ ] . • disclosure of information: hackers can disclose any private/personal information through the interception of communication traffic using wireless hacking tools [ ] , violating both privacy and confidentiality [ ] . • unauthorised access: attackers try to gain an unauthorized access through either a logical or physical network breach and to retrieve important data, leading to a privacy breach [ ] . • interception: hackers can intercept private conversations through the exploitation of already existing or new vulnerabilities leading to another type of privacy and confidentiality breach [ ] . • gps exploitation: hackers can track a device or even a car by exploiting (gps) navigation systems, resulting in a location privacy violation [ ] , [ ] . • information gathering: software manufacturers covertly gather files and audit logs stored on any given device in order to sell this huge amount of personal information for marketing and commercial purposes in an illegal manner. ) physical threats: cps systems are recently evolving into the industrial domain by introducing an advanced metering infrastructure (ami), and neighbourhood area networks (nans), along with data meter management systems to maintain the robustness of cps in industrial domains [ ] . in fact, physical threats might be classified according to the following three factors: are well protected. this is due to the fact that these stations are well-manned and well-guarded based on the implementation of access controls, authorisation and authentication mechanisms such as usernames and passwords, access cards, biometrics and video surveillance. however, the main concern is related to the less protected power-generating sub-stations since transmission lines are vulnerable to sabotage attacks and disruption. in fact, smart meters are also vulnerable to a number of threats as explained in [ ] . to address this problem, smart meters must be tamper-resistant by relying on outage detection or even host-based intrusion detection. however, it is almost impossible to prevent physical tampering or theft by adversaries (such as advanced persistent threats (apts)), except that it is possible to mitigate the risk and reduce its impact. • loss: the most worrying scenario is having more than a single substation failure caused by a malicious attacker. in case of a severe damage in the smart grid, a total blackout of major metropolitan areas may occur for several hours [ ] . a real-case scenario includes the cascading blackout that managed to hit the u.s. on august th, [ ] , caused by the people liberation army (pla), which is a chinese politically-motivated group [ ] . • repair: it can be based on a self-healing process [ ] , which is based on the ability to either sense faults or disruptions, whilst isolating the problem and sending alerts to the corresponding control system to automatically reconfigure the back-up resources in order to continuously provide the necessary service. the aim is to ensure a fast recovery in as short of a time as possible. however, critical components do suffer from either a lack or a limited backup capability. therefore, self-healing can respond faster to a severe damage. some of the threats associated with cps systems include: • spoofing: it consists of masquerading the identity of a trusted entity by a malicious unknown source. in this case, attackers are capable of spoofing sensors, for example, by sending misleading and/or false measurements to the control center. • sabotage: sabotage consists of intercepting the legal communication traffic and redirecting it to malicious third party or disrupting the communication process. for example, attackers can sabotage physically exposed cps components across the power grid, to cause a service disruption or even denial of service that leads to either total or partial blackout. • service disruption or denial: attackers are capable of physically tampering with any device to disrupt a service or to change the configuration. this has serious effects, especially in the case of medical applications. • tracking: since devices are physically exposed, an attacker can gain access to a given device, and/or even attach a malicious device or track the legal ones. in the following, we present the main cps vulnerabilities that can be targeted by the above-mentioned threats. a vulnerability is identified as a security gap that can be exploited for industrial espionage purposes (reconnaissance or active attacks). hence, a vulnerability assessment includes the identification and analysis of the available cps weaknesses, while also identifying appropriate corrective and preventive actions to reduce, mitigate or even eliminate any vulnerability [ ] . in fact, cps vulnerabilities are divided into three main categories: • network vulnerabilities: include weaknesses of the protective security measures, in addition to compromising open wired/wireless communication and connections, including man-in-the-middle, eavesdropping, replay, sniffing, spoofing and communication-stack (network/transport/application layer) [ ] , back-doors [ ] , dos/ddos and packet manipulation attacks [ ] . • platform vulnerabilities: include hardware, software, configuration, and database vulnerabilities [ ] . • management vulnerabilities: include lack of security guidelines, procedures and policies. vulnerabilities occur due to many reasons. however, there are three main causes of vulnerabilities: • assumption and isolation: it is based on the "security by obscurity" trend in most cps designs. therefore, the focus here is to design a reliable and safe system, taking into consideration the implementation of necessary security services, without assuming that systems are isolated from the outside world. • heterogeneity: cps systems include heterogeneous third party components which are integrated to build cps applications. this has resulted in cps becoming a multivendor system, where each product is prone to different security problems [ ] . • usb usage: this is a main cause of cps vulnerabilities, such as the case of the stuxnet attack that targeted iranian power plants, since the malware is inside the usb. upon plugging it, the malware spread across several devices through exploitation and replication. • bad practice: is primarily related to a bad coding/weak skills that lead to the code to execute infinite loops, or to become too easy to be modified by a given attacker. • spying: cps systems are also prone to spying/surveillance attacks, mainly by using spyware (malware) types that gain a stealthy access and remain undetected for years with the main task to eavesdrop, steal and gather sensitive/confidential data and information. • homogeneity: similar cyber-physical system types suffer from the same vulnerabilities, which once exploited, can affect all the devices within their vicinity, a prime example is the stuxnet worm attack on iranian nuclear power plants [ ] . • suspicious employees: can intentionally or inadvertently damage or harm cps devices, by sabotaging and modifying the coding language, or granting remote access to hackers through the opening of closed ports or plugging in an infected usb/device. thus, cps vulnerabilities can be of three types, including cyber, physical, and when combined, they result into a cyberphysical threat. ) cyber vulnerabilities: since ics heavily relies on open standard protocols including inter-control center communications protocol (iccp) [ ] and transmission control protocol/internet protocol (tcp/ip) [ ] , ics applications are prone to security attacks. in fact, iccp suffers from a critical buffer overflow vulnerability [ ] and also lacks the basic security measures [ ] . in fact, the remote procedure call (rpc) protocol [ ] and icss are prone to various vulnerabilities including the stuxnet ( & ) [ ] , [ ] , [ ] and duqu malware ( . , . & . ) attack types [ ] , [ ] , [ ] , gauss malware [ ] , [ ] , [ ] , and red october malware [ ] , [ ] , as well as shamoon malware ( , & ) [ ] , [ ] , [ ] , mahdi malware [ ] , [ ] , [ ] , and slammer worm [ ] . open/non-secure wired/wireless communications such as ethernet are vulnerable to interception, sniffing, eavesdropping, wiretapping and wardialing and wardriving attacks [ ] , [ ] , [ ] and meet-in-the-middle attacks [ ] . short-range wireless communications are also vulnerable, since they can be captured, analysed, damaged, deleted or even manipulated by insiders [ ] . moreover, employees' connected devices to ics wireless network, if not secure, are prone to botnet, remote access trojan and rootkit attacks, where their devices will be remotely controlled by an attacker [ ] . long-range wireless communications are vulnerable to eavesdropping, replay attacks, and unauthorized access attacks. yet, sql injection remains the most web-related vulnerability since attackers can access any server database without authorization through the injection of a malicious code that keeps on running endlessly once executed without the user's knowledge [ ] . since many medical devices heavily rely on wireless communications, they are prone to a large number of wireless attacks including jamming, modification and replay attacks due to the lack of encryption. moreover, gps and the device's microphone are now becoming a tracking tool, allowing the identification of the target's location, or intercepting the in-car conversations through eavesdropping [ ] . by default, ics relies on modbus and dnp protocols to monitor and send control commands to sensors and actuators. in [ ] , humayed et al. stated that the modbus protocol lacks basic security measures such as encryption, authentication and authorization. this has made it prone to eavesdropping, wiretapping, and port-scan [ ] , with the risk of the controller being spoofed through false data injection [ ] . the dnp protocol is also prone to the same vulnerabilities and attacks, with one main difference which is the integration of cyclic redundancy check (crc) as an integrity measure [ ] . moreover, windows server services were vulnerable to remote code execution [ ] , with more attacks being achieved through the exploitation of buffer overflow vulnerabilities in any running operating system (os). moreover, power system infrastructure of smart grids is prone to the same vulnerabilities as ics, modbus and dnp , since they are based on the same protocols. as a result, iec protocol was introduced in substations' communications, which lack security properties and are prone to eavesdropping attacks. therefore, leading to interference attacks [ ] , or false information injection attacks [ ] . in [ ] , santamarta et al. analysed the available documentation of smart meters, and located a "factory login" account used to perform basic configurations. this gives the user full control over a smart meter and leads to power disruption, wrong decision making and targeting neighbouring smart meters within the same network. in addition, many devices are prone to battery exhausting attacks [ ] . gollakota et al. [ ] and halperin et al. [ ] exploited the implantable cardioverter defibrillator (icd) wireless vulnerabilities through injection attacks. the authors also showed that smart cars are vulnerable to various attack types. in [ ] , radcliffe, revealed another vulnerability with continuous glucose monitoring (cgm) devices being vulnerable to replay attacks. the cgm device was spoofed with the injection of incorrect values. this is due to the fact that security considerations were not made when the smart cars were designed [ ] . in fact, the controller area network (can) protocol suffers from many vulnerabilities, which if exploited could result in attacks against smart cars. this will increase the likelihood of a dos attack [ ] . a tire-pressure monitoring system (tpms) is also vulnerable to eavesdropping and spoofing due to the lack of encryption [ ] . in addition, adaptive cruise control (acc), which forms a part of the can network can be directly exploited [ ] . in fact, a well-equipped attacker is able to interrupt acc sensors' operations by adding noise or spoofing. thus, controlling the car by either reducing, increasing its speed or even causing collisions. ) physical vulnerabilities: physical tampering may result into misleading data in cyber-physical components. in fact, physical attacks with cyber impact were studied in [ ] . the physical exposure of ics components is classified as a vulnerability due to the insufficient physical security provided to these components. thus, making them prone to physical tampering, alteration, modification or even sabotage. cps field devices (i.e smart grids, power grids, supply chains etc.) are prone to the same ics vulnerabilities since a large number of physical components is exposed without physical security, making them prone to physical destruction. therefore, in [ ] , mo et al. stressed on detection and prevention solutions. in [ ] , humayed et al. stated that medical devices are vulnerable to physical access along with the possibility of installing malware into them, or even modifying the device's configurations, risking the patient's health. moreover, a physical access to any medical device is also a vulnerability since an attacker can retrieve the device's serial number to launch targeted attacks [ ] . as listed above, cps systems suffer from various vulnerabilities making them prone to different types of attacks, which are discussed next. in this section, we present the different types of attacks that target the different aspects of cps systems, including cyber and physical ones: ) physical attacks: physical attacks were more active in past years, especially against industrial cps systems [ ] , [ ] . many of these attacks were already presented in [ ] . nonetheless, this paper presents a broader range of physical attack types: • infected items: this includes infected cds, usbs, devices and drives such as the case of the stuxnet worm [ ] , which upon their insertion into a cyberphysical device, a covert malware is installed containing a malicious software. • abuse of privilege: this attack occurs when rogue or unsatisfied employees access the server rooms and installation areas within the cps domain. this allows them to insert a rogue usb for infection through the installation of malicious malware/code or as keystroke, or to capture confidential data. • wire cuts/taps/dialing: since communication lines including telephony and wi-fi of many cyber-physical headquarters (hqs) are still physically visible, attackers can cut the wires or wiretap into them to intercept the communicated data [ ] . • fake identity: this attack occurs when attackers masquerade themselves as legitimate employees, with enough experience to fool the others. they mainly act as cleaners to gain an easier access and better interaction with other employees. a prime example of that is australia's maroochy water breach in [ ] . • stalkers: these are usually legal employees who act curious (with malicious intents) by being on the shoulder of cps administrators and engineers to acquire their credentials to blackmail or sell them to other competing cps organisations. • cctv camera interception: this includes intercepting the footage of closed-circuit television cameras that are securing entry and key points within cps areas. this can be done by distorting the signals of cameras, cutting off the communication wires, deleting the footage, gaining access to the remote control and monitoring area, etc., before performing a physical attack in an undetected manner. • key-card hijacking: this includes cloning legitimate cards that are stolen from employees, or creating lookalike genuine copies to gain full/partial access and to compromise the cps domain. • physical breach: this attack requires gaining an illegal physical access to the system, mainly through a physical breach such as the case of the springfield pumping station in [ ] , a backdoor such as the case of us georgia water treatment plant in [ ] , or an exploited security gap such as the case of the canadian telvent company in [ ] . this allows an attacker to damage and shut-down network-connected manufacturing systems and cps devices, resulting into loss of availability and productivity. • malicious third party software provider: the main purpose of this attack is to target the company's cps by compromising the legitimate "industrial control systems" software, such as the case of the georgia nuclear power plant shutdown in [ ] . this includes replacing legitimate files in their repositories with a malware that will be installed to offer remote access functionalities to control or compromise a given system. • abuse of privilege: is mainly led by insiders or "whistleblowers" to perform or help perform a (cyber)-attack from within. such high privilege grants them the ability to conduct these attacks by exposing valuable knowledge on cps systems' vulnerabilities and weaknesses. this abuse of privilege can take many forms. -physical tampering: including gaining unauthorised or masqueraded authorised access to restricted areas to damage cps systems, devices, modify their operational mode, inject malicious data/information or steal confidential documents. -unauthorised activities: are based on performing suspicious tasks, such as opening/closing pumping stations, increasing/decreasing power voltage, opening closed ports, communicating with an external entity, network traffic redirection or information leakage. • social engineering: can take many deceptive forms [ ] such as reverse engineering (impersonating a techysavvy), baiting (selling malicious usbs or software), tailgating (following authorised personnel) or quid pro quo (impersonating technical support teams), and is based on the art of manipulating people (either mentally or emotionally) to reveal confidential information by manipulating their emotions to gain their trust to reveal sensitive information related to a cps, plc or ics system. recently, cps systems became the new target of hackers for espionage, sabotage, warfare, terrorism, and service theft [ ] , mainly as part of cyber-warfare [ ] , cybercrimes [ ] , [ ] , (cyber)-terrorism [ ] , [ ] , [ ] , (cyber)-sabotage [ ] (such as cyber-attacks against estonia in [ ] , and georgia in [ ] ), or (cyber)espionage [ ] , [ ] . the lack of (cyber)-security revealed a serious issue with possibly drastic effects [ ] , especially in countries like lebanon [ ] , [ ] . ) cyber attacks: in recent years, there was a rise in the rate of cyber-attacks targeting cps and iocpt with very devastating consequences. according to current studies carried out by [ ] , [ ] , cps is highly prone to malicious code injection attacks [ ] and code-reuse attacks [ ] , along with fake data injection attacks [ ] , zero-control data attacks [ ] , and finally control-flow attestation (c-flat) attacks [ ] . such attacks can result into a total blackout targeting cps industrial devices and systems as presented in table ii. • eavesdropping: eavesdropping includes the interception of non-secure cps network traffic to obtain sensitive information (passwords, usernames, or any other cps information). eavesdropping can take two main forms:passive by listening to cps network message transmission, and active by probing, scanning or tampering the message by claiming to be a legitimate source. • cross-site scripting: or xss occurs when third-party web resources are used to run malicious scripts in the targeted victim's web browser (mainly a targeted cps engineer, contractor, workers, etc. ) by injecting malicious coding script into a website's database. xss can achieve session hijacking, and in some cases, can log key strokes along and remotely accesses a victim's machine. • sql injection: or sqli targets cps database-driven websites to read and/or modify sensitive data, along possibly executing administrative operations such as database shutdown, especially when cps systems are still relying on sql for data management [ ] . • password cracking: aim to target the authenticity of cps users [ ] , [ ] (mainly engineers and managers) by trying to crack their passwords using bruteforce [ ] , dictionary [ ] (mitigated by using key exchange [ ] ), rainbow table [ ] , birthday (mitigated by hashing) [ ] or online/offline password guessing attacks [ ] to gain access to the password database, or to the incoming/outgoing network traffic. therefore, it is important to prevent such escalation from taking place [ ] , [ ] . • phishing: has many types such as e-mail phishing, vishing, spear phishing or whaling that target some or all cps users (such as engineers, specialists, businessmen, chief executive officers (ceos), chief operations officers (coo), or/and chief financial officers (cfo)), through impersonation of business colleagues or service providers. • replay: includes intercepting transmitted/received packets between icss, rtus, and plcs through impersonation to cause delays that affect cps's real-time operations and affect their availability. in some cases, these intercepted packets can be modified, which would seriously hinder normal operations. • dos/ddos: dos attacks target the cyber-physical system resources and are launched from a large number of locally infected devices. ddos attacks are usually exploited by botnets, whereby a large number of infected devices simultaneously launch a ddos attack from different geo-graphical locations. dos attacks can take many forms (i.e blackhole [ ] , teardrop [ ] ), while ddos can take the following forms (i.e ping-of-death [ ] , smurf [ ] and black energy series (be- , be- and be- [ ] , [ ] , [ ] ), all targeting cps systems. -tcp syn flood: exploits the tcp handshake process by constantly sending requests without responding back to the server, causing the server to constantly allocate space awaiting a reply [ ] . this leads to a buffer overflow and causes the cyberphysical system to crash. • malicious third party: includes software that covertly exploit data aggregation network and compromises them, mainly using botnets, trojans or worms to infiltrate information through a cps encrypted channel from an internal system (i.e plc, ics or rtu) through the reliance on trusted third party in disguise, to a botnet commandand-control server. thus, targeting cpss [ ] and amis [ ] . • watering-hole attack: the attacker scans for any cyberphysical security weakness. once a weakness is identified, the chosen cps website will be manipulated by a "watering hole", where a malware will delivered by exploiting the targeted cps system mainly through backdoor, rootkits or zero-day exploit [ ] . • malware: is used to compromise cps devices in order to steal/leak data, harm devices or bypass access control systems. the malware can take many forms, however, the main forms that target cps are briefly listed and presented in the following. -botnets: this includes exploiting cps devices vulnerabilities to turn them into bots or zombies, mainly to conduct hardly-traceable ddos attacks (i.e ramnit ( ) [ ] , mirai ( ) [ ] , smominru botnet ( ) [ ] , mootbot ( ) [ ] , wild-pressure and victorygate ( ).) -trojan: is a disguised malware that seems legitimate and tricks users to download it. upon download, the trojan infects the device and offers a remote access to steal data credentials and monitor users activities. this also includes remote access trojans which in turn, can be used to turn a device into a bot (i.e turla ( ) [ ] , minipanzer/megapanzer ( ) [ ] , gh st rat ( ) [ ] , shylock ( ) [ ] , coreflood ( ) [ ] , darkcornet ( ) [ ] , memz ( ) [ ] , tinybanker ( ) [ ] and banking.br android botnet ( )). -virus: it can replicate and spread to other devices through human/non-human intervention. viruses spread by attaching themselves to other executable codes and programs to harm cps devices and steal information. -worms: spread by exploiting operating system vulnerabilities to harm host networks by carrying payloads to steal, modify and delete data, or overload to web-servers (aside stuxnet, flame and duqu, i.e acode red/code red ii ( ) [ ] , nimda ( ) [ ] , triton ( [ ] )). -rootkit: is designed to remotely and covertly access or control a computer to execute files, access/steal information or modify system configurations (i.e moonlight maze ( ) [ ] , and blackhole exploit kit ( ) [ ] ). -polymorphic malware: constantly and frequently changes its identifiable to evade being detected to become unrecognizable against any pattern-matching detection technique. -spyware: is a malicious software covertly installed on a device without the user or authorization knowledge, for spying purposes (e.g surveillance, reconnaissance, or scanning). in fact, they can be used for future cyber-attack purposes (i.e projectsauron ( ) [ ] , dark caracal ( ) [ ] , red october ( ) [ ] , warriorpride ( ) [ ] , fin-fisher ( ) [ ] , and covid- spyware.) -ransomware: is a malicious software that holds and encrypts cps data as a ransom by exploiting cps vulnerabilities, targeting oil refineries, power grids [ ] , manufacturing facilities, medical centers and encrypting all data-backups until a ransom has been paid. a prime example of that is the siskey ( ) ( ) and ekans ( ) ransomware [ ] , [ ] , [ ] , [ ] . • side-channel: is based on the information gained from the implemented cps system such as timing information, power consumption and electromagnetic leaks that can be exploited. for this reason, some of the most infamous cyber-attacks deserve being mentioned (table ii) . moreover, for further details, you can refer to [ ] . in fact, do et al. presented a much more detailed attack description as early as s in [ ] . however, this paper aims to classify the occurrence of these attacks as early as and based on, but not limited to, political, religious, and criminal motives. after reviewing the main cps attacks, it is essential to assess their associated risks to design the convenient countermeasures. in the next section, the risks associated with the different cps security attacks are evaluated. given the different threats, attacks and vulnerabilities that the cps domain suffers from, it is important to highlight the main failures than cps systems suffer from. these failures can either be minor (limited damage) or major (severe damage). in fact, further details can be found in [ ] , where avizienis et al. presented a well-defined and detailed explanation in this regards. • content failure: means that the content of the delivered information is inaccurate, which would result into some functional system failure. content failure can be ei- ther numerical or non-numerical (i.e alphabets, graphics, sounds or colours). • timing failure: means that the timing of information delivery (transmission/receiving) is delayed or interrupted (received/transmitted too early or too late). this would affect the decision making process and may cause data management issues. • sensors failure: means that the sensors are no longer functioning properly, and would seriously hinder the decision making process due to misinformation, or bringing a cps system to a sudden halt. a similar case occurred in , at taum sauk hydroelectric power station [ ] . • silent failure: occurs when there is no message sent or received in a distributed system. • babbling failure: occurs when the information is delivered, causing the system to malfunction and to operate in a babbling manner. • budget failure: occurs when the cost of implementing a cyber-physical system outweighs the budget set, before ever reaching the testing level. this is mainly caused by poor planning. • schedule failure: occurs when the schedule set for planning, testing and evaluating a given cps is not achieved due to further upgrades, additional testing, or inadequacy for users needs. • service failure: occurs when having an error propagates through the service interface and affects its decision making or/and normal performance ability. this failure can either cause a partial or full cps system failure either temporarily or permanently. • consistent/inconsistent failures: a consistent failure occurs when a given service is identically perceived by all cps users. an inconsistent failure takes place when all cps users differently perceive an incorrect service (i.e bohrbugs, mandelbugs, heisenbugs and byzantine failures) [ ] . evaluating risks is essential to assess the risk's economic impact of an attack on any cps system, before managing it. such management is based on assessing and analysing the risk before mitigating it, then deploying the right security measures according to the level of severity and risk impact (see fig. ). risk management is implemented in order to identify, analyse, rank, evaluate, plan and monitor any possible risk through risk assessment. • identifying risks: identification is based on uncovering and recognising risks that can negatively affect a project/project outcome and describing it [ ] . • analysing risks: risks likelihood and consequence must be determined once they are identified, to understand the nature of a risk. • ranking risks: risks rank is evaluated according to the risk magnitude, based on the combination of both risk likelihood and consequence in case it occurred. • evaluating risks: based on their ranks, risks are either deemed as acceptable or require serious treatment and urgent attention. • planning risks response: highest ranked risks are assessed to treat, modify and mitigate them to once again achieve an acceptable risk level. therefore, risk mitigation strategies are created, along with the deployment of preventive and contingency plans. • monitoring and reviewing risks: risks are constantly monitored, tracked and reviewed. in case of any suspicious activity, these risks are mitigated before any serious threat occurs. risk assessment is implemented to minimize the impact of a given attack [ ] . in fact, risks are evaluated based on calculating the average loss in each occurring event [ ] . additionally, several risk assessment methods, as well as various techniques to secure cps were revealed in [ ] . in fact, since most studies are focused on securing enterprise systems in order to assess risks, security became an emerging issue that imposes a serious risk on cps [ ] . as a result in [ ] , [ ] , lu et al. presented an adequate risk assessment method. the main security focus was based on transferring it from risk assessment, to computer risk assessment (cra), to network risk assessment (nra) with a heavy reliance on the internet [ ] . asset identification: is also important, since it is a resource value that can either be tangible, or intangible that impacts daily transactions and services [ ] . in fact, cps assets can be divided between cyber assets, physical assets, and cyber-physical assets. finally, since asset quantization is estimated from both direct and indirect economic losses [ ] , it is important to determine the asset value (av). risk is assessed based on its possible impact on cps systems. it is divided into three main types: • high impact: in case the risk has occurred, this can result in devastating and damaging effects on cps systems. it is used to evaluate and mitigate persistent advanced threats [ ] . • medium impact: in case of its occurrence, the impact is less severe. however, it also imposes a serious threat against cps. it is used to evaluate and mitigate advanced threats [ ] . • low impact: in case this risk has occurred, its impact is not severe, nor has damaging effects. as a result, its impact is very limited and can be easily mitigated. it is used to evaluate and mitigate basic threats [ ] . risk mitigation requires the adaptation and implementation of a well-built management strategy in addition to cyber and physical security in order to counter-espionage, theft, or/and terrorist attacks. such a mitigation model also requires, data security and protection, as well as anti-counterfeit and supply chain risk management [ ] . these models should also be supported by both forensic and recovery plans. this can help in analyzing cyber-attacks whilst coordinating and cooperating with the responsible agencies to identify external cyber-attack vectors [ ] . therefore, preventive, detective, repressive and corrective logical security measures can be adopted. as a result, a qualitative risk assessment table is presented (see table iii the cost of security attacks can take many forms, and the main ones are highlighted as follows: • delays: cps systems may be prone to service delays, which may affect their performance and render them inactive (blackout, burnout) until the issue is sorted either through maintenance or back up. • affected performance: system delays due to a malicious (cyber-attack)/non-malicious (accident) event can gradually affect the cps performance and cause it to operate in an abnormal manner which can seriously affect the decision making process. • additional spending: may be required to tackle the advanced persistent threat attempts and zero-day attacks, which require additional spending in terms of security protection in a defense-in-depth manner. • loss of life: can be the result of flooding, radioactivity, fire or electric shock due to hazardous or intentional acts. • disclosure of information: can affect cps businesses and business trades and put the privacy of users at risk of having their personal information being exposed. before proceeding any further, it is important to classify cps components as critical, moderate and non-critical, to identify the risk of an event occurrence (malicious/hazard) along its impact to define the proper security measures (basic, standard or advanced), as seen in fig. . while adopting all possible security measures might be costly in all terms (i.e. complexity, financial cost, delay, etc.), risk management is key for selecting the convenient security solutions. in the next section, the different security solutions proposed to defend the security issues are reviewed. while these security solutions aim at preventing, detecting or correcting system damage, the cps forensics aim at knowing the system issues causes, which help in reducing and preventing future attacks. thus, the main cps forensics solutions are also reviewed. securing cps is not a straightforward task. for this reason, various existing solutions are mentioned and discussed in this section. already existing testing tools are also introduced. all of these schemes are presented to protect cps domains against attacks that target the confidentiality, integrity, availability, authentication and privacy of both data and systems as seen in fig. . according to national institute of standards and technology (nist) guidelines [ ] , [ ] , ensuring trust between iot and cps, should consist of various multi-factors. this is due to both iot and cps systems relying on safety, security, privacy, consistency, dependability, resiliency, reliability, interaction and coordination, all of which are combined to form a well-designed and trustworthy system. if this condition is satisfied, a perfect cps mechanism is achieved. as a result, several cps testing tools were used to evaluate the security of industrial control devices upon their development (see table iv) . for further details, these tools are explained in [ ] . moreover, several security certifications are also discussed, reviewed, analysed and compared according to their different aspects [ ] (see table v) . in the following, the main cps security requirements are defined and discussed. • privacy: in cps, a huge data collection process is constantly taking place, and this is what most people are not aware of [ ] , [ ] . therefore, a person has the right to access his own data, along with being given the right to know what type of data is being collected about them by data collectors, and to whom these data is being given or sold to. however, this also requires preventing the illegal/unauthorised access to the user's personal data and their information disclosure [ ] , [ ] . • dependability: intelligent physical world (ipw) ensures that the cps adaptive behaviour is achieved to bring a higher dependability and ensure the right quality of service (qos) through the adoption of fault-tolerance mechanisms in a timely manner. dependability includes two other qualities, safety and reliability. safety is often an objective defined in terms of the organisation's [ ] . this is due to the negative impact of cybersecurity risks, where vulnerabilities can be compromised and exploited by a hacker, or due to cps failure. hence, safety is of a high concern for iot, cps and (internet of cyber-physical things) iocpt users alike. while reliability is based on the ability to adapt to changing conditions to overcome and recover from any possible disruption either based on cyber or/and physical attacks led by adversaries, in addition to natural disasters [ ] . physical systems rely on timing and proper functionality. however, in case of any possible mismatch, unreliability and uncertainty can cause problems and disruptions for cps services. therefore, maintaining a high reliability requires reducing the uncertainty levels. in fact, it is also recommended to implement error-correction algorithms to sort electronic components imperfect reliability [ ] . as a result, rajamaki et al. in [ ] stated that cps behaviour can be predictable through the implementation and use of artificial intelligence or/and even machine learning (ml) schemes. this allows the prediction of the so called "next-time system state". • resiliency: cps must be resilient to overcome accidents and malicious attacks. therefore, cps logical and physical systems are prone to cyber security vulnerabilities from a security aspect. this included the demonstration of carshark software tools that control a car in [ ] , along with the successful design of a virus in which attacked siemens plant-control systems [ ] , along with how hackers broke into the united states federal aviation administration (us faa) air traffic control system in [ ] . resiliency is achieved by each cps component in a base architecture (ba) presented in [ ] , where each communication and physical connection path between elements is granted access by the ba's connectors. this requires the ba system to know and identify every possible path, while overcoming any connection disruption. moreover, in case the elements were inconsistent, a multi-view editor will be deployed to make corrections. • interaction and coordination: are essential to maintain an all-time operational cps security. in [ ] , hu et al. stated that cps interaction and coordination between cyber and physical system elements are a key aspect. in fact, the main physical world characteristics are based on the constant system change over time. however, the cyber world characteristics are based on sequence series with no temporal semantics. moreover, two basic approaches are presented to study and analyse this problem. these approaches are based on the "cyberizing" the physical (ctp) aspect through the introduction of cyber-properties and interfaces into physical systems, and "physicalizing" the cyber (ptc) where cyber-software components are to be represented in real-time [ ] . • operational security (opsec): operational security (opsec) was introduced in to ensure physical security, information security, and personnel security [ ] through careful planning, risk assessment and risk management [ ] . its primary task is to ensure operational effectiveness by denying any adversary access to public/private information; hence controlling information and observable actions about a given cyber-physical system, especially in hostile environments/areas [ ] . one of its key benefits is providing means to develop cost-effective security measures to overcome a given threat. to achieve this task, opsec involves five main steps: -critical information identification: includes identifying which information, if targeted, can effectively degrade a cps's operational effectiveness or place its potential organizational success at risk, and develop an initial plan to protect it. -threat analysis: includes determining an adversary's potential and capabilities to gather, process, analyze, and use the needed information. -vulnerability analysis: includes studying the weaknesses of a given cyber-physical system and the strengths of an adversary. thus, building a possible view over how a potential adversary might exploit this security gap to perform a security breach. -risk assessment: risks are assessed based on the threat and vulnerability levels combined, depending on how high or how low these levels are. risk assessment levels include evaluating the cost of implementing the right security measures by ensuring a trade-off between the effective cost and benefit balance. -appropriate application countermeasures: once the trade-off is achieved in the earlier phase, the appropriate countermeasures are then developed to offer the best protection of cps against these ongoing threats in terms of feasibility, cost, and effectiveness. • system hardening: system hardening can be used to defend a wider range of threats. therefore, it is highly recommended to isolate critical applications that lack the proper security measures, from any os that is not trusted in order to boost the iocpt and cpt security. in [ ] , shepherd et al. analysed different trustcomputing technologies along with their applications in the cps domain. according to [ ] , such analysis included a trusted platform module (tpm), trusted execution environments (tee), secure elements (se), and encrypted execution environment (e ), to increase the os's integrity. moreover, the authors' work in [ ] has successfully achieved a higher security level in the presence of untrustworthy components. this allowed the improvement of cps by enhancing system's integrity. however, if the graph-based optimization was combined with parameters, it can provide a reasoning basis to ensure an overall system integrity [ ] . therefore, it is essential to set the right privileges (task-based, role-based, rulebased, etc..) and strong password complexity policies in order to enhance the security level. moreover, this also includes getting rid of old unused accounts and open yet unused ports to reduce the exposure to remote wireless attacks. as a result, cps nature must be considered before achieving any design. in [ ] , mo et al. presented a cyber-physical security by combining systems-theoretic with cyber-physical security controls. the adoption of security measures has many benefits when it comes to protecting cps components, layers and domains. however, despite these advantages, cps systems are impacted by the application of these security measures, which can be summarized as follows: • reduced performance: security measures can partially or fully affect the performance of a given cps, in the absence of careful consideration for a balanced securityperformance trade-off. this can affect normal operations and requires more human interventions to manually assign services and domains. • higher power consumption: is a serious issue, especially for resource-constrained and battery-limited cps end devices. a higher power consumption means a shorter lifespan and a higher cost to maintain their availability. • transmission delays: transmitted/received data is prone to delays due to the additional encryption process that is being added to thwart passive/active eavesdropping and sniffing attacks. despite the protective advantage that is offers, this is unacceptable in a real-time cps systems. • higher cost: higher security levels are associated with higher computational costs, which are not limited to the initial capital spending phase, but also include training, update, and operational phases. • compatibility issues: some cps systems are not compatible with the employed security measures and vice versa. this can be due to the software in-use, firmware, operating system, etc. • operational security delays: upon the deployment of any security service, there is a training phase that precedes the full operational security mode, and during which the service is temporarily ineffective or basic and thus, prone to attacks. maintaining a secure cps environment is not an easy task due to the constant increase of challenges, integration issues and limitation of the existing solutions including the lack of security, privacy and accuracy. nonetheless, this can be mitigated through different means including cryptographic and non-cryptographic solutions as seen in fig. . • safety critical: in such a cps type, an attack can lead to loss of life or to chronic deadly diseases, with significant damage to the environment such as fire, floods, radioactivity (e.g. chernobyl in and fukushima in ) incidents [ ] , [ ] . • mission critical: for this type of cps, an attack can result into a fatal/non-fatal, total/partial failure of a cps to achieve its objectives [ ] . • business critical: in such a cps type, an attack can result into huge financial and economic losses, damaged reputation and loss of cps contractors and clients. • security critical: for this type of cps, an attack can result into a security breach of the cyber-physical system (security gap, exploitable vulnerability, rootkits, backdoors, etc.). cryptographic measures are mainly employed to secure the communication channel from active/passive attacks, along any unauthorized access and interception, especially in scada systems [ ] . in fact, traditional cryptography approaches based on utilizing ciphers and hash function are not easily applied to cps including iocpt due to power and size constraints. as a result, the main focus should be limited to data security alone, instead it should maintain and ensure the efficiency of the overall system process along. therefore, various solutions were presented. in [ ] kocabas et al. conducted their own survey which was dedicated to conventional and emerging encryption schemes which could be employed to offer secure data storage and sharing. in [ ] , lai et al. reviewed and discussed prominent cryptographic authentication and encryption methods [ ] to secure distributed energy resources (der) systems, while providing recommendations on applying cryptography to der systems. in [ ] , ding et al. presented an overview of recent advances on security control and attack detection of industrial cps, especially against denial-of-service, replay, and deception attacks. in [ ] , sklavos et al. presented a tutorial that discusses the implementation efficiency of communications confidentiality, user authentication, data integrity and services availability, along attacks and modern threats with their countermeasures. many solutions were presented to maintain a secure cps environment by fulfilling its main security goals. in [ ] , adam et. al. presented a novel framework to understand cyber-attacks and cps risks. their framework offers a novel approach to ensure a comprehensive study of cps attack elements, including the attacker and his objectives, cyber exploitation, control-theoretic and physical system properties. in [ ] , stouffer et al. provided a comprehensive ics security guideline that is related to technical controls including intrusion detection systems (ids), access controls (ac), firewalls, and operational controls including training, awareness and personnel security. in [ ] , security experts were able to gain the employees' credentials due to their lack of awareness and training, using phishing and social engineering techniques through a simulated attack. in [ ] , sommestad et al. conducted a keyword mining comparison, and concluded that the main focus was either on operational controls, or technical controls only. in [ ] , sharma et al. presented a novel multi-level network security evaluation scheme (nses) that represent five different levels of security. therefore, providing a holistic view over whether nses is suitable for wireless sensor networks (wsn) security for iot/cps/iocpt applications. nses offers recommendation for network administrators on early design phases to achieve the right security needs. as a result, this paper classifies these solutions in terms of them fulfilling one of the following security goals: • confidentiality: securing cps communication lines is essential. as a result, various cryptographic solutions were presented. in [ ] , the authors presented a solution based on the use of compression techniques before being encrypted. their solution reduces the overhead and mitigates the problem. since, lightweight cryptography became the centre of attention with various lightweight block ciphers being presented by different authors, including an ultra-lightweight block cipher by bogdanov et al. [ ] and a low-latency block cipher for pervasive computing applications [ ] . this was due to their lowcost and low-latency with the ability to provide cryptographic blocks for any resource constrained, normal, industrial, or even medical devices. in [ ] , shahzad, et al. suggested the installation of encryption-decryption modules at both ends of non-secure modbus communication to protect its connection from confidentiality attacks. thus, requiring an additional overhead to convert plaintexts into ciphertexts and vice versa. in [ ] , the american gas association (aga) presented its aga- standard to provide "bump-in-the-wire" encryption services for cps, but at the expense of large latency overheard [ ] . in [ [ ] . ssu is complementary to the existing siem architectures, and it can transparently intercept its communication control channels along with its physical process input/output lines to constantly assess both security and operational status of plc or rtu. another approach was also presented in [ ] , by asem et. al to overcome mitm, replay and command modification attacks by providing an encryption level for the transferred packets, along with the use of hardware cipher models. in [ ] , cao et al. presented a layered approach with the aim of protecting sensitive data. their techniques relied on hash chains that provide a layered protection for both high and low security levels zones along with a lightweight key management mechanism. thus, preventing attackers from intercepting data from a higher security level zone. therefore, ics applications vendors should work on releasing compatible versions of their applications to ensure that the ics operators will not resort to older versions of vulnerable os [ ] . their presented approach revealed the ineffectiveness of interception, injection and denial of service attacks, along with the ability of their openplc project to overcome man-in-the-middle attacks through data encryption, without interfering with its own real-time characteristics. • authentication: authentication is the first line of defense that should be well-built, designed and maintained [ ] , [ ] , [ ] , [ ] . as a result, in [ ] , halperin et al. presented a public key-exchange authentication mechanism to prevent unauthorized parties from gaining access. their mechanism relies on external radio frequency rather than batteries as an energy source. in fact, out-ofband authentication were deployed in certain wearable devices, where the authentication mechanism uses additional channels including audio and visual channels [ ] . on the other hand, medical cps (mcps) biometrics, including mainly heart rates and blood pressure [ ] , can possibly be used to generate a key to encrypt and secure the body sensor network communication [ ] . in [ • privacy preserving preserving the privacy of users' big data is not an easy task. as a result, various privacy preserving techniques were presented to solve this issue including differential privacy and homomorphic encryption. -differential privacy: limits the disclosure of private real-time big-data and information during its transmission. in [ ] , keshk et al. studied the feature reduction role along privacy protection levels using independent component analysis (ica) as a technique on big power cps data. results revealed that ica is more secure without breaching confidential data and offers a better privacy preservation and data utility. in [ ] , j. feng et al. presented a lightweight privacy-preserving high-order bi-lanczos scheme in integrated edge-fog-cloud architectural paradigm for big data processing. user's privacy is achieved using an homomorphic cryptosystem, while computation overheads are offloaded using privacy-preserving tensor protocols. in [ ] , ye et al. presented a secure and efficient outsourcing differential privacy (dp) scheme to solve data providers issues related to being vulnerable to privacy attacks. in [ ] , zhang et al. presented a practical lightweight identity-based proxy-oriented outsourcing with public auditing scheme in cloudbased mcps, by using elliptic curve cryptography to achieve storage correctness guarantee and proxyoriented privacy-preserving property. -homomorphic encryption: for a better data confidentiality and privacy protection, homomorphic encryption techniques were adopted. in [ ] , zhang et al. presented a secure estimation based on kalman filtering (sekf) using a multiplicative homomorphic encryption scheme with a modified decryption algorithm to reduce network overhead and enhance the confidentiality of the communicated data. in [ ] , kim et al. a fully homomorphic encryption (fhe) as an advanced cryptographic scheme to directly enable arithmetic operations on the encrypted variables without decryption. moreover, a tree-based computation of sequential matrix multiplication is introduced to slow down the decrease of the lifespan. in [ ] , min et al. presented a parallel fully homomorphic encryption algorithm that supports floatingpoint numbers to achieve an efficient ciphertext operation without decryption. results revealed that the ability to limited application problems while meeting the efficient homomorphic encryption requirements in cloud computing environment. many noncryptographic solutions were also presented to mitigate and eliminate any possible cyber-attack or malicious event. this was done by implementing intrusion detection systems (ids), firewalls and honeypots. as a result, various solutions presented by various authors are mentioned and discussed. various ids methodology types are available due to the availability of different network configurations [ ] . each ids methodology is characterised by its own advantages and drawbacks when it comes to detection, configuration, cost, and their placement in the network. in [ ] , almohri et al. stated that various research activities were implemented to detect attacks against the cps. these attacks are split into two main models. physics-based model, which defines normal cps operations in cps through anomaly detection. cyber-based model which is used in order to recognize potential attacks as listed in [ ] , [ ] . in fact, existing approaches were mainly designed to detect specific attacks against specific applications, including unmanned aerial vehicles (uav) [ ] , industrial control processes [ ] , and smart grids [ ] . in [ ] , zimmer et al. exploited the possibility of a worst case execution time, through obtaining information using a static application analysis in order to detect malicious code injection attacks in cps. in [ ] , mitchell et al. analysed a behaviour-rule specification-based technique to employ ids mainly in medical cps. the authors also presented the transformation of behaviour rules in a state machine, which can detect any suspicious deviation initiated from any medical device behaviour specification. -intrusion detection system placement: ids can be placed at the border router of any given iot network, in one or many given hosts, or in every physical object to ensure the required detection of attacks. simultaneously, ids may be able to generate a communication overhead between the lln (low power lossy networks) nodes and the border router due to the ids ability to frequently query the network state. in fact in [ ] , zarpel at al. described three main ids placement strategies (see fig. ): fig. : ids structure * distributed ids: d-idss are being employed in every physical lln object, whilst being optimized in each resource-constrained node. therefore, a lightweight distributed ids was presented. in [ ] , oh et al. identified a lightweight algorithm matching the attack signatures, and the packet payloads, while suggesting other techniques that require less matching numbers to detect any possible attack. in [ ] , lee et al. suggested their own lightweight method that allows them to monitor a node's energy consumption by assigning nodes to monitor their neighbours in the distributed placement. these nodes are defined as "watchdogs". in [ ] , cervantes et al., presented a solution called "intrusion detection of sinkhole attacks on ipv over low -power wireless personal area networks ( lowpan) for iot" (inti), which combines their concepts of trust and reputation with the watchdogs nodes to mainly detect and mitigate sinkhole attacks. this included the node's role possibly changing every time a network is reconfigured or an attack event has occurred. * centralized ids: c-ids is mainly deployed in centralized components. this allows all data to be gathered and transmitted by the lln to the internet across the border. therefore, centralised ids can analyse all of the exchanged traffic between the lln and the internet. in fact, it is not enough to only detect attacks involving nodes within the lln, since it is difficult to monitor each node during an occurring attack [ ] . in [ ] , cho et al. presented their solution which is based on analysing all the packets that pass through the border router between physical and network domains. however, the main task is based on how to overcome a botnet attack. in [ ] , [ ] , kasinathan et al. deployed a centralized placement that allows them to take into consideration the possibility of overcoming dos attacks, where in case of a dos attack, the ids data transmission would not be affected. in [ ] , wallgren et al. employed their centralized approach which is placed in the border router to detect the attacks that target the physical domain. * hybrid ids: h-ids utilizes both concepts of centralized and distributed placements, by combining their advantages and overcoming their drawbacks. the initial approach allows the network to be organised into clusters with the main node of each cluster being able to host an ids instance before taking the responsibility for monitoring other neighbouring nodes. therefore, hybrid ids placements can be designed in order to consume more resources than a distributed ids placement. in [ ] , le et al. followed the same approach, through the use of a hybrid placement using a relatively small number of "watchdogs" nodes covering the network. this offered them the ability to sniff the communication of its surrounding neighbours in order to indicate whether a node was compromised or not. therefore, reducing the communication overhead. in [ ] , le et al. also managed to organize the network into smaller clusters with a cluster head for each, using the same number of nodes. this allowed an ids instance to be placed in each cluster head, with each cluster member reporting its own related information and other neighbours related information to the cluster head. in the second approach, ids modules were placed in, both the border router and other network nodes with the presence of a central component. in [ ] , raza et al. presented their own ids named as svelte, where the border router hosts are given the task of processing intensive ids modules that are responsible for detecting any intrusion attempt by analysing the routing protocol low-power and lossy device's (rpl) network data. based on pongle et al.'s work [ ] , network nodes were responsible for any detectable changes in their neighbourhood. moreover, network nodes were also responsible for sending information about their surrounding neighbours to their centralized module which is deployed in the border router having the main assigned responsibility of storing and analysing data. thus, making it easier to detect and intrusion while identifying attacks in their early stages. in [ ] , thanigaivelan et al. presented an ids, which allocates different responsibilities to the network nodes and also to the router's border. thus, ensuring a cooperative combined work amongst them, with the ids module monitoring neighbouring nodes, detecting any intrusion attempt, and sending notifications to the ids modules. -intrusion detection methods: the four main ids methods are signature-based, anomaly-based, behaviour-based and hybrid based. in fact in [ ] , these methods were presented, while testing methods and techniques were classified into five main categories, depending on their detection mechanism . * signature based: such a detection technique is very fast and easy to configure. however, it is only effective for detecting known threats. thus, showing a high weakness against unknown threats mainly polymorphic malwares and crypting services. despite its limited capability, signature based ids is very accurate, and also very effective at detecting known threats, with an easy way to understand mechanism. however, this approach is ineffective against the detection of both new and variants of known attacks, due to their matching signature remaining unknown, and constantly updating its signature patches [ ] , [ ] . in [ ] , oh et al.'s aimed to reduce the computational cost by comparing attack signatures and packet payloads. in [ ] , liu et al. presented a signaturebased ids that employs an "artificial immune system" (ais) mechanism with detectors being modelled as immune cells with an ability to classify any datagram as malicious or non-malicious according to the matching signature. such approach can evolve into the adaptation ability new conditions in new environments that are being monitored. in [ ] , kasinathan et al. integrated a signature-based ids into the network framework, with the objective of being able to detect dos attacks against lowpan-based networks. this ids was implemented through the adaptation of "suricata " used for lowpan networks, with the main objective of reducing the false alarm rate. in [ ] , kasinathan et al. presented a signaturebased approach as an extension of their presented approach in [ ] . * behaviour based: behaviour based can be classified as a set of rules and thresholds implemented to define the expected behaviour of the network's components including both nodes and protocols. this approach is capable of detecting any intrusion as soon as the network behaviour deviates from its original behaviour. behaviour-based acts in the same way as the anomaly-based detection with a slight difference from specification-based systems where a human expert is needed to manually define each specification rule. thus, providing a lower false-positive rate than the anomaly based detection [ ] , [ ] . therefore, there will be no need for any training phase, since they are implemented to operate instantly. however, such an approach is not fit for all scenarios, and may become time consuming and error prone. in [ ] , misra et al. presented their new approach to protect the iot middleware from ddos attacks, by triggering an alert whenever the request number exceeds the threshold line. in [ ] , le et al. presented a different specification-based approach, aimed at detecting rpl attacks [ ] , by specifying the rpl behaviour through network monitoring operation and malicious action detection. in [ ] , le et al.'s work was extended. their experimentation resulted in a high true-positive rate, where false positive rates were low throughout their experimentation, whilst also causing an energy overhead compared to a typical rpl network as stated in [ ] . in [ ] , amaral et al. presented a specification-based ids that grants the network administrator the ability to create and maintain rules in order to detect any potential attack. whenever the rule is violated, the ids would right away send an alert to the event management system (ems) that correlates these alerts for different available nodes in a given network. the success of misra et al. [ ] and amaral et al. [ ] approaches highly relied on the expertise of the network administrator, as well as his experience and skills combined. therefore, in case of any wrong specifications, it will cause an excessively high false-positive rate and/or a high false-negative rate, leading to a possibly serious risk that threatens the network's security. * anomaly based: this type compares system's activities instantly with the ability to generate an alert whenever a deviation from normal behaviour is detected. however, such a detection method suffers from a high false positive rate [ ] , [ ] , [ ] . in [ ] , cho et al. presented a botnet detection scheme using the anomaly-based method, by computing an average for each three metrics composing the normal behaviour profile. this was achieved before the system monitors the network's traffic and raises the alert whenever a metric violates the already defined computed averages. in [ ] , gupta et al. presented their own architecture for a wireless ids, by applying the necessary computational intelligence algorithms which are used in order to a construct normal profile behaviour. moreover, a distinct normal behaviour profile will be implemented for each different ip address being assigned. in [ ] , lee et al. suggested that energy consumption should be classified as parameter in order to be used in analyzing each node's behaviour. thus, defining a regular energy consumption model for each mesh-under routing scheme and route-over routing scheme, where each node will monitor its own energy consumption. in case the node deviates, the ids classifies the node as malicious and removes it. in [ ] , summerville et al. successfully managed to develop a deep-packet anomaly detection approach aimed at reducing the run on resource constrained iot devices, by using a bit-pattern matching technique which performs a feature selection. in their experimental evaluation, they used internet enabled devices against four main attack types (including sqli, worms, etc..), and results have shown low false-positive rates. in [ ] , thanigaivelan et al. successfully introduced an iot distributed internal anomaly detection system, that monitors the node's data rate and packet size. moreover , in [ ] pongle and chavan presented an ids that is designed specifically in order to detect wormhole attacks in iot devices, in addition to presenting three main algorithms to detect network anomalies. as a result, their experiment revealed that the system has achieved a true positive rate of % when tested against wormhole detection, whilst scoring an % when it came to detecting both, the attack, and the attacker launching it. in [ ] , k. demertzis et al. presented an advanced spiking one-class anomaly detection framework (soccadf) based on the evolving spiking neural network algorithm. this algorithm implements a one-class classification methodology in an innovative applicable way, due to it being exclusively trained with data to characterise normal ics operations. moreover, this algorithm can detect any divergence in behaviours and abnormalities that are associated with apt attacks. the authors stated that soccadf is highly suitable for difficult problems, and applications with a huge amount of data. according to their results, the authors stated that soccadf has a better performance at a very fast learning speed, with higher accuracy, reliability, and efficiency, and it outperforms the other approaches. * radio-frequency based: in [ ] , stone et al. presented a radio-frequency based anomaly detection method for programmable logic controllers in the critical infrastructure [ ] . their experimental results have demonstrated that the use of a single collected waveform response provides sufficient separability to enable the differentiation between anomalous and normal operational conditions. however, in case of using multi-time domain waveform response, their performance significantly degrades. to solve this problem, the authors presented anomaly detection method based on rf fingerprint feature retrieved from the waveform amplitude, phase, and frequency response to ensure a qualitative differentiation between an anomalous and normal operating conditions. in [ ] , stone et al. also presented an rf-based methodology to detect anomalous programmable logic controller behaviours with a superior timedomain rf emissions performance. the cincinnati bell any distance (cbad) approach reached a threat agent detection and response (tadr) detection rate higher than % benchmark realised at an signal power ratio (snr) higher or equal to db. despite these results, this approach is prone to rf noise, signal degradation and coding loops. in [ ] , stephen et al. presented a timing-based side channel analysis technique to help control system operators in detecting any firmware and ladder logic programs modification to the programmable logic controllers. this approach allows a field device to be fingerprinted upon deployment to create an supplicate baseline fingerprint. various fingerprints of the device are taken and compared to the baseline in order to detect and alert operators of both intentional and unintentional modifications in programmable logic controllers. * hybrid based: it is based on using a specification-based techniques of signature-based, and anomaly-based detection in order to maximize their advantage whilst minimizing their drawbacks. in [ ] , raza et al. presented a hybrid ids known as svelte which offers the right trade-off between storage cost of signature-based methods, and computational cost of anomalybased methods. in [ ] , krimmling et al. tested their anomaly and signature-based ids using the ids evaluation framework that they presented. their results revealed the failure of each approach in detecting certain attacks alone. as a result, the authors combined these approaches to cover and detect a wider attack range. in [ ] it is not enough to encrypt, detect and protect against passive and active attacks. in fact, aside from identifying the source of the attack, it is also important to know how the attack was performed despite of the challenges [ ] . hence, there an urgent need for the forensics domain to enhance the forensics tools and techniques to retrieve and analyze logs of events that took place before, during and after the incident. in fact, cps forensic analysis is still in its early stages of development, due to the ics specialized nature along with its proprietary and poorly documented protocols [ ] . in [ ] , awad et al. surveyed the digital forensics applied to scada systems and covered the challenges that surround them. therefore, presenting the current state-of-the-art device and networkspecific tools. in [ ] , grispos et al. presented a forensicby-design framework that ensure the integration of forensics principles and concepts in mcps. in [ ] , h. al-khateeb et al. shed a light on a new approach where a blockchainbased chain-of-custody may be simultaneously established to the generated preidentified data (data of interest) by an iot device. in [ ] , chan et al. described a novel security block method for detecting memory variable changes that may affect the integrity of programmable logic controllers and efficiently and effectively enhancing security and forensics. this is done by by adding monitoring and logging mechanisms to plcs. therefore, ensuring faster anomaly detection with higher accuracy, less overhead and adjustable impact. in [ ] , ahmadi et al. presented a federated blockchain (bc) model that achieves forensic-readiness by establishing a digital chain-of-custody (coc) and a cps collaborative environment to qualify as digital witnesses (dw) to support post-incident investigations. in [ ] , parry et al. presented a high speed hardware-software network forensics tool that was specifically designed for capturing and replaying data traffic in scada systems. experimental results guaranteed preserving the original packet ordering with improvement in data capture and replay capabilities. in [ ] , cebe et al. presented a blockchain infrastructure by integrating a vehicular public key infrastructure (vpki) to achieve membership establishment and privacy along a fragmented ledger related to detailed vehicular data. moreover, identities pseudonyms were used to preserve users' privacy. in [ ] , p. taveras presented a high level software application that detects critical situations like abnormal changes of sensor reads and traffic over the communication channel, mainly. therefore, helping by improving critical infrastructure protection and providing appropriate scada forensics tools for incident response and forensics analysis. in [ ] , ahmed et. al. presented a testbed of three ipps (industrial physical processes) using real-world industrial equipment including plc. the authors stated that their presented testbed is useful in cyber-security, education (scada systems) and forensics research including plc analysis and programming. moreover, their testbed includes fully functional physical processes which are deemed very essential for both research and pedagogical efforts. in [ ] , yau and chow presented a novel methodology which logs relevant memory address values, that are being used by programmable logic controller programs, in addition to their timestamps. this methodology can be extremely valuable in a forensic investigation in case of an ics incident. this is realized by applying machine learning techniques to the logged data in order to identify any anomalous programmable logic controller operation. in [ ] saman et. al. combined symbolic execution with model checking to analyse any malicious plc code bound injection. their combined approach can also be used for forensic purposes including the identification of the areas where the code injection took place, along with which part of the code caused its execution. in [ ] , mcminn et al. presented a firmware verification tool used for the forensics analysis of trials of the altered firmware codes to gain unauthorised access over ics networks. such verification is achieved either though the analysis of the plc's captured data to check whether the plc's firmware is modified or not. in [ ] , kleinmann et al. presented an accurate ids that utilizes a deterministic finite automaton that models the network traffic with a . % accuracy, after analysing and observing the highly periodic network traffic of siemens s plc. in [ ] , saranyan et al. provided a comprehensive forensic analysis of network traffic generated by the pccc (programmable controller communication commands) protocol, and also presented prototype tool that extracts updates of the programmable logic and crucial configuration information. authors also stated that their proof-of-concept tool, "cutter", which is capable of parsing the content of pccc messages, extracts and presents digital artifacts in a human-readable form such as simple mail transfer protocol (smtp) configuration. moreover, the smtp configuration can be retrieved from the network log and can be parsed, too. in [ ] , chan et. al. presented a novel security block method that enhances ics security and forensics by adding monitoring and logging mechanisms to plcs, and ics's key components. their results demonstrated that their approach increased the anomaly detection range, speed and accuracy with a slight performance impact and a reduced network overhead. thus, ensuring a more enhanced, efficient and effective forensic investigation procedure. in [ ] , yua et al. described the design and implementation of a novel plc logging system. to overcome the inadequacy of information in forensics investigations, their logging system is used to extract data from siemens s communications protocol traffic. this logging system also helps in recording the evidence based on the exchanged data between the plc and other network devices. thus, providing key information about the attack source, actions and timelines. the choice of simatic s plc is due to their widespread use [ ] and successful exploitation by insidious stuxnet malware. in [ ] , chan et al. focused on the logging mechanism of a siemens plc, including the siemens total integrated automation portal v program (siemens tia portal, known as siemens step- ). the author's methodology performs an effective and practical forensics analysis of the plc. moreover, it focuses on siemens plc along with an installed computer workstation with the siemens tia portal (previously targeted by stuxnet). during the evaluation and analysis of the existing presented security solutions, several limitations can be deduced, presented and discussed as follows: • asymmetric cryptography: introduces overhead in terms of latency and resources. the asymmetric nature of certain cryptographic work [ ] , [ ] leaves cps's real-time communication prone to network latency and overhead due to delays in the encryption/decryption process. • weak device/user authentication scheme: many of the presented authentication techniques [ ] , [ ] , [ ] , [ ] are not very suitable for a secure appliance, due to the lack of multi-factor authentication schemes to protect cps systems from unauthorised users and access. • cps forensics field: are still prone to many challenges including the lack of tools, skills and responses against any potential anti-forensics activity [ ] , [ ] . • inefficient honeypot & deception system: despite of the recently proposed techniques in [ ] , [ ] , [ ] , [ ] , there are no appropriate honeypot techniques that can be specifically adopted to protect cps systems, especially in the wake of industry v . . • lack of firewall protection: firewall solutions including [ ] , [ ] are not very applicable and suitable for employment into the cps domain, nor they offer an effective protection. the best solution requires dynamic firewalls, as well as application and next generation firewall types. • inefficient intrusion detection systems: despite the availability of various ids types such as anomalybased [ ] , behaviour-based [ ] and signaturebased [ ] , these are generally applied within iot-based domains and not specifically designed to protect cps systems. to secure cps, many lessons were learnt as how to maintain and achieve their required security goals. among such lessons: ) maintaining security services: new lightweight cryptographic solutions are required to secure cps and iocpt in real-time operations but with minimum computational complexity. these cryptographic solutions can help ensure the following security services: • confidentiality: there is a need for a new class of lightweight block or stream cipher algorithms to secure cps resource-constrained real-time communications. recently, a new approach was presented, and it is based on the dynamic key-dependent cipher structure and it requires two or one iteration with few operations [ ] , [ ] , [ ] , [ ] . a set of these solutions can be applied at the physical layer [ ] , [ ] , [ ] . • message/device integrity: this includes the protection of cps data and devices' integrity from any physical/logical alteration(s). this can be done by ensuring that the operating system, applications, and software are securely designed and without any flaws to prevent tampering, with strong cryptographic hash functions (sha , sha and sha ). in this end, a new lightweight hash function was presented in [ ] and it requires a single round compared to the existing ones. • device/data availability: requires the need for computational resources along with verified backups, and a self-healing ability of cps in such a way to recover immediately from availability attack types. also, maintaining data availability is as necessary [ ] , and this can be done by defining a multi-secure connection [ ] - [ ] . ) strong device/user authentication: an efficient device/user mutual multi-factor authentication scheme is necessary,along with enhancing verification and identification phases based on attribute access-control privileges (least-privilege) to ensure non-repudiation and stronger accountability. ) protecting digital evidences: this is highly important since most of the advanced attacks focus on eliminating any source of evidence that traces back to the attack source, such as the case of shamoon, duqu, flame and stuxnet malware types [ ] , [ ] , [ ] . furthermore, modern digital forensics solutions should define new countermeasures to preserve digital forensics logs. ) enhancing security policy: in many cases, cps attacks occurred by insiders (by accident or on purpose). accordingly, all employees must undergo a screening process before recruitment, and have their privileges suspended outside working hours and monitored their actions in the case of advanced tasks. this means that cps security policy should be contain new rules to limit access and to reduce the potential damage. ) smart cooperation with non-cryptographic solutions: intrusion detection systems should be hybrid in all terms and should be coordinated in an efficient manner with firewalls and dynamic honeypot systems. ) enforcing compliance: by respecting users' privacy through ensuring data access regulatory compliance that processes cps's big data via clouds, especially when stored by utility providers (trusted third party (ttp)) to prevent any data leakage and users privacy violations. therefore, maintaining a suitable trade-off between users privacy and systems' security and performance, while also ensuring firmer accountability measures [ ] , [ ] . ) achieving trade-off: is essential for maintaining systems' availability, safety and security [ ] , [ ] . therefore, such a trade-off must be achieved based on the combination of these three key requirements while taking into consideration available budget and cost requirements in terms of risk assessment: • availability & safety: both features are linked together since issues related to the safety of a cps system also affect its operational availability. to ensure this trade-off, verified back-ups of computational devices must always be considered in the planning phase, as a second line of defense to handle any sudden service/system disruption (power cuts, blackouts, pumping stoppage), or maintenance (updates, renovation, installation, etc. different security measures could be adopted and enhanced to enhance the protection against various threats and attacks. these include: • prioritization & classification: of critical cps components and assets before assessing, managing and analysing risks to ensure the proper budget spending on the right choice of security measures (basic, standard or advanced) in accordance to their costs compared to the likelihood of the occurrence of a given incident and its impact. • careful financial planning & management: must be conducted in terms of available budget and needed costs/resources to protect critical/non-critical cps assets and components. • lightweight dynamic key dependent cryptographic algorithms: these solutions can be used to to ensure several security services such as message confidentiality, integrity and authentication, which are mandatory during any secure cps communications. this can be done by using new generation of cryptographic algorithms, which were presented in [ ] , [ ] , [ ] . the advantage of these solutions that it can reach a good balance between security and performance level. the robustness against attacks were proved since a dynamic key is used per message (or a set of messages; depend of application constraints and requirements). moreover, this dynamic key is used to produce a set of cryptographic primitives and update cryptographic primitives. this means different ciphertext can be obtained for the same plaintext since different cryptographic primitives are used. while, the effectiveness is validates since these algorithms require only one round iteration and uses simple operations in addition to avoid diffusion operation. the new generation of these cryptographic algorithms reduce the required latency, resources and computation overhead, which help cps devices to preserve better their main functionalities. • defining privileges: this should be considered as the most suitable access control policy, which assigns permissions and rights depending on the users' roles/tasks/attributes when it comes to accessing cps, and removing these access rights upon completing the task or upon the employee's leave. this also includes the use of the least privilege policy. therefore, the definition of privilege should be done based on attribute based access control (abac), where policies combined with attributes specify access authorizations. note that abac makes access control decisions based on boolean conditions of attribute values. it provides a high level of granularity, which is necessary to make cps control access scheme more secure. • strong entity multi-factor authentication: unfortunately, entity authentication schemes that are based on a single factor of authentication (you have, you know, you do or you are) are not resistant enough against authentication attacks, which are increasingly becoming more dangerous. the first line of defense in any system is the entity authentication scheme since any entity authentication attack can lead to confidentiality, integrity and/or availability attack. recently, the concept of multi-factor authentication was applied by combining two or more factors: ) "you are" which includes device fingerprint, user fingerprint, hand geometry, iris scan, retina scan, etc., and ) "you have" which includes cryptographic keys to increase its robustness against authentication attacks such as the ones described in [ ] , [ ] . this mechanism should be an essential requirement in cps systems, in addition to the use of the geographical location. the advantage of these solutions is their ability to reduce false positives, and to complicate the authentication attacks since several factors should be broken instead of one. consequently, this limits the access only to authorised entities and personnel (devices/users). • strong password & dynamic hashing process: passwords are considered as the "you know" authentication factor. however, several attacks such as rainbow and hash table attacks can be applied. in order to prevent them from occurring, after a periodic interval, passwords must be re-hashed with a new dynamic nonce for each user. moreover, a secure cryptographic hash function should be used such as sha- and sha- (variant ). this avoids birthday attacks and reduces rainbow/hash table attacks. • secure and protected audit: can be done by using an audit manager system that collects and stores logs in a distributed system. a possible solution that can be applied in this context was presented recently in [ ] . this limits any insider attempt against a cyber-physical system and it preserves the digital evidence of internal and external attacks to trace them back. • enhanced non-cryptographic solutions: require the need for hybrid ids/ips systems or ai-based ids/ips (using machine learning algorithms), along with advanced firewalls (i.e application and next generation firewalls) [ ] , and dynamic honeypots [ ] to prevent any future security breach based on a vulnerability exploit. this can be done by employing lightweight ids/ips and especially the anomaly-based ones. in fact, one should select the anomaly detection algorithm according to the cps device constraints, which can be statistical for limited ones or based on machine algorithm, such as random forest, for powerful cps devices. on the other hand, signature-based techniques can be applied at the gateway (gw) where all network traffic can be analyzed. • secure & verified backups: this is essential to maintain the cps data availability and to avoid data destruction or alteration by ensuring robustness against dos/ddos and ransowmare attacks, especially that such attacks may result in total blackouts as in the case of the us. this can be done by using lightweight data protection solutions such as the ones presented in [ ] . • forensic efforts: are essential to retrieve the traces of any occurring attack. also, new solutions against antiforensic techniques should be introduced to preserve any digital evidence [ ] . this is realized by recovering logs and monitoring network and system behaviour, which can successfully limit various reconnaissance attempts. however, the newly introduced forensics tools must be compatible with different cps devices' software/hardware, especially resource constrained devices, and must also be resistant against anti-forensics attempts. • enhanced incident response: includes the ability to identify, alert and respond to a given incident. moreover, incident recovery and incident investigation plans should be put in place to mitigate attacks. this provides protection against non-intentional technical and operational failures (power shortage, blackout) through backup plans, and from intentional failures (cyber-attacks), through cert (computer emergency response) [ ] , csirt (computer security incident response) [ ] , and ircf (incident response and computer forensics) teams [ ] , [ ] . as such, cps scientists and engineers must undergo further education and training to ensure an enhanced and efficient cyber, physical and computational environment with secure computing and communications. • real time monitoring: running real-time systems using specialised forensics or non-forensics tools and methods is essential to prevent any cyber-physical system accidental or non-accidental failure. this enables constant checking and monitoring of cps devices' behaviour and hence, the detection of any cyber-attack attempt in its early stages. • security check: and employee screening must be done for each employee before and during the job to eliminate and contain any possible insider/whistle-blower attempt. therefore, signing agreements [ ] such as non-disclosure agreement (nda), confidentiality agreement (ca), confidential disclosure agreement (cda), proprietary information agreement (pia) or secrecy agreement (sa) is highly recommended. such security checks are essential especially in critical areas such as nuclear power plants [ ] . • periodic employee training: includes periodic awareness training of ics and plc employees on the best cyber-security practices based on their level and knowledge, with the ability to detect any suspicious behaviour or activity. moreover, employees must be trained over various security threats and wrong practices such as avoiding the installation of any software update, how to counter social-engineering and phishing attempts, while also maintaining accountability in case of wrong doings. • periodic pen testing & vulnerability assessment: must be maintained in a periodic manner to enforce system auditing, detecting threats, and mitigating them in a real-time manner before they are discovered and exploited by an attacker under the zero-day exploit conditions. • periodic risk assessment: must also be enforced to study the likelihood and impact of a given risk against a critical/non-critical cyber-physical system based on a qualitative or/and quantitative risk assessment and a cost-benefit analysis (cba), to classify the risk based on acceptable/non-acceptable level and to mitigate it as early as possible. • up-to-date systems: cyber-physical systems must be kept up-to-date in terms of software, firmware and hardware through constant verified patches and updates [ ] . moreover, such systems must be secured at different levels of their implementations (layered protection), with the ability to mitigate and tackle a given attack to reduce its impact and prevent further escalation and damage. furthermore, usb ports must be physically and logically removed to prevent any payload injection, and plc systems behaviour and activities must be constantly monitored for any suspicious/abnormal behaviour [ ] . • ai security solutions: artificial intelligence is used in ids/ips anomaly detection schemes or in "you are" or "you do" entity authentication schemes. in fact, ai is now being considered as a game-changing solution against a variety of cyber-physical attacks targeting cps systems, devices and communication points. despite the time consuming process of training an ai system, the accuracy of detection and prevention are much higher than any human intervention. recent advancements in machine learning, and especially in deep learning, can make cps systems more secure, robust and resistant against cyber-physical attacks. • defense in-depth: most of the existing solutions offer protection against a single attack aspect or a security requirement. instead, there is need for a multi-purpose security solution that ensures the best protection at each operational layer (perception, transmission and application) of cps. for example, the two most known international standards for functional safety in the automotive industry, the iso [ ] and iec /edition [ ] , [ ] should be respected and applied. this ensures a safe cps implementation based on the functional safety, which includes the safety integrity level (sil) basics [ ] which in turn, rely on the probability of failure on demand (pofod) and the risk reduction factor (rrf) to ensure a much more accurate and efficient hazard and risk analysis (hra) [ ] , [ ] , mainly in the electronic control units (ecu) [ ] , [ ] ). • cps security & privacy life-cycle: finally, to sum up this work, our paper presents a combined operational and functional safety/security (ofss) life-cycle that ensures a successful and safe cps employment as seen in fig. ). this framework is derived from iso and iec /edition protocols and their approach towards ensuring the cps functional safety/security. the framework consists of six main phases: -phase : devising a plan to design a cps system by following a well-defined time-table and schedule in accordance to the needed budget and corresponding costs. this also requires the assistance of humans (businessmen, engineers, workers, etc.) and nonhuman assets (vehicles, machines, etc.). -phase : requires a careful risk and hazard analysis, which consists of a proper risk management and asset classification, as well as the mutual connection between the two to ensure an accurate decision-making over the adoption of the right security measures/counter-measures. -phase : defines the right functional safety, security and dependability requirements along their key components/mechanisms that are essential to mitigate a risk/hazard and to reduce their likelihood and impact in case of their occurrence. -phase : consists of evaluating the performance of cps in terms of the recently introduced functional safety, security and dependability measures in an operational manner where a performance management and analysis will be conducted to ensure a proper/mutual security-performance, safetyperformance and dependability-performance tradeoffs. -phase : once the performance is evaluated, the cyber-physical system is tested and validated to detect any remaining software/hardware bug, security gap, or performance issue to apply the required modifications before being commissioned. if the testing is unsuccessful, the process restarts again to find where the issue took place. if successful, the cps will head towards further commissioning before being officially deployed. -phase : upon successful testing, the deployed cps system will undergo a trial phase to evaluate its operational status, while monitoring its behaviour and performance before becoming fully operational. cps systems are key components of industry v . , and they are already transforming how humans interact with the physical environment by integrating it with the cyber world. the aim of implementing cps systems, either within or outside iot (iocpt), is to enhance the products' quality and systems' availability and reliability. however, cps systems suffer from various security and privacy issues that can degrade their reliability, safety, efficiency, and possibly hindering their wide deployment. in this paper, we first overview all components within cps systems and their interconnections including iot systems, and we focus on the main cps security threats, vulnerabilities and attacks, as related to the components and communication protocols being used. then, we discuss and analyze the recently available cps security solutions, which can be categorized as cryptographic and non-cryptographic solutions. next, we highlight the important lessons learnt throughout, and accordingly, we present suggestions and recommendations with respect to the various security aspects, services, and best practices that must be put in place to ensure resilient and secure cps systems, while maintaining the required performance and quality of service. acknowledgement this paper is supported with funds from the maroun semaan faculty of engineering and architecture at the american university of beirut. a cyber-physical systems architecture for industry . -based manufacturing systems industry . : a survey on technologies, applications and open research issues predictive manufacturing system-trends of next-generation production systems industry . : huge potential for value creation waiting to be tapped. deutsche bank research cascading data corruption: about dependencies in cyber-physical systems: poster ninth ieee international symposium on object and component-oriented real-time distributed computing autonomic computing technologies for cyber-physical systems smart monitoring of potato crop: a cyber-physical system architecture model in the field of precision agriculture industrial and medical cyber-physical systems: tackling user requirements and challenges in robotics role of cyber security in drone technology securing internet of medical things systems: limitations, issues and recommendations situation management, and impact assessment ii; and visual analytics for homeland defense and security ii a survey of remote automotive attack surfaces. black hat usa a brief survey of security approaches for cyberphysical systems cryptography and security in internet of things (iots): models, schemes, and implementations cyberphysical systems security-a survey challenges and research directions for heterogeneous cyber-physical system based on iec : vulnerabilities, security requirements, and security architecture. future generation computer systems cyber-physical systems and their security issues a survey of security and privacy in big data a survey of security and privacy in big data a survey on internet of things: security and privacy issues survey of scada security challenges and potential attack vectors emerging security mechanisms for medical cyber physical systems cryptography considerations for distributed energy resource systems cyber physical systems security: analysis, challenges and solutions internet of things (iot) security: current status, challenges and prospective measures securing physical processes against cyber attacks in cyber-physical systems a survey on the internet of things security future internet: the internet of things architecture, possible applications and key challenges identity-based key agreement and encryption for wireless sensor networks security of the internet of things: perspectives and challenges security of distributed, ubiquitous, and embedded computing platforms. wiley handbook of science and technology for homeland security research on the architecture of internet of things scada system cyber security-a comparison of standards scada-specific intrusion detection/prevention systems: a survey and taxonomy cyber security in power systems protecting industrial control systems from electronic threats expanding gate level information flow tracking for multilevel security the design of ics testbed based on emulation, physical, and simulation (eps-ics testbed) cyber security for cyber physcial systems: a trust-based approach security architecture on the trusting internet of things camouflage: automated anonymization of field data data masking system and method cyber-physical systems: a security perspective lightweight security solutions for the internet of things internet of things (iot): a vision, architectural elements, and future directions. future generation computer systems time synchronization of automation controllers for power applications an open and flexible cybersecurity training laboratory in it/ot infrastructures method and apparatus providing remote reprogramming of programmable logic devices using embedded jtag physical layer and protocol sustainable and flexible industrial human machine interfaces to support adaptable applications in the industry . paradigm automated remote telemetry paging system guide to supervisory control and data acquisition (scada) and industrial control systems security. national institute of standards and technology remote terminal industrial control communication system the earlier the better: a theory of timed actor interfaces bundle: a group-based programming abstraction for cyber-physical systems context-sensitive synthesis of executable functional models of cyber-physical systems co-simulation framework for design of time-triggered cyber physical systems robust cyber-physical systems: concept, models, and implementation. future generation computer systems a concept lattice-based event model for cyber-physical systems the algorithmic analysis of hybrid systems hybrid system modeling and autonomous control systems cyber-physical systems modeling based on extended hybrid automata hybrid systems modeling challenges caused by cyberphysical systems anuradha annaswamy, kai lampka, and lothar thiele. a hybrid approach to cyberphysical systems verification towards configurable real-time hybrid structural testing: a cyber-physical system approach event driven monitoring of cyber-physical systems based on hybrid automata vulnerability assessment of cybersecurity for scada systems scada systems and their vulnerabilities within the smart grid: can they be defended from a cyber attack vulnerability analysis of network scanning on scada systems in power and energy society general meeting-conversion and delivery of electrical energy in the st century smart grid security technology comprehensive experimental analyses of automotive attack surfaces sok: security and privacy in implantable medical devices and body area networks leveraging information security and computational trust for cybersecurity deconstructing flame: the limitations of traditional defences a survey scada of and critical infrastructure incidents security and privacy challenges in the smart grid an evaluation of cyber threats to industrial control systems security and privacy for implantable medical devices challenges and research directions in medical cyber-physical systems automotive system security: challenges and state-of-the-art intelligent substation automation systems for robust operation of smart grids ieee innovative smart grid technologies-asia (isgt asia) petri net modeling of cyber-physical attacks on smart grid securing the electricity grid. the bridge blackout in the united states and canada: causes and recommendations, us-canada power system outage task force cyberwar: taking stock of security and warfare in the digital age realizing the smart grid imperative risk management and critical infrastructure protection: assessing, integrating, and managing threats, vulnerabilities and consequences a taxonomy of cyber attacks on scada systems backdoors and holes in network perimeters cyber security of water scada systems-part i: analysis and experimentation of stealthy deception attacks the myths and facts behind cyber security risks for industrial control systems in quest of benchmarking security risks to cyber-physical systems cyber attack: a dull tool to shape foreign policy smart grid technologies: communication technologies and standards transmission control protocol/internet protocol (tcp/ip) packet-centric wireless point to multi-point (ptmp) transmission system architecture scada security in the light of cyber-warfare rpc: remote procedure call protocol specification version reliability of exploits and consequences for decision support stuxnet worm impact on industrial cyberphysical system security lessons from stuxnet the cousins of stuxnet: duqu, flame, and gauss duqu . : a comparison to duqu duqu: a stuxnet-like malware found in the wild gauss malware: nation-state cyber-espionage banking trojan related to flame, stuxnet stuxnet-risk & uncertainty in the first salvo of global cyber warfare. the sais red october and its reincarnation analysis and triage of advanced hacking groups targeting western countries critical national infrastructure: apt , red october, and regin the middle east under malware attack dissecting cyber weapons saudi arabia's response to cyber conflict: a case study of the shamoon malware incident cybercrime and analysis of laws in kingdom of saudi arabia world war c: understanding nation-state motives behind today's advanced cyber attacks the role of malware in reported cyber espionage: a review of the impact and mechanism the trajectory of iran's nuclear program inside the slammer worm an ontology for network security attacks cyberattacks on scada systems war, peace, or stalemate: wargames, wardialing, wardriving, and the emerging market for hacker ethics a meet-in-the-middle attack on -round aes integrating physical and cyber security resources to detect wireless threats to critical infrastructure wireless vulnerability of scada systems scada security: a new concerning issue of an inhouse egat-scada an experimental investigation of malware attacks on scada systems rose tsang. cyberthreats, vulnerabilities and attacks on scada networks attack taxonomies for the modbus protocols evaluating electricity theft detectors in smart grid networks cyber security in the smart grid: survey and challenges here be backdoors: a journey into the secrets of industrial firmware they can hear your heartbeats: non-invasive security for implantable medical devices pacemakers and implantable cardiac defibrillators: software radio attacks and zero-power defenses hacking medical devices for fun and insulin: breaking the human scada system securing vehicles against cyber attacks experimental security analysis of a modern automobile security and privacy vulnerabilities of in-car wireless networks: a tire pressure monitoring system case study cyber/physical security vulnerability assessment integration cyber-physical security of a smart grid infrastructure cyber-physical attacks and defences in the smart grid: a survey secure estimation and control for cyber-physical systems under adversarial attacks cyber-security incidents: a review cases in cyber-physical systems stuxnet malware and natanz: update of isis december lessons learned from the maroochy water breach security of scada systems against cyber-physical attacks. ieee aerospace and electronic systems magazine fbi probes georgia water plant break-in on terror concern telvent hit by sophisticated cyber-attack, scada admin tool compromised cyber incident blamed for nuclear power plant shutdown securing the smart grid: next generation power grid security cyber-physical systems: an overview of design process, applications, and security cyber threats impacting critical infrastructures weapons against cyber-physical targets risk of terrorism to cyber-physical and organizational-societal infrastructures future of all technologies-the cloud and cyber physical systems cybercrime and risks for cyber physical systems: a review an exceptional war that ended in victory for estonia or an ordinary e-disturbance? estonian narratives of the cyber-attacks in . the institute ecole supérieure en informatique electronique et automatique cyber attacks on estonia: short synopsis. double shot security russian operational art in the russo-georgian war of malware classification for cyber physical system (cps) based on phylogenetics cybercrime and risks for cyber physical systems does lebanon possess the capabilities to defend itself from cyber-theats? learning from estonia's experience.(c ) cyber warfare awareness in lebanon: exploratory research c-flat: control-flow attestation for embedded systems software towards automated dynamic analysis for linux-based embedded firmware code injection attacks on harvard-architecture devices return-oriented programming: systems, languages, and applications targeted attacks on teleoperated surgical robots: dynamic model-based detection and mitigation data-oriented programming: on the expressiveness of non-control data attacks data management issues in cyber-physical systems cyber-physical attacks: a growing invisible threat privilege escalation attacks on android a study of passwords and methods used in brute-force ssh attacks fast dictionary attacks on passwords using time-space tradeoff extended password key exchange protocols immune to dictionary attack ioannis papaefstathiou, and charalampos manifavas. fast, fpga-based rainbow table creation for attacking encrypted mobile communications hash function balance and its impact on birthday attacks guess again (and again and again): measuring password strength by simulating password-cracking algorithms preventing privilege escalation xmandroid: a new android evolution to mitigate privilege escalation attacks black hole attack in mobile ad hoc networks denial of service attack and classification techniques for attack detection analysis of ping of death dos and ddos attacks smurf-based distributed denial of service (ddos) attack amplification in internet threat analysis of blackenergy malware for synchrophasor based real-time control and monitoring in smart grid blackenergy-what we really know about the notorious cyber attacks blackenergy malware used in ukraine power grid attacks resisting syn flood dos attacks with a syn cache taking control: design and implementation of botnets for cyber-physical attacks with cpsbot short-term risk assessment of botnet attacks on advanced metering infrastructure smart factories in industry . : a review of the concept and of energy management approached in production based on the internet of things paradigm botnet protocol inference in the presence of encrypted traffic ddos in the iot: mirai and other botnets the social roles of bots: evaluating impact of bots on discussions in online communities regin, an old but sophisticated cyber espionage toolkit platform reconsidering human dignity in the new era building a gh st malware experimentation environment anonymity vs. trust in cybersecurity collaboration a coreflood investigation of nanofluid enhanced oil recovery to catch a ratter: monitoring the behavior of amateur darkcomet rat operators in the wild how cybercriminals can abuse chat platform apis as c&c infrastructures it threat evolution in q global routing instabilities triggered by code red ii and nimda worm attacks nimda worm analysis triton: the first ics cyber attack on safety instrument systems cyber security: the lifeline of information and communication technology blackhole exploit kit: rise & evolution. malware research team technical paper how port security has to evolve to address the cyber-physical security threat: lessons from the sauron project cyber threat report big game hunting: the peculiarities in nation-state malware research the smartphone who loved me: finfisher goes mobile how cyber-attacks in ukraine show the vulnerability of the us power grid jigsaw: an investigation and countermeasure for ransomware attacks current trend, challenges, and research directions ransomware in industrial control systems. what comes after wannacry and petya global attacks? comprehensive survey on petya ransomware attack protection model of pcs of subway from attacks type «wanna cry»,«petya» and «bad rabbit» iot ransomware attacks: detection, prevention and cure slammer worm crashed ohio nuke plant network overview of the taum sauk pumped storage power plant upper reservoir failure electricity grid in us penetrated by spies. the wall street journal infiltrating critical infrastructures with nextgeneration attacks. fraunhofer institute for secure information technology (sit) ukraine claims hackers caused christmas power outage challenges and threats of ukraine's national cyber security in hybrid war the ransomware "petya" as a challenge to the cybersecurity of ukraine, main factors of spreading this virus in the focus of ukraine, the steps taken by the authorities to combat this phenomenon and suggest ways to improve such activities using experience of other countries. phd thesis, victor zhoghov the ransomware "petya" as a challenge to the cybersecurity of basic concepts and taxonomy of dependable and secure computing fault-tolerant distributed cyber-physical systems: two case studies challenges for securing cyber physical systems risk assessment of information and communication systems-analysis of some practices and methods in the electric power industry adaptive fault-tolerance faulttolerance for cyber-physical systems threat modeling for security assessment in cyberphysical systems a new multilevel framework for cyber-physical system security an analysis of cyber physical system security theories cyber-physical system risk assessment an impact review on internet of things attacks guide to industrial control systems (ics) security. nist special publication the big four-what we did wrong in advanced persistent threat detection classification of security threats in information systems type of security threats and it's prevention stress test scenario: sybil logic bomb cyber catastrophe. cambridge risk framework series cyberphysical systems: the next computing revolution a study on secure shell (ssh) protocol hardware designs for security in ultra-low-power iot systems: an overview and survey new security perspectives around byod comments of the sierra club historical analysis of us onshore hazardous liquid pipeline accidents triggered by natural hazards cyber-physical systems in manufacturing analysis of cyber security for industrial control systems security testing methods and techniques of industrial control devices achilles -the world's first man-in-the-middle web security tool dark reading. breakingpoint unveils firestorm cyber tomography implementation of the canfd protocol in the fuzzing tool bestorm codenomicon defensics finds risks that lurk in your protocols mu studio performance suite peach fuzzing platform. peach fuzzer unraveling scada protocols: using sulley fuzzer an introduction to spike, the fuzzer creation kit. presentation slides) exida certification -iec , iec , iec , iso isasecure -iec - - -edsa certification pu-abe: lightweight attribute-based encryption supporting access policy update for cloud assisted iot mohamed mohamed, and giovanni russello. c-absc: cooperative attribute based signcryption scheme for internet of things applications information security and innovation; guide to secure technology innovation initiatives data security and privacy preservation in cloud storage environments based on cryptographic mechanisms resilience of cyber-physical system: a case study of safe school environment virus attacks siemens plant-control systems hackers broke into faa air traffic control system an architectural approach to the design and analysis of cyber-physical systems state estimation in spatially distributed cyber-physical systems: bounds on critical measurement drop rates operational security management in violent environments risk assessment and risk management: review of recent advances on their foundation secure and trusted execution: past, present, and future-a critical review in the context of the internet of things and cyber-physical systems on threat modeling and mitigation of medical cyber-physical systems process authentication for high system assurance security optimization of dynamic networks with probabilistic graph modeling and linear programming environmental consequences of the chernobyl accident and their remediation: twenty years of experience. report of the chernobyl forum expert group 'environment' sti/pub/ , , international atomic energy agency radioactivity release from the fukushima accident and its consequences: a review ensuring safety, security, and sustainability of mission-critical cyber-physical systems cryptographic protection of scada communications part : background, policies and test plan restricted authentication and encryption for cyber-physical systems a survey on security control and attack detection for industrial cyber-physical systems a multi-layered and kill-chain based security analysis framework for cyber-physical systems haytham elmiligi, and musfiq rahman. network security evaluation scheme for wsn in cyber-physical systems trustworthiness of medical devices and body area networks present: an ultra-lightweight block cipher prince-a low-latency block cipher for pervasive computing applications real time modbus transmissions and cryptography security designs and enhancements of protocol sensitive information aga- , part performance test results. pacific northwest national laboratories revisiting a watermark-based detection scheme to handle cyber-physical attacks secure and efficient communication in cyber-physical systems through cryptography and complex event processing continuous analytics on geospatial data streams with wso complex event processor solving the grand challenge using an opensource cep engine logarithmic encryption scheme for cyber-physical systems employing fibonacci q-matrix vehicular ad hoc networks (vanets): status, results, and challenges a comprehensive survey on vehicular ad hoc network lightweight attribute based encryption scheme for mobile cloud assisted cyberphysical systems secure pub-sub: blockchain-based fair payment with reputation for reliable cyber physical systems postquantum enabled cyber physical systems design and implementation of a security framework for industrial control systems improving network security monitoring for industrial control systems sans scada and process control security survey on plc network security a layered encryption mechanism for networked critical infrastructures on the interdependence of reliability and security in networked control systems attacks against process control systems: risk assessment, detection, and response embedding encryption and machine learning intrusion prevention systems on programmable logic controllers proud: verifiable privacy-preserving outsourced attribute based signcryption supporting access policy update for cloud assisted iot applications. future generation computer systems pcs, a privacy-preserving certification scheme cloud data storage security based on cryptographic mechanisms secure key-exchange protocol for implants using heartbeats physical layer security for wireless implantable medical devices multi-factor authentication in cyber physical system: a state of art survey an authentication scheme with identity-based cryptography for m m security in cyber-physical systems plc access control: a security analysis advanced key-management architecture for secure scada communications elena sitnikova, and benjamin turnbull. privacy-preserving big data analytics for cyber-physical systems practical privacypreserving high-order bi-lanczos in integrated edge-fog-cloud architecture for cyber-physical-social systems secure and efficient outsourcing differential privacy data release scheme in cyber-physical system identity-based proxy-oriented outsourcing with public auditing in cloud-based medical cyber-physical systems secure kalman filter state estimation by partially homomorphic encryption encrypting controller using fully homomorphic encryption for security of cyber-physical systems a privacy protection-oriented parallel fully homomorphic encryption algorithm in cyber physical systems intrusion detection system and intrusion prevention system: a comparative study unearthing stealthy program attacks buried in extremely long execution paths a sharper sense of self: probabilistic reasoning of program behaviors for anomaly detection with context sensitivity adaptive intrusion detection of malicious unmanned air vehicles using behavior rule specifications limiting the impact of stealthy attacks on industrial control systems cyberphysical system security for the electric power grid time-based intrusion detection in cyber-physical systems behavior rule specification-based intrusion detection for safety critical medical cyber physical systems a survey of intrusion detection in internet of things a malicious pattern detection engine for embedded security systems in the internet of things a lightweight intrusion detection scheme based on energy consumption analysis in lowpan detection of sinkhole attacks for supporting secure routing on lowpan for internet of things intrusion detection systems for wireless sensor networks: a survey management enabling the future internet for changing business and new computing services: th asia-pacific network operations and management symposium denial-of-service detection in lowpan based internet of things an ids framework for internet of things empowered by lowpan routing attacks and countermeasures in the rpl-based internet of things specification-based ids for securing rpl from topology attacks a specification-based ids for detecting attacks on rpl-based network topology svelte: realtime intrusion detection in the internet of things real time intrusion and wormhole attack detection in internet of things distributed internal anomaly detection system for internet-of-things intrusion detection system: a comprehensive review computer and information security handbook research on immunity-based intrusion detection technology for the internet of things a survey of intrusion detection techniques for cyber-physical systems a survey of intrusion detection systems in wireless sensor networks a learning automata based solution for preventing distributed denial of service in internet of things internet of things: a survey on enabling technologies, protocols, and applications policy and network-based intrusion detection system for ipv -enabled wireless sensor networks an introduction to intrusion-detection systems guide to intrusion detection and prevention systems (idps). nist special publication computational intelligence based intrusion detection systems for wireless communication and pervasive computing networks ultralightweight deep packet anomaly detection for internet of things devices a spiking one-class anomaly detection framework for cyber-security on industrial control systems radio-frequency-based anomaly detection for programmable logic controllers in the critical infrastructure security for critical infrastructure scada systems. sans reading room detecting anomalous programmable logic controller behavior using rf-based hilbert transform features and a correlation-based verification process using timing-based side channels for anomaly detection in industrial control systems integration and evaluation of intrusion detection for coap in smart city applications research of paired industrial firewalls in defense-in-depth architecture of integrated manufacturing or production system on the use of open-source firewalls in ics/scada systems argus: an orthogonal defense framework to protect public infrastructure against cyber-physical attacks real time failure prediction of load balancers and firewalls a partition-driven integrated security architecture for cyber-physical systems the use of deception techniques: honeypots and decoys. handbook of information security towards high-interaction virtual ics honeypots-in-a-box rethinking the honeypot for cyber-physical systems honeybot: a honeypot for robotic systems investigation of cyber crime conducted by abusing weak or default passwords with a medium interaction honeypot defense strategies against network attacks in cyber-physical systems with analysis cost constraint based on honeypot game model conceal: a strategy composition for resilient cyber deception-framework, metrics and deployment a novel architecture for cyber-physical security in industrial control networks deception-as-defense framework for cyber-physical systems scada systems: challenges for forensic investigators programmable logic controller forensics tools, techniques, and methodologies: a survey of digital forensics for scada systems medical cyber-physical systems development: a forensicsdriven approach blockchain for modern digital forensics: the chain-of-custody as a distributed ledger enhancing the security and forensic capabilities of programmable logic controllers federated blockchain-based tracking and liability attribution framework for employees and cyber-physical objects in a smart workplace a network forensics tool for precise data packet capture and replay in cyberphysical systems block forensic: an integrated lightweight blockchain framework for forensics applications of connected vehicles scada live forensics: real time data acquisition process to detect, prevent or evaluate critical situations a scada system testbed for cybersecurity and forensic research and pedagogy detecting anomalous programmable logic controller events using machine learning detecting industrial control malware using automated plc code analytics a firmware verification tool for programmable logic controllers accurate modeling of the siemens s scada protocol for intrusion detection and digital forensics scada network forensics of the pccc protocol a forensic logging system for siemens programmable logic controllers exploiting siemens simatic s plcs forensic analysis of a siemens programmable logic controller lightweight, dynamic and efficient image encryption scheme one round cipher algorithm for multimedia iot devices. multimedia tools and applications a physical encryption scheme for low-power wireless m m devices: a dynamic key approach. mobile networks and applications an efficient ofdm-based encryption scheme using a dynamic key approach a survey on ofdm physical layer security erdia: an efficient and robust data integrity algorithm for mobile and wireless networks an efficient secure storage scheme based on information fragmentation erss-rlnc: efficient and robust secure scheme for random linear network coding preserving data security in distributed fog computing secure and resilient scheme for data protection in unattended wireless sensor networks additively homomorphic encryption and fragmentation scheme for data aggregation inside unattended wireless sensor networks a simple approach for securing iot data transmitted over multi-rats design and realization of efficient & secure multi-homed systems based on random linear network coding on the feasibility of online malware detection with performance counters idbased user-centric data usage auditing scheme for distributed environments security sla based monitoring in clouds aligning cyber-physical system safety and security security analysis on cyber-physical system using attack tree efficient & secure cipher scheme with dynamic key-dependent mode of operation lightweight stream cipher scheme for resource-constrained iot devices lightweight multifactor mutual authentication protocol for iot devices secure and lightweight mutual multi-factor authentication for iot communication systems distlog: a distributed logging scheme for iot forensics improving network security: next generation firewalls and advanced packet inspection devices a dynamic honeypot design for intrusion detection the human and computer as a team in emergency management information systems computer security incident response team development and evolution guide to integrating forensic techniques into incident response incident response & computer forensics the importance of having a non-disclosure agreement how to measure employee reliability plc code-level vulnerabilities assessing automotive functional safety microprocessor with iso hardware requirements introduction and revision of iec introduction to iec assessing and computing the safety integrity level (sil) for turbo machinery protection electronic control unit us patent , , . declare the following financial interests/personal relationships which may be considered as potential competing interests: jean-paul yaacoub is a master student in the department of electrical and lebanon. hassan noura is a research associate in the department of electrical and computer engineering at the american university of beirut (aub), lebanon. nesrine kaaniche is lecturer in cybersecurity and expert in cryptographic solutions at the university of salford, school of computing ali chehab is a professor in the department of electrical and key: cord- -tmyeh y authors: fu, chang-yong; zhang, zhen-zhong; chen, jin; jaiswal, sandip kumar; yan, fu-ling title: unhealthy lifestyle is an important risk factor of idiopathic bppv date: - - journal: front neurol doi: . /fneur. . sha: doc_id: cord_uid: tmyeh y background: benign paroxysmal positional vertigo (bppv) is a self-limiting and recurrent disease but the cost is considerable. the number of patients with bppv increased significantly under the quarantine policy in hangzhou. the unhealthy lifestyle risk factors of bppv have not yet been investigated. thus, the objective is to analyze whether an unhealthy lifestyle is a risk factor of bppv. methods: one hundred and sixty three patients with idiopathic bppv aged – years (bppv group), and aged – years sex-matched control subjects (non-bppv group) were enrolled in this study. all bppv patients received a definitive diagnosis which excluded secondary bppv. non-bppv cases excluded bppv, sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma history. we obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. to get the time of physical activities and recumbent positions, we asked the patient or their family from february to june , and the rest of the patient's information was acquired by phone or wechat. data analyses: the t-test or chi-squared test, univariate, and multiple logistic regression analyses were performed for the two groups. for each factor, odds ratios were calculated with % confidence intervals (cis). moreover, test equality of two or more receiver operating characteristic (roc) analyses were applied to the physical activities, and recumbent position time; area under curve (auc) measures were calculated with % cis and compared with each other. results: the bppv group had unhealthy lifestyles such as poor physical activities, prolonged recumbent position time, and low rate of calcium or vd supplementation in univariate logistic regression analyses (p < . ). poor physical activities and prolonged recumbent position time were independently associated with bppv in multiple logistic regression models (or = . , % ci: . – . , p = . and or = . , % ci: . – . , p < . ). in the comparison of roc curves of recumbent position time and physical activities in identifying bppv, aucs were . ( . – . ), and . ( . – . ), respectively. conclusion: we conclude that poor physical activities and prolonged recumbent position time may be independent risk factors for bppv patients, but hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, chd, and ci, may not be. background: benign paroxysmal positional vertigo (bppv) is a self-limiting and recurrent disease but the cost is considerable. the number of patients with bppv increased significantly under the quarantine policy in hangzhou. the unhealthy lifestyle risk factors of bppv have not yet been investigated. thus, the objective is to analyze whether an unhealthy lifestyle is a risk factor of bppv. methods: one hundred and sixty three patients with idiopathic bppv aged - years (bppv group), and aged - years sex-matched control subjects (non-bppv group) were enrolled in this study. all bppv patients received a definitive diagnosis which excluded secondary bppv. non-bppv cases excluded bppv, sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma history. we obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. to get the time of physical activities and recumbent positions, we asked the patient or their family from february to june , and the rest of the patient's information was acquired by phone or wechat. data analyses: the t-test or chi-squared test, univariate, and multiple logistic regression analyses were performed for the two groups. for each factor, odds ratios were calculated with % confidence intervals (cis). moreover, test equality of two or more receiver operating characteristic (roc) analyses were applied to the physical activities, and recumbent position time; area under curve (auc) measures were calculated with % cis and compared with each other. results: the bppv group had unhealthy lifestyles such as poor physical activities, prolonged recumbent position time, and low rate of calcium or vd supplementation in univariate logistic regression analyses (p < . ). poor physical activities and prolonged recumbent position time were independently associated with bppv in multiple logistic regression models (or = . , % ci: . - . , p = . and or = . , % ci: . - . , p < . ). in the comparison of roc curves of recumbent position time and physical activities in identifying bppv, aucs were . ( . - . ), and . ( . - . ), respectively. we conclude that poor physical activities and prolonged recumbent position time may be independent risk factors for bppv patients, but hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, chd, and ci, may not be. keywords: bppv-benign paroxysmal positional vertigo, risk factors, physical activity, quarantine policy, recumbent position time background vertigo is one of the most common symptoms in neurological illness and the cost of evaluating dizziness is considerable. benign paroxysmal positional vertigo (bppv) is the most common peripheral vertigo disease ( ) . it amounts to % of all vertigo patients ( ) . bppv has a recurrence rate of about % every year ( ) . some studies have found that the age, gender, hypertension, hyperuricemia, hyperlipidemia, diabetes, and osteoporosis may be the risk factors of bppv ( , ) . there are few studies on the unhealthy lifestyle and bppv. after the quarantine policy was performed to prevent covid- in hangzhou, it was found that the number of bppv diagnoses increased more rapidly than in the same period in (figure ) . therefore, in this study, we aimed to ( ) investigate the risk factors of bppv; and ( ) explore the association between an unhealthy lifestyle and bppv. we hypothesized that the onset of bppv is associated with people's unhealthy lifestyles. a retrospective observational study was conducted in the department of neurology in tongde hospital of zhejiang province from june , to june , . the study included patients with idiopathic bppv aged - years (bppv group), and aged - years sex-matched control subjects (non-bppv group). the bppv group patients received a definitive diagnosis and crm treatment, and excluded secondary bppv. the non-bppv group enrolled patients who after an annual physical examination in our hospital excluded diagnoses for bppv, sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma. we obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. to get the time of physical activities and recumbent position we asked the patients or their family from february to june , and the rest of the patient's information was acquired by phone or wechat. this references the diagnosis standard of bppv in the new england journal ( ) . all the patients were examined by dix-hallpike and roll-tested. the definition of hyperuricemia is based on the laboratory standard of our hospital that states that serum uric acid in female patients must be higher than µmol/l and in male patients higher than µmol/l. hyperlipidemia is defined when lowdensity lipoprotein is higher than . mmol/l, total cholesterol is higher than . mmol/l, or triglyceride is higher than . mmol/l. lack of physical activity is defined as < exercises per week and < min at a time. the prolonged recumbent position time is defined as when the daily lying time is longer than or equal to h, including the time of falling asleep and not falling asleep. if the patient had suffered from the following diseases, it will be classified as secondary benign paroxysmal positional vertigo and will be excluded. such as sudden deafness, meniere's disease, ear or craniofacial surgery, vestibular neuritis within year, or head trauma within year. the measurement data in accordance with normal distribution are expressed byx ± s, and the comparison between groups is expressed by the t-test; the numeration data were statistically analyzed with the chi-squared test. when p < . , the differences between the two groups were deemed to be statistically significant ( table ) . multivariable logistic regression was performed to identify the risk factors of bppv in all of the patients ( table ). the comparison of roc curves of recumbent position time and physical activities are shown in (figure ) . for each factor, odds ratios were calculated with % confidence intervals (cis). all statistical analyses were performed using the stata statistical software version . . univariate analysis of bppv related risk factors of the two group's patients were summarized in table . no significant difference was found between the two groups with respect to age, md, sudden deafness migraine, hypertension, hyperlipidemia, chd, ci, and diabetes (p > . ). although lifestyles including prolonged recumbent position time (≥ h) (or = . , % ci: . - . , p = . ), and poor physical activities (or = . , % ci: . - . , p = . ) reached statistical significance in patients with bppv compared with controls. to identify the predictors of bppv, multiple logistic regression analyses were performed. due to the strong correlation, recumbent position time and poor physical activities values were found to be independently associated with bppv in the multiple logistic regression model ( table ) . multivariable logistic regression revealed that prolonged recumbent position table ) . receiver operating characteristic analyses were applied to recumbent position time and physical activities variables. aucs were . ( . - . ), and . ( . - . ), respectively (figure ) . as we all know, age, gender, sex hormones, osteoporosis, hypertension, hyperlipidemia, diabetes, plasma vitamin d level, and hyperuricemia are all considered as risk factors for bppv ( , , ( ) ( ) ( ) ( ) . according to a previous study, cerebrovascular risk factors influence bppv onset ( , ) . in addition, some studies have found that age does not increase the recurrence rate of bppv ( ) and seasonal vitamin d deficiency in winter is not enough to cause bppv ( ) . the risk factor of bppv needs further analysis. in theory, with the increase of age, the function of human organs gradually declines and cardiovascular risk factors increase with age. as a part of the inner ear structure, the metabolism, absorption, and regeneration of otoliths are affected, and can easily fall off and lead to bppv. previous studies have found that the high morbidity of bppv in women may be related to widespread osteoporosis ( ) . it may also be related to the abnormal hormone metabolism in post-menopausal women. we found that there was no obvious correlation to the common bppv related risk factors in this study, such as hypertension, hyperuricemia, hyperlipidemia, diabetes, serum bilirubin, chd, and ci. we found that the numbers of idiopathic bppv was significantly higher than the same period a year earlier under the quarantine policy in hangzhou from january to march . this may correlate with the unhealthy lifestyle of patients during the covid- spread. to verify this hypothesis, we expanded the sample size of idiopathic bppv and set up a non-bppv health checker as a control group. as to the lifestyle of the bppv group, the majority of patients had the following characteristics, poor physical activities and prolonged recumbent position time. it can be seen that prolonged recumbent position time and poor physical activities may be important pathogenic factors for bppv. van we confirmed that % of the dizziness symptoms in parkinson's patients are likely to be bppv, which is also considered to be related to poor physical activities ( ) . it has been suggested that a prolonged recumbent position may promote calcium carbonate deposition and otolith relaxation in the elliptical capsule ( ) . the author believes that this view can explain the mechanism of the significant increase of bppv patients in our study. studies have found that poor physical activities is one of the most important risk factors for bppv in women and the morbidity of women who do not exercise is . fold that of women who regularly exercise ( ) . regular physical exercise may be a good choice to prevent bppv. some studies found that the decrease in the plasma vitamin d level is directly related to bppv ( , ) . we believe that prolonged recumbent position time and poor physical activities can lead to sunlight insufficiency, which in turn leads to vitamin d deficiency. through this clinical study, we hypothesized that the broken otolith of the endolymph in healthy people may be continuous, which may be absorbed and dissipated due to regular exercise and suitable recumbent position time. for those who have prolonged recumbent position time or poor regular physical activities, the deposition is affected by gravity, and when they move position such as getting up from a resting position or turning over, it may result in bppv. this finding may explain why bppv occurs several days after trauma, rather than immediately after trauma. the movement of the body and head may promote the circulation of the endolymph in the semicircular canal, and the degenerative otolith also dissolves and dissipates with the circulation. however, prolonged recumbent position time or poor regular physical activities will slow down the circulation. the otolith particles in the membranous labyrinth will also increase due to the unhealthy lifestyle. the three-dimensional movement of the body and head may promote the formation of the normal structure and functional remodeling of otoliths on the utricle. however, an unhealthy lifestyle may lead to otolith structural disorder, which may lead to the otolith falling off easily. this study found that idiopathic bppv had no obvious relationship with hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, chd, or ci. in this study, poor physical activities and prolonged recumbent position time are important predictors for bppv. changing unhealthy lifestyles may be the solution to decrease the morbidity of bppv. the authors speculate that bppv is associated with poor physical activities and prolonged recumbent position time which may be the independent risk factors. the limitations of the study are that it failed to assess the anxiety and depression of all patients. sleep quality was not included in the analysis ( ) . bppv styles were not classified. osteoporosis information was obtained only through asking the patient for their medical history, lacking relevant examinations. all datasets presented in this study are included in the article/supplementary material. the studies involving human participants were reviewed and approved by ethics committee of tongde hospital of zhejiang province. written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. c-yf conceived the study and design, conducted the experiment, and wrote the manuscript. f-ly prepared manuscript, and revised this manuscript. z-zz, jc, and sj conducted the acquisition of subjects and the interpretation of data. all authors contributed to the article and approved the submitted version. characteristics and mechanism of apogeotropic central positional nystagmus epidemiology of benign paroxysmal positional vertigo: a population based study recurrence of benign paroxysmal positional vertigo a geriatric perspective on benign paroxysmal positional vertigo serum uric acid levels correlate with benign paroxysmal positional vertigo concurrent posterior semicircular canal benign paroxysmal positional vertigo in patients with ipsilateral sudden sensorineural hearing loss: is it caused by otolith particles? med hypotheses hyperinsulinemia and hyperglycemia: risk factors for recurrence of benign paroxysmal positional vertigo the impact of diabetes on mobility, balance, and recovery after repositioning maneuvers in individuals with benign paroxysmal positional vertigo vitamin d deficiency and benign paroxysmal positioning vertigo serum levels of -hydroxy vitamin d correlate with idiopathic benign paroxysmal positional vertigo clinical characteristics and risk factors for the recurrence of benign paroxysmal positional vertigo a relationship between blood levels of otolin- and vitamin d benign paroxysmal positional vertigo in parkinson's disease physical activity in the prevention of benign paroxysmal positional vertigo: probable association assessment of sleep quality in benign paroxysmal positional vertigo recurrence the first author thanks their family for their support and would like to apologize to the babies for sacrificing the time that is supposed to accompany their growth in order to finish the study. 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 © fu, zhang, chen, jaiswal and yan. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -p zh irp authors: kirkness, carmen s.; fritz, julie m. title: translating research into clinical practice: functional recovery post total hip arthroplasty using outcomes gathered in the usual physical therapy practice setting date: - - journal: health outcomes res med doi: . /j.ehrm. . . sha: doc_id: cord_uid: p zh irp purpose: the purpose of this study is to determine the pattern of functional change after total hip arthroplasty (tha) in patients attending physical therapy (pt) in a usual care setting and to explore the effect of sex and time from surgery to the first physical therapy visit as potential prognostic factors influencing postoperative tha recovery. study design: adults with tha were retrospectively identified in an electronic medical record pt database (october , -april , ). hierarchical linear modeling was used to evaluate growth curves and individual variations in function using the lower extremity function scale (lefs). investigated predictors were: sex, age, start time, and pt visit. results: a total of ( female, male) postoperative tha patients were included in the study; mean age was . years (sd . , range - years). the majority ( %) of patients initiated pt < weeks postsurgery; predominately lower-functioning women started at ≥ weeks. for patients initiating treatment at < weeks, the curvilinear slopes of recovery were similar between sexes, although the predicted levels of functional status were lower for females than for males (p = . ). conclusions: this study of usual physical therapy practice supports the findings from controlled studies that post-tha women enter and are discharged from outpatient pt with lower functional status than men. new findings suggest that functional status for early start patients steadily improves over weeks postsurgery. modeling change in clinical practice using outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of tha rehabilitation. r e s u l t s : a total of ( female, male) postoperative tha patients were included in the study; mean age was . years (sd . , range - years). the majority ( %) of patients initiated pt < weeks postsurgery; predominately lower-functioning women started at $ weeks. for patients initiating treatment at < weeks, the curvilinear slopes of recovery were similar between sexes, although the predicted levels of functional status were lower for females than for males (p ¼ . ). c o n c l u s i o n s : this study of usual physical therapy practice supports the findings from controlled studies that post-tha women enter and are discharged from outpatient pt with lower functional status than men. new findings suggest that functional status for early start patients steadily improves over weeks postsurgery. modeling change in clinical practice using outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of tha rehabilitation. total hip arthroplasty (tha) is a successful and cost-effective elective surgical procedure frequently used to alleviate pain and dysfunction due to osteoarthritis. the prevalence of tha has rapidly increased in the us and the demand is expected to continue in the future. changes in the perioperative management of tha have resulted in decreased length of hospital stay, shifting the emphasis to postoperative care following hospital discharge. after being discharged from the hospital, patients will often receive postoperative rehabilitation services in inpatient rehabilitation centers, or from home health agencies or outpatient physical therapy clinics. an increasing number of tha procedures will likely lead to an increased use of outpatient physical therapy care. the economic impact resulting from the increased tha procedures will make it even more important to maximize the available rehabilitation resources and to show the effectiveness of rehabilitation options such as outpatient physical therapy. examining the pattern of recovery following tha and the factors associated with recovery is necessary to understand prognosis and to benchmark outcomes after tha. benchmarking provides a means to compare groups and individual patients to the expected outcome. the identification of characteristics that may influence outcome is also important to understanding and predicting the pattern of recovery. controlled studies have found a link between sex and rates of tha recovery. [ ] [ ] [ ] [ ] [ ] [ ] compared with females, males have been shown to have better function immediately after surgery. this trend is maintained through the recovery period as the rate of recovery between males and females is similar. [ ] [ ] [ ] [ ] [ ] [ ] sex differences may be attributable to the patient deciding when surgery is necessary; women appear to be more disabled than men at the time of tha, thereby having lower physical function at the time of surgery. [ ] [ ] [ ] [ ] [ ] [ ] understanding the pattern of recovery after tha surgery can help answer questions patients often ask clinicians related to the recovery process, providing a timeline and reasonable expectations for patients. establishing the pattern of early recovery after tha has been identified as an important marker to provide best practice services in the management of tha rehabilitation. [ ] [ ] [ ] [ ] [ ] little research has been completed evaluating the pattern of recovery following tha, , and existing studies have been completed mainly in controlled research environments rather than in routine care settings, and they may provide estimates not generalizable to usual outpatient physical therapy care. examining recovery from tha in usual outpatient physical therapy care has been difficult due to a lack of outcomes data collection in physical therapy settings , and the lack of appropriate methods to allow the contribution of each patient's unique visit (time point) to be taken into account. at present there is no published evidence examining recovery after tha for patients seeking and attending physical therapy in a usual outpatient physical therapy care setting. the purpose of this study is to examine the pattern of change seen in patients attending physical therapy after tha in a usual outpatient physical therapy care setting and to explore the effect of sex and time from surgery to the first physical therapy visit as potential prognostic factors influencing postoperative tha recovery. all data were collected as part of routine clinical practice in outpatient physical therapy clinics of intermountain healthcare, located in the salt lake city, utah region from october , through april , . the intermountain physical therapy clinics maintain an electronic database that stores data from all physical therapy visits. the database contains basic demographic information about each patient (age, sex, onset/surgical date, and reason for referral). clinical outcomes, including a pain rating and region-specific disability score, are collected at the beginning of each visit and entered into the electronic database. the lower extremity functional scale (lefs) is used as the region-specific disability questionnaire for all patients with disorders related to the hip at intermountain physical therapy. the lefs is a -item selfreport measure designed to assess functional status for patients with a variety of conditions affecting the lower extremity. each item of the lefs is scored from - , with the final score expressed as a sum out of possible e physical therapy after total hip arthroplasty points. higher scores are associated with higher functional status. although the lefs was designed for use with a variety of lower-extremity conditions, high reliability estimates have been shown in the tha population (internal consistency . , intraclass correlation coefficient . - . , and minimally detectable change of points). , the lefs is easy for the patient to use and it is quick to administer and score. , a numeric pain rating scale (nprs) is used to assess the patient's current pain level at each visit. the nprs is a - scale with representing "no pain" and the "worst imaginable pain" (cronbach coefficients . - . ; test-retest reliability . - . ). [ ] [ ] [ ] [ ] [ ] extracted demographic data for this study included age, sex, date of surgery, the number and dates of all visits during the physical therapy episode of care, and the clinical outcome scores (nprs and lefs) recorded for each visit. this study qualified for exempt review from the institutional review board at intermountain healthcare. this study examined patients receiving outpatient physical therapy following a recent tha. specifically, patients were included if they met all of the following criteria: age years or older on the date of the first physical therapy visit, at least one physical therapy visit with an lefs value entered into the database, and the first physical therapy visit was within weeks from date of surgery. patients were identified in of ways. first, we examined the reason for referral in the intermountain physical therapy electronic database. all patients categorized as referred following arthroplasty of the hip were considered for inclusion. to identify patients who may have been categorized otherwise in the electronic database, we examined the intermountain healthcare electronic medical record (emr) from the hospital within intermountain healthcare performing the majority of tha procedures, identifying all patients with an international classification of diseases- procedure code indicating a tha procedure ( . ); we then cross-referenced these cases with the physical therapy electronic database. if a patient identified as having a tha was also in the electronic database with an initial visit date that was after the tha surgical date, the patient's physical therapy record was reviewed for inclusion. a total of people receiving physical therapy within a participating clinic following a tha were identified; were identified from the intermountain physical therapy electronic database, and additional patients were identified from the hospital emr, as shown in figure . upon application of the inclusion criteria, patients were excluded as follows: were under age years, had a missing surgery date, and patients had their first visit more than weeks after surgery. we defined the episode of care in physical therapy as the number of days from the initial visit to the final visit. if more than days elapsed between visits, the episode of care was judged to be completed. indicative of usual outpatient physical therapy practice, the patient's initial visit in physical therapy occurred at varying times from the date of surgery. recovery curves constructed from the lefs scores of patients after tha in a controlled research study suggest that at weeks postsurgery, the patient's rate of recovery slows and the patients appear to function moderately well, such that they would have no difficulty with light activity, but would still have a little difficulty with stairs, walking far distances, and with heavy activities. therefore, physical therapists may expect patients who begin physical therapy within weeks after surgery to have diminished physical function due to the natural recovery progression postsurgery; whereas those patients initiating physical therapy weeks or more following surgery may be seeking treatment because their recovery is not progressing as anticipated. we therefore defined an episode of care with the initial visit occurring within weeks (ie, < days) of the date of surgery as an "early start" in physical therapy. an episode of care with an initial visit occurring after weeks (ie, $ days) was defined as a "late start." there is no standardized treatment protocol for postoperative tha used within intermountain physical therapy clinics. typical of usual outpatient physical therapy care, the frequency, number, and content of the physical therapy visits were expected to be variable. the primary reason for this study was to explore physical function between sexes using patient demographics, and treatment characteristics at first visit. the secondary reason was to investigate the relationship between sex and physical therapy start time. first, descriptive statistics (mean, sd, percentage) were calculated for the entire study sample, and for sub-groups of patients based on sex and physical therapy start time. the primary outcome measure was the lefs score. we examined the lefs score as a continuous variable. further analyses exploring sex differences were completed using chi-squared (fishers' exact for late start) and independent t tests for categorical or continuous variables, respectively. variables meeting statistical significance (p <. ) were incorporated into the multilevel model. to evaluate the pattern of recovery from tha, growth curves and individual variations in the pattern of lefs scores across the episode of care were characterized using a randomeffects multilevel modeld hierarchical linear modeling, which allows both the patient's rate of change and initial functional status to vary randomly. the use of a multilevel model allows repeated measures to be gathered over the treatment time by accommodating different time points between scores, allowing different numbers of scores between subjects, and accounting for the correlation that occurs with repeated scores. an unconditional covariance structure was used in the basic model, with lefs scores as the repeated variable (independent variable) and weeks after surgery as the dependent variable. to explain the variation in intercepts and slopes across individual predictors of recovery such as sex, age, and episode of care, early/late start time and number of physical therapy visits were evaluated. following the basic model, a conditional analysis examined predictors of recovery, which were added as level fixed-effect terms into the model. a growth curve will depict the predicted lefs scores over time using the final conditional model. statistical analyses were performed using stata statistical software: release (statacorp lp, college station, tx). physical therapy after total hip arthroplasty the final study population included patients; female patients ( . %) and male patients ( . %). their ages ranged from to years (mean . , sd . ). there were a total of lefs score measurements, with % (n ¼ ) of the study population having or more measurements per patient (range - ). on average, the first clinical visit occurred . days (sd . ) after surgery and patients had an average lefs of . (sd . ), as shown in table . comparing treatment characteristics, the time from tha until the first physical therapy visit was significantly longer (p ¼ . ) for women ( . weeks, sd . ) than men ( . , sd . ). in addition, women had significantly higher initial nprs scores (p ¼ . ) than men (table ). demographics and treatment characteristics were compared by sex and start time as shown in table . the majority (n ¼ , . %) of patients were categorized as having an "early start" in physical therapy. the majority of men ( ; . %) were early start, while only ( . %) of the women were considered early start (p ¼ . ). mean age, time to first visit, total number of visits, and length of treatment were similar between men and women early-start patients. the only significant difference between males and females in the early-start group was that women had more pain on their first visit (p ¼ . ). stratified analysis results by start time and sex indicate that start time differences were significantly associated with sex (p ¼ . ); there were times more women in the late start group (n ¼ , . %) compared with men (n ¼ ; . %). women in the late start group were, on average, years older than the late-start men (p ¼ . ). limited postoperative recovery was found in late-start patients; initial functional status and pain scores for late-start patients were similar to early-start patients. due to the disproportion of males (n ¼ ) to females (n ¼ ) and the small sample size, predicted recovery was not completed for latestart patients. growth curves were modeled only for early-start patients due to the low number of patients in the latestart group and the confounding effects of sex in the late-start group. the basic growth model included parameters that estimate the intercept (lefs score) and the patient's rate of change (weeks) with a second-degree polynomial growth term (weeks squared), which provided a reasonable fit for the data over the study interval as the rate of improvement decreased over time. when the potential predictive variables were examined, only establishing the pattern of recovery after tha surgery has been identified as an important benchmarking outcome for both clinicians and patients. in this study, functional ability was measured at varying time points unique to each patient and then used to map recovery after tha for those patients attending usual outpatient physical therapy. the results of this study suggest that in the clinics examined, the majority of patients attend physical therapy within the first weeks after tha surgery, but there was a segment of patients who initiated physical therapy more than weeks after tha surgery. the patients initiating physical therapy later (> weeks after tha surgery) had initial pain and function scores similar to the early-start patients, perhaps indicating that recovery was not progressing as anticipated. in addition, those initiating physical therapy later were significantly older than early starters, and the proportion of women that were late starters was times that for men. further research is warranted to explore the determinants characterizing why patients, particularly women, may be initiating physical therapy late in the recovery process and why these patients are well below the predicted level of functional recovery. in addition, investigating whether this trend can be established across different usual outpatient physical therapy practice care settings (ie, national level) would be an important next step for physical therapists. being able to discuss what to expect after tha is important for the patient and clinician. patients want to know what their functional level may be and how long it may take them to recover. to answer the ( ) have been instrumental in providing evidence about the recovery process following tha. in a controlled setting (where patients met specific inclusion criteria, gave consent to participate, and had designated follow-up times), kennedy et al used standardized measures of physical function to evaluate recovery over the first weeks post-tha. using consecutive patients undergoing tha, they found an increased rate of recovery in the first - weeks, which was followed by a plateau in recovery between weeks and . our study builds on the foundation initiated by kennedy et al ( ) by providing insight into the recovery of tha patients that attend usual physical therapy (a noncontrolled setting) and by monitoring weeks of tha recovery. in our early start patient sample, there was an increased rate of recovery in functional ability, with similar levels of functional ability at weeks, similar to the findings of kennedy et al. however, our study found that the recovery plateau occurred weeks after surgery, compared with the plateau at - weeks reported by kennedy et al. differences between our study and the previous report by kennedy et al may be attributed to multiple factors. first, using outcomes obtained from a usual clinical setting may have removed the selection bias that occurs when patients are part of a controlled study that includes an inclusion criteria and patient's informed consent, factors that may not translate to conditions seen in clinical practice. second, during the study by kennedy et al, a near pandemic of severe acute respiratory syndrome restricted patients' activity due to quarantine procedures and led to loss of follow-up in some cases. although the use of clinically gathered data in our study provides a generalizable sample of patients for those who attend physical therapy, it excludes those who are unable to pay for and attend physical therapy. therefore, those with low socioeconomic status may not be represented in our sample. finally, methodological factors may contribute to the differences due to the lack of preoperative scores available and the longer duration of our study. gathering clinical outcomes data in usual clinical practice is important to advance the understanding of prognosis and the recovery process for a variety of conditions, including tha. clinicians reporting outcome measure use in clinical practice describe "enhanced communication with patients and help to direct the plan of care." the findings of our study illustrate that in day-to-day clinical practice, the use of outcome measures allows recovery to be quantitatively monitored for the individual patient and contributes new information in the recovery process post-tha. barriers in the availability and usability of outcome measures seen in research that examine postoperative tha recovery, such as the womac and short-form health survey, are not in the public domain and readily available to clinicians. advances in the recent literature the present study have shown that clinically available and relevant outcome measures are available and feasible for clinical use. with the advent of emrs and electronic databases into clinical practice, barriers that limit the routine collection of outcome measures may be alleviated, as these tools present the capability of aggregating data to facilitate the routine use of outcome measures in clinical practice. in addition, there are advanced statistical techniques available that can be used to analyze the clinical data. [ ] [ ] [ ] [ ] these techniques allow each individual patient to contribute their time point (ie, patient visit) so that a natural process reflective of usual care results. the aggregation of usual physical therapy practice data can serve to move the physical therapy practice forward in providing evidence on the effectiveness of practice. this study demonstrated that in clinical practice, functional gains occur over a longer recovery period, changing the expectation of recovery and the plan of care after tha. the database used in this study originates from actual physical therapy clinical practice; therefore, the data are only as reliable as what is documented in the patient record. thus, there exists the possibility that some lefs scores may not have been documented in the emr, which may have influenced the results of this study. the application of the hierarchical modeling techniques minimize the potential limitation of missing values by allowing each patient to contribute independently to time points. second, the data were limited to clinics within one practice setting. therefore, practice patterns and patient progress may not be reflective of all total post-tha patients. third, the preoperative functional status was unknown due to patients initiating physical therapy after their tha. in controlled studies, preoperative function has been shown to predict postoperative recovery. the lack of preoperative scores in our study may overestimate the rate of recovery. lastly, only patients who attended physical therapy were included in this study. the pattern of recovery is unknown for those post-tha patients who did not seek physical therapy. after tha surgery, women enter and are discharged from outpatient physical therapy with lower function status than men, although the rate of recovery is similar between groups. there are patients who enter physical therapy later in the recovery period and may present a unique problem set that requires further investigation. evaluating change in clinical practice utilizing outcomes measures acquired through usual practice can feasibly and adequately serve to guide decisions in the management of tha rehabilitation. f i g u r e : predicted recovery curve for early start patients by sex. lefs ¼ lower-extremity functional score. physical therapy after total hip arthroplasty e-mail address: carmen the burden of musculoskeletal diseases in the united states. rosemont, il: american academy of orthopaedic surgeons prevalence of primary and revision total hip and knee arthroplasty in the united states from through future clinical and economic impact of revision total hip and knee arthroplasty effectiveness and practice variation of rehabilitation after joint replacement identifying achievable benchmarks of care: concepts and methodology outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery gender differences in functional status and pain in a medicare population undergoing elective total hip arthroplasty gender differences in patient preferences may underlie differential utilization of elective surgery differences between men and women undergoing major orthopedic surgery for degenerative arthritis comparison of gender and group differences in self-report and physical performance measures in total hip and knee arthroplasty candidates preoperative function and gender predict pattern of functional recovery after hip and knee arthroplasty effect of baseline functional status and pain on outcomes of total hip arthroplasty modeling early recovery of physical function following hip and knee arthroplasty mapping recovery after total hip replacement surgery: health-related quality of life after three years predictors of patient relevant outcome after total hip replacement for osteoarthritis: a prospective study use of standardized outcome measures in physical therapist practice: perceptions and applications the lower extremity functional scale (lefs): scale development, measurement properties, and clinical application. north american orthopaedic rehabilitation research network validation of the lefs on patients with total joint arthroplasty physical rehabilitation outcome measures pain: a review of three commonly used pain rating scales minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale pain intensity assessment in older adults: use of experimental pain to compare psychometric properties and usability of selected pain scales with younger adults an interdisciplinary expert consensus statement on assessment of pain in older persons validation study of womac: a health status instrument for measuring clinically important patient-relevant outcomes following total hip or knee arthroplasty in osteoarthritis sf- health survey: manual and interpretation guide condition-specific western ontario mcmaster osteoarthritis index was not superior to region-specific lower extremity functional scale at detecting change assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty assessing recovery and establishing prognosis following total knee arthroplasty clinical interpretation of a lower-extremity functional scale-derived computerized adaptive test evidence for electronic health record systems in physical therapy applied longitudinal data analysis: modeling change and event occurrence a growth curve approach to the measurement of change application of hierarchical linear models to assessing change hierarchical linear models: applications and data analysis methods analysis of nonlinear patterns of change with random coefficient models prevalence of outcome measure use by physiotherapists in the management of low back pain key: cord- - khdh nf authors: munasinghe, sithum; sperandei, sandro; freebairn, louise; conroy, elizabeth; jani, hir; marjanovic, sandra; page, andrew title: the impact of physical distancing policies during the covid- pandemic on health and well-being among australian adolescents date: - - journal: j adolesc health doi: . /j.jadohealth. . . sha: doc_id: cord_uid: khdh nf purpose: physical distancing policies in the state of new south wales (australia) were implemented on march , , because of the covid- pandemic. this study investigated changes in physical activity, dietary behaviors, and well-being during the early period of this policy. methods: a cohort of young people aged – years from sydney (n = ) were prospectively followed for weeks (november , , to april , ). daily, weekly, and monthly trajectories of diet, physical activity, sedentary behavior, well-being, and psychological distress were collected via smartphone, using a series of ecological momentary assessments and smartphone sensors. differences in health and well-being outcomes were compared pre- and post-implementation of physical distancing guidelines. results: after the implementation of physical distancing measures in nsw, there were significant decreases in physical activity (odds ratio [or] = . , % confidence interval [ci] = . –. ), increases in social media and internet use (or = . , % ci = . – . ), and increased screen time based on participants' smartphone screen state. physical distancing measures were also associated with being alone in the previous hour (or = . , % ci: . – . ), decreases in happiness (or = . , % ci = . –. ), and fast food consumption (or = . , % ci = . –. ). conclusions: physical distancing and social restrictions had a contemporaneous impact on health and well-being outcomes associated with chronic disease among young people. as the pandemic evolves, it will be important to consider how to mitigate against any longer term health impacts of physical distancing restrictions. aged children, a move to the online delivery of schooling. authorities requested that people remain in their homes wherever possible and limit their travel to obtaining essential goods and services. this public health strategy was absolutely necessary and appears to be yielding the desired result in terms of "flattening the curve" in the australian context [ ] . there are potential impacts of physical distancing and social isolation, particularly among younger people, where social connection is a key part of psychosocial development. the necessary policy responses to covid- may impact the determinants of poor mental health outcomes, including suicidal behavior [ ] . previous studies have shown psychological and physical health impacts of social isolation during quarantine [ ] , and more generally, social isolation has been shown to be associated with poor mental and physical health outcomes [ ] . in addition, adolescents are likely to have reduced physical activity, particularly incidental physical activity, and increased screen time as a consequence of the physical distancing measures. previous studies have shown the impacts of sedentary behavior on health outcomes in young people [ , ] and interrelated factors of diet, overweight and obesity, and well-being [ , , ] . the impact of the public health interventions in response to covid- to the daily routine of young people in australia on key health and well-being measures known to be associated with chronic disease has not previously been investigated. accordingly, this study investigates whether the physical distancing policies and school closures in the state of new south wales (australia) were associated with changes in physical activity, dietary behaviors, and well-being during the early period of this policy. participants were recruited as part of a broader prospective cohort study of adolescents investigating determinants of health and well-being over time. young people were recruited via social media (instagram and facebook) from the general population aged e years of a sydney population catchment. promotional and recruitment materials were developed and modified by members of a youth advisory group, and the social media strategy targeted those residing in western sydney; however, participants from areas outside of this catchment were not excluded if they enrolled in the study. the western sydney population catchment is a socioeconomically and ethnically diverse population of approximately one million people. participants were followed prospectively over a period of weeks, from november , , to april , , after a social media campaign that ran from november , , to january , . institutional ethics approval for the study was obtained from the western sydney university human research ethics committee (hrec approval number: h ). the total reach of the social media recruitment campaign was , adolescents in the western sydney area, of which % were female (n ¼ , ) and % were male (n ¼ , ). the total number of impressions (i.e., the number of times advertisements were displayed in news feeds) was , , , and this was higher among females (n ¼ , , %) than males (n ¼ , , %). the total number of click-throughs to the study webpage was , , with a higher level of interest among females (n ¼ , , %) than males (n ¼ , , %). of , individuals who clicked through to the study website, a total of , participants enrolled in the study and completed the baseline questionnaire, from which participants were selected who provided one or more responses to follow-up ecological momentary assessment (ema). participants were predominantly female and aged e years (table ) , reflecting the higher engagement in instagram and facebook among females than males more generally [ , ] . the ethica data smartphone app (https://ethicadata.com/ product) was used to collect data from questionnaires, emas, and smartphone sensors. mobile sensor data were collected automatically through the ethica app only from those participants who provided consent and included geolocation information (via gps, wi-fi, and bluetooth), pedometer, motion-based activity recognition (mbar) data, and screen state (whether the screen of the smartphone is "on" or "off"). a baseline questionnaire and a -week schedule of follow-up emas were triggered when participants enrolled in the study, with questions sent directly to each participant's smartphone. there were nine emas relating to psychological distress, well-being, positive emotion, social networks, relationships, diet, physical activity, sleep, and academic behavior. each ema, except psychological distress and well-being, was administered weekly, but on different days. emas relating to psychological distress or well-being were administered monthly. thus, participants received daily emas but received a different ema on each day. emas were sent to participants at random times between a.m. and a.m. or between p.m. and p.m. to avoid notifications during school hours and periods when participants may have been sleeping. the week schedule of emas resulted in weekly or monthly measures for each domain spanning the -week follow-up period. the primary outcome variables for this study included measures of physical activity, sedentary behavior, dietary behavior, and psychological well-being. self-reported physical activity at baseline was based on responses to the pace þ adolescent physical activity measures [ ] , and sedentary behavior was based on the adolescent sedentary activities questions [ ] with the tv and computer items modified to also capture information on internet streaming, mobile phone, tablet, or gaming console use. self-reported physical activity and sedentary behavior relating to the previous -hour period were also collected each week for the - week follow-up period via an ema. questions included: (i) "in the past hours, were you physically active for a total of minutes or more? 'physical activity' is any activity that increases your heart rate and makes you get out of breath some of the time"; (ii) "in the past hours, did you spend any time watching tv?"; and (iii) "in the past hours, did you spend any time on the internet, social media (like instagram, youtube, or facebook), or playing computer games?" for participants who answered "yes" to this question, a follow-up question was asked: "if yes, how long did you spend on the internet, social media, or playing computer games?" additional information on physical activity was collected passively via smartphone sensors, including pedometer, screen state (i.e., whether the phone was "on" or "off"), and mbar. the daily number of steps for each participant was collected via the pedometer. screen state was used as a proxy measure of sedentary behavior, with the assumption that during periods where the phone screen was active, participants were less likely to be engaging in physical activity. mbar is a composite indicator of activity provided by the ethica data app, which combines information from the phone sensors, including accelerometer, gyroscope, gravity, and magnetic field [ ] . the mbar indicator is a categorical variable that divides each moment into an activity type: "on foot," "walking," "running," "on bicycle," "in vehicle," "unknown," "still" (the device is not moving), and "tilting" (the device angle relative to gravity has changed significantly). each categorization is also ascribed a confidence level score between and . in the present study, each participant's mbar category was weighted by this score, such that categories with high confidence level scores were considered a more accurate assessment of the type of activity. self-reported dietary behavior at baseline was measured using questions validated for adolescents by the nsw centre for public health nutrition [ ] to allow comparisons with dietary guidelines for children and adolescents in australia [ ] . selfreported dietary behaviors relating to the previous -hour period were also collected each week for the -week followup period via an ema. questions included: (i) "in the past hours, have you eaten any serves of fruit?" if participants responded "yes," a follow-up question was asked: "how many serves of fruit? (a serve ¼ medium piece or small pieces of fruit or cup of diced pieces)"; (ii) "in the past hours, have you eaten any serves of vegetables?" if participants responded "yes," a follow-up question was asked: "how many serves of vegetables? (a serve ¼ / cup cooked vegetables or cup of salad vegetables)"; and (iii) "in the past hours, have you had any meals or snacks such as burgers, pizza, chicken, or chips from places like mcdonalds, hungry jacks, pizza hut, kfc, red rooster or local takeaway food places?" if participants responded "yes," a follow-up question was asked: "how many meals?" psychological well-being self-reported psychological distress was based on the kessler psychological distress -item scale (k ) [ ] . response options for each k item included "none of the time," "a little of the time," "some of the time," "most of the time," and "all of the time" and were scored in the range of e respectively. a score was used as indicative of probable mental disorder as recommended [ ] ; however, it is important to note that this standard cut point may overlook those with more moderate levels of psychological distress that may still be important [ ] . the engagement, perseverance, optimism, connectedness, and happiness (epoch) measure of well-being was also included in the study to capture information on positive psychological characteristics [ ] using a -point scale from "almost never" to "almost always." the k and epoch questionnaires (supplementary materials) were completed by participants at baseline with follow-ups sent to each participant every weeks and short emas relating to selected epoch items sent weekly [ ] . in addition, social relationships were measured based on the question: "in the past hour, who were you with?" participants could respond to one or more of the following options: "alone," "mother," "father," "sister(s)," "brother(s)," "other relatives," "classmates, peers," "strangers," "boyfriend or girlfriend," "friends," and "other, please specify." for participants who answered "friends," an additional question was asked: "how many friends?" finally, self-reported sleep duration in the previous hours was also collected at baseline via a weekly ema over the -week follow-up period. a range of sociodemographic and other health factors were also collected at baseline. these factors included sex, age, language spoken at home, current year of school and educational achievement, employment status, income, and body mass index (based on self-reported height and weight; table ). the change in measures of physical activity, dietary behavior, and well-being was compared pre-and post-implementation of the nsw guidelines for physical distancing to determine whether this policy resulted in significant changes in these key health behaviors. these guidelines officially came into effect on march , [ ] ; however, physical distancing began in the earlier period of march with the closure of pubs, clubs, gyms, cinemas, places of worship on march , [ ] and evidence of parents keeping children at home from school. accordingly, the period for when physical distancing began to be implemented was defined as march , . analyses were restricted to those participants who completed at least one ema over the follow-up period (n ¼ ; table ). participants were predominantly female, with a median age of years (interquartile range, e ). most participants spoke english at home ( %), were either in their senior year of schooling ( %) or finished school ( %), and almost % worked in a job (mainly part time). these participants contributed , responses to emas over the -week follow-up period, including responses in the period after implementation of physical distancing guidelines ( table ). the mean number of emas per week for this group was . (standard deviation ¼ . ), and the median number of emas per week was (interquartile range ¼ e ). comparisons of participant characteristics between ( ) those who completed baseline and follow-up, ( ) those who completed emas pre-and post-implementation of the physical distancing policy, and ( ) those who provided or did not provide sensor are provided in supplementary tables and descriptive plots of trajectories of physical activity were examined over the -week follow period, based on daily pedometer data, mbar, and weekly self-report emas. trajectories of self-reported fruit, vegetable, and fast food consumption were also examined based on weekly emas, as were trajectories of psychological well-being based on distress, well-being, and sleep duration. multivariate multilevel mixed effect logistic regression models were conducted to investigate associations between the implementation of nsw guidelines (specified as a binary pre-post variable on march , ) and subsequent changes in physical activity, dietary behavior, and well-being measures. there were significant decreases in physical activity in the period after the implementation of physical distancing measures in nsw. adolescents were significantly less likely to report minutes of physical activity in the previous figure a ). declines in physical activity were also evident based on the average number of steps per day and mbar (figure a,b) . there was also a significant increase in sedentary activity postimplementation of physical distancing, with higher social media and internet use (or ¼ . , % ci ¼ . e . ; table , figure a ) and also evidence of increased screen time based on participants' smartphone screen state ( figure c ). the implementation of physical distancing measures was associated with lower levels of happiness (or ¼ . , % ci ¼ . e. ) and positive emotions (or ¼ . , % ci ¼ . e. ), respondents reporting being alone in the previous hour (or ¼ . , % ci ¼ . e . ), and slightly higher increases in psychological distress (or ¼ . , % ci ¼ . e . ; table , figure b ). there were also declines in fast food consumption following implementation of physical distancing (or ¼ . , % ci ¼ . e . ) but no substantial changes in fruit and vegetable consumption, tv watching, or sleep duration (table ; figure c ). this study investigated the impact of physical distancing guidelines implemented in new south wales, australia, on a range of health and well-being outcomes among a cohort of adolescents aged e years in sydney. the implementation of physical distancing interventions was associated with decreases in physical activity and well-being, and increases in being alone and social media and internet use in the weeks after the policy was implemented. there was also a decrease in selfreported fast food consumption in the weeks after the policy was implemented, but little change in fruit or vegetable consumption. these findings suggest that the substantial changes to the way in which communities are currently functioning, particularly for young people, has had a contemporaneous impact on health and well-being outcomes associated with chronic disease. an important finding in the present study were the decreases in happiness reported after the implementation of the physical distancing guidelines and a higher likelihood of being alone during this period. social isolation is an important risk factor for poorer psychological well-being among young people and, conversely, peer-, family-and school-connectedness play key roles as protective factors [ ] . these protective connections may not have been as accessible to young people during the period of physical distancing resulting in lower levels of psychological well-being. it will be important to ensure that protective connections and other strategies to support the well-being of young people are maintained, to mitigate the potential psychological impact on young people. in australia, covid- cases remain low at the time of reporting; however, it is possible that physical distancing restrictions and online education may need to be reinstated if a second or third wave of infections eventuates. the shift to online delivery of education in nsw and the requirement to defer any nonessential travel is reflected in the increase in social media and internet use for the corresponding period in this study. there was also a decrease in physical activity likely related to the suspension of school and community sport and potentially mediated by a lack of access to green space in home environments. recent reviews have suggested both positive and negative impacts of social media, determined by the type of involvement (e.g., passive use, high investment, or support seeking) as well as the amount of time spent on screenbased activity [ , , ] . in addition, some studies have found that screen-based sedentary behavior supplants time spent sleeping or engaged in physical activity [ ] . the present study did not directly examine the association between screen-based sedentary behavior and physical activity, but while the pattern of findings is consistent with the idea of displacement, this may only be relevant when time is constrained (such as during school term or nonholiday periods). the finding that sleep hours did not decline contemporaneously with increased screen time perhaps suggests study participants had more time to engage in sedentary behavior without disrupting sleep duration. it remains to be seen whether sedentary behavior observed during the period of physical distancing will revert back to levels observed before physical distancing measures. this will be an important focus for future research, given the evidence that sedentary habits in adulthood are typically established during adolescence [ ] . an interesting finding was the decrease in fast food consumption in the context of limited changes to fruit and vegetable consumption. this likely reflects a decrease in opportunistic purchases of fast food during the day and traveling either to school or to work. previous research has found increased consumption of this food type among adolescents and young people where there is a high density of fast food outlets located near schools and transport hubs [ , ] . since the initial period of physical distancing, many fast food outlets have moved to take away and home delivery; however, the reduced consumption observed may indicate that fast food consumption was opportunistic and more associated with connecting socially with friends [ ] . future studies could consider the impact of these changes on food delivery on the consumption of fast food among younger people of different ages and with differing discretionary income and access to private transport. the present study also found that consumption of fruit and vegetables did not increase, suggesting either that similar food types were substituted or there was a decrease in overall caloric intake. consumption of calorie-dense foods can be positively associated with feelings of stress, and given the reduction in fast food consumption occurred in the context of increased social isolation and psychological distress, this might explain the lack of nutritional substitution implied in this finding. despite reduced consumption of these food types via fast food outlets, there may have been an overreliance on processed supermarket food during this periodda limitation to this finding was that more specific questions relating to processed or junk food (i.e., not fast food purchases) were not explicitly measured. australia experienced panic buying of processed foods resulting in supermarkets placing limits on a number of food items because of shortages. however, this was not observed for fresh fruit and vegetables. alternatively, it may be that the development of new healthpromoting behaviors takes time to develop, and the observation period of the present study was not long enough for this to emerge. there are a number of methodological limitations to this study. first, although there was a positive response to the study through instagram and facebook, participants who were more likely to engage were overwhelmingly female and more likely to be older in age ( e years). the higher proportion of females may reflect greater engagement in social media among females than males, a phenomenon that has been noted in representative studies of social media use in australia [ , ] . despite the imbalance by sex, the distribution of responses by key dietary behaviors, physical activity, and wellbeing outcomes was not substantially dissimilar to other representative prevalence studies of adolescents [ , ] . the higher proportion of older-age adolescents likely reflects that for those aged e years, parental or guardian consent was required before enrollment in the study. this involved additional steps in making contact with parents or guardians via email and to arrange for links to download the ethica app, which likely discouraged some younger potential participants from enrolling in the study. an additional limitation was the low ema and follow-up survey completion rate. despite the use of an incentive (aud $ giftpay voucher), only % of baseline participants (n ¼ , ) completed one or more subsequent ema, and < % completed all emas over the follow-up period. the weekly schedule of emas may have been too burdensome for participants, and future research may need to consider different schedules or incorporation of personalized feedback to keep young people engaged. there is also the risk of recall bias in this study, given the self-reported nature of the baseline and follow-up questionnaires. however, emas in (near) real time potentially reduce the likelihood or recall bias, in that questions relate to the immediate -hour period. patterns of ema responses relating to physical activity and screen time were also consistent with objective measures of physical activity based on available mobile phone sensor data, and the results were also generally comparable with previous adolescent health surveys for some of the measures [ , ] . smartphone sensor data, collected passively from participants, were also used as proxy measures of physical activity and sedentary behavior. this was an innovative aspect of the study design and allowed comparison with ema responses and investigation of trajectories of spatiotemporal movement among participants. however, a large proportion of participants either did not turn on some smartphone sensors (e.g., geolocation) or there were intermittent trajectories of movement, where sensor data were not collected. this resulted in complete sensor information being available on only participants over the follow-up period, only % of baseline participants (n ¼ , ) . the reasons for participants choosing not to engage in this aspect of the study are unclear but may relate to concerns about individual privacy, among both participants and caregivers (who were required to give parental consent for young people aged < years). there is also likely to be misclassification in smartphone sensor data, where periods between the initiation and cessation of a given state (e.g., "walking" in the mbar sensor) were likely overestimated, as the smartphone did not register the cessation of the state but only the initiation of the subsequent state (e.g., "still" in the mbar sensor). this means that the overall level of activity as measured by the smartphone sensor will be an overestimate; however, relative changes over time are likely to reflect actual declines or increases, and changes in emas appear to be consistent with changes in activities as measured by smartphone sensors. the present study suggests the potential immediate impacts on health behaviors that are intermediary to chronic disease outcomes. however, it is not clear whether there will be longterm psychosocial and health impacts associated with the physical distancing policies. these policies will be slowly wound back over coming weeks, and education and employment experiences will return to a degree of normality. the wider economic impacts associated with physical distancing and other policies relating to the closure of businesses and entertainment precincts on health outcomes are also not known. it is unclear whether the changes in health and well-being documented in the present study will be transient or whether there may be ongoing impacts. additional research needs to establish longer term trends in these outcomes to inform public health policy and intervention responses. this study provided a unique opportunity to measure health behaviors and psychological well-being among australian adolescents during the covid- pandemic. data collection occurred pre-and post-implementation of widespread physical distancing regulations in the community. these public health interventions have successfully "flattened the curve" on covid- to date; however, there have also been important changes among young people on a range of health and well-being outcomes. further research is needed to monitor the longer term trends in these outcomes. as the pandemic evolves, it will be important to consider how best to support psychological and physical wellbeing for young people to mitigate against potential longer term negative impacts. supplementary data related to this article can be found at https://doi.org/ . /j.jadohealth. . . . australian government department of health. coronavirus (covid- ) current situation and case numbers suicide risk and prevention during the covid- pandemic the psychological impact of quarantine and how to reduce it: rapid review of the evidence an overview of systematic reviews on the public health consequences of social isolation and loneliness child and adolescent obesity: part of a bigger picture long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review the health indicators associated with screen-based sedentary behavior among adolescent girls: a systematic review longitudinal impact of sleep on overweight and obesity in children and adolescents: a systematic review and bias-adjusted meta-analysis office of the esafety commissioner. state of play -youth, kids and digital dangers yellow social media report. melbourne: a sensis company a physical activity screening measure for use with adolescents in primary care the reliability of the adolescent sedentary activity questionnaire (asaq) available at: https://learn.ethicadata. com/documentation/data-sources/motion-sensors recommendations for short questions to assess food consumption in children for the nsw health surveys. sydney: nsw centre for public health nutrition dietary guidelines for children and adolescents in australia. canberra: commonwealth of australia the psychometric properties of the kessler psychological distress scale (k ) in a general population sample of adolescents validity study of the k scale as a measure of moderate mental distress based on mental health treatment need and utilization the epoch measure of adolescent well-being a comparison of affect ratings obtained with ecological momentary assessment and the day reconstruction method please cancel travel to regional nsw coronavirus: australia to close pubs, cafes and places of worship social isolation, psychological health, and protective factors in adolescence social networking sites and associations with depressive and anxiety symptoms in children and adolescentsea systematic review. child adol ment health association between social networks and subjective well-being in adolescents: a systematic review obesogenic neighbourhoods: the impact of neighbourhood restaurants and convenience stores on adolescents' food consumption behaviours overweight/obesity, physical activity and diet among australian secondary students-first national dataset - . cancer forum. the cancer council australia key: cord- -yc jw s authors: romero-blanco, cristina; rodríguez-almagro, julián; onieva-zafra, maría dolores; parra-fernández, maría laura; prado-laguna, maría del carmen; hernández-martínez, antonio title: physical activity and sedentary lifestyle in university students: changes during confinement due to the covid- pandemic date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: yc jw s regular physical activity is related to many factors in a university student’s environment. the coronavirus pandemic and the resulting lockdown have restricted many elements of our environment. the aim of this study was to evaluate students’ physical activity and sedentary behaviour at two points in time: before and during the coronavirus lockdown. as a secondary aim, we also wanted to look at changes resulting from other factors (alcohol, tobacco, diet, stages of change, symptoms of anxiety/depression and sociodemographic characteristics). we conducted an observational, cross-sectional, pre-post study with two cut-off points. two hundred and thirteen students took part in the study. the main dependent variables were physical activity and sitting time, measured using the international physical activity questionnaire—short form (ipaq-sf). parametric and non-parametric tests were used for paired and unpaired data, as well as group-stratified analysis. during lockdown, both weekly physical activity (md: − . ; ci: − . , − . ) and weekly sitting time increased (md: − . ; ci: − . , − . ). in the group analysis, differences were observed in relation to gender, year of study, bmi, alcohol consumption, tobacco use, symptoms of anxiety/depression, mediterranean diet, living situation and stage of change. the results showed an increase in both physical activity and sitting time globally and by group. a healthy lifestyle should be promoted among all ages, but the earlier a habit is formed, the more likely it is to become rooted [ ] . regular physical activity is one of the most effective ways of preventing premature death [ , ] . the world health organization (who) recommends at least min of moderate physical activity, min of vigorous activity, or a combination of the two, per week [ ] . independently of the physical activity carried out, it is important to assess sedentary behaviour (sb) as this is related to increased morbidity and cardiovascular risk factors [ ] . by , the who aims to reduce the prevalence of physical inactivity by % worldwide [ ] . in spain, the amount of physical activity carried out by university students is low [ ] and is in many cases linked to other healthy habits such as eating fruit and not smoking [ ] . meanwhile, sedentary behaviour is a health problem in the child and youth population, which is aggravated with age [ ] . in university students, sitting time can exceed h a day [ ] . it is known that individual factors such as age, sex and health status affect the physical activity that individuals do [ ] . other factors associated with physical activity are motivation, lack of time and aspects related to body image or physical appearance [ ] ; some of the beneficial effects of physical activity are reduced anxiety and depression [ , ] . however, there are several factors that come into play throughout an individual's lifetime that can either facilitate or impede a behaviour, with the transition from secondary education to university being a decisive moment [ ] . it is at this time that young adults form their behavioural habits, so the role of healthy universities and the healthy habits they acquire at this stage are fundamental in maintaining this behaviour in the years to come [ ] . when it comes to making physical activity a regular habit, the elements that may be related have been studied in depth [ ] . ecological models are considered one of the most significant theoretical approaches when it comes to analysing habit formation [ ] . these models establish that in addition to individual factors, social and environmental factors are determinant in forming and maintaining physical activity habits [ ] . the covid- pandemic led to the population being confined to their homes [ ] . in spain, from march to april , there was a prohibition on going outside to engage in sporting or social activities. during this period, elements of the built environment and other factors related to individuals' environments were restricted due to the state of alarm. this created a valuable opportunity to assess physical activity without taking these factors into account. experts' recommendations to prevent sedentary behaviour during lockdown included taking active breaks, getting up and walking around the house, and doing online workouts [ ] . however, during the pandemic, an overall negative effect on physical activity intensity was observed, as well as a rise in the consumption of less healthy food and a . % increase in sedentary behaviour [ ] . a reduction in physical activity was also observed in university students [ ] , along with increased levels of anxiety among -to -year-olds [ ] . spanish university students had to continue attending classes online, and their social lives were limited due to the prohibition on going outside. during lockdown, physical activity could have been an opportunity to pass the time, or, conversely, sedentary behaviour could have increased. the other characteristics of each individual (gender, motivation, eating habits, mental state etc.) could have either facilitated or interfered with the decision to exercise. the hypothesis put forward was that students' sedentary behaviour would have increased during lockdown since they were confined to their homes, and that their physical activity would have decreased since they could not go outside to exercise. in this study, we aimed to analyse the physical activity university students did before and during lockdown. to broaden our approach, as a secondary aim, we also wanted to look at changes in physical activity and sedentary behaviour resulting from other factors such as alcohol and tobacco consumption, adherence to a mediterranean diet, motivation, symptoms of anxiety/depression and sociodemographic characteristics. we aimed to evaluate whether there were any differences when certain factors affecting individuals' environments were restricted. this was an observational, cross-sectional, pre-post study on health sciences students, with two cut-off points. the first cut-off point was between and january , prior to the state of alarm being put in place, and the second sample point was between and april . this study received the approval of the ethics and clinical research committee of ciudad real, in spain, with protocol number (c- , / ). this study was carried out within the context of another study that we conducted on healthy habits and lifestyles, with an estimated follow-up period of months. due to the state of alarm and lockdown, recruitment of subjects was temporarily suspended and a decision was made to study the impact of lockdown on the population already participating. there were no exclusion criteria, other than failure to fully complete the questionnaire. to estimate the sample considering a bilateral hypothesis, the following criteria were used: variance in the pre-lockdown control group of , . , obtained using the total minutes of physical activity [ ] , a beta risk of % (power = %), a confidence level of % and a clinically important difference of min with respect to the control group. it was therefore estimated that a minimum of study subjects would be needed. considering a missing values ratio of %, the resulting sample size would be subjects. the students invited to take part were first-to fourth-year students who agreed to respond to the questionnaire at both time points. the questionnaires were administered during the second university semester. the first data collection point was two weeks after the end of the exam period, while the second data collection point was four weeks into lockdown. at the second data collection point, students could not leave their homes except for essential purposes such as buying food or going to hospital. outdoor exercise was prohibited across spain; anyone breaching the rules faced a euro fine. during lockdown, university classes continued online with the same schedule as usual. the university provided internet access or technological devices to any students who requested them so that they could continue attending classes. online classes did not contain any recommendations for students to carry out physical activity. an ad hoc self-administered questionnaire was used, collecting sociodemographic information such as sex, age, weight, height, place of residence during the academic year, smoking habits (yes/no and number of cigarettes per day) and alcohol consumption (yes/no and number of drinks per week). for perceived health status and the existence of problems with anxiety/depression, the euroqol d (eq- d) questionnaire was used [ ] . to assess adherence to the mediterranean diet, the predimed questionnaire [ ] was used, which uses questions to assess the frequency of food consumption and eating habits. each question has a possible score of or . the result allows classification into low adherence or high adherence. stages of change (soc) in physical activity were assessed using prochaska and diclemente's transtheoretical model (ttm) [ ] . five stages of motivation for change were evaluated: pre-contemplation (i don't exercise and i don't intend to), contemplation (i don't exercise, but i'd like to), preparation (i exercise sometimes), action (i have been regularly exercising for less than months) and maintenance (i have been regularly exercising for more than months). physical activity was measured using the international physical activity questionnaire-short form (ipaq-sf), which contains questions [ ] . the questionnaire was used to obtain the total minutes of physical activity per week and sitting time per day. first, descriptive statistical analysis was performed using absolute and relative frequencies for categorical variables and mean with standard deviation (sd) for the quantitative variables. next, bivariate analysis was performed on the whole sample for paired data between weekly minutes of physical activity for the two sample points (pre-lockdown and lockdown). we used the kolmogorov-smirnov test to verify the normality of the quantitative variables. since there were variables that were not normally distributed, we then used the non-parametric wilcoxon signed-rank test. we also used the parametric student-fisher t-test to evaluate whether there were statistical differences in some comparisons and to obtain an approximation of the differences found. finally, the same analyses were performed again, but this time stratified for different sub-groups. mean differences (md) were obtained with a confidence interval of % (ci). all calculations were done using the program spss v . (ibm corp, new york, ny, usa). two hundred and thirteen health sciences students participated in this study. the mean age was . years (sd = . ). of the participants, . % ( ) were women, . % ( ) were normal weight and . % ( ) were smokers. the rest of the demographic characteristics and health parameters are shown in table . then, the results of the ipaq questionnaire were analysed: days and minutes of physical activity per week, as well as time spent sitting per week at both time points studied ( table ) . we observed a significant increase in the number of days on which students engaged in physical activity, both vigorous we then analysed physical activity by group (table ). when we looked at the differences in average minutes of physical activity, all groups analysed spent more time doing physical activity during lockdown (although not all of them significantly). groups that showed significant differences were women; first, second and third year of study; normal or low bmi; and those who did not eat a mediterranean diet. average physical activity time reduced during lockdown for participants in the pre-contemplation (md: . ; % ci: − . , . ) and contemplation (md: . ; %ci: − . , . ) stages. in other words, they spent less time on physical activity, although this difference was not significant. conversely, for those in the preparation (md: − . ; %ci: − . , − . ) and action (md: . ; %ci: − . , − . ) stages, significant differences (p < . ) were observed. in the rest of the groups analysed, statistically significant differences were observed between the two time points, except for men, final-year students, those that were overweight or obese and those that ate a mediterranean diet. finally, the analysis by group (table ) showed significant differences (p < . ) in sitting time before and during lockdown in all groups except first-year students, those that were overweight or obese, smokers and those in the pre-contemplation stage. sitting time increased in all groups of the variables gender, alcohol, symptoms of anxiety/depression and mediterranean diet. it also increased in the following groups: second, third and fourth year of study; normal and underweight bmi; non-smokers; those living in a university residence, shared apartment or with family; and those in the contemplation, preparation, action and maintenance stages. this study aimed to evaluate physical activity and sedentary behaviour in health sciences students before and during the lockdown. at the first time point, students were in their normal study environment, while at the second, their social and environmental setting was limited due to lockdown. the results showed changes in physical activity and sedentary behaviour patterns both globally and by group. overall, students spent more time doing physical activity and spent more time sitting when their usual environment was limited. in the analysis by group, minutes of physical activity increased significantly during lockdown among the following groups: women; all years of study except final year; normal or low bmi; those who did not eat a mediterranean diet; and those in the preparation or action stage of change. sitting time increased in all groups of the variables gender, alcohol, symptoms of anxiety/depression and mediterranean diet. the groups that did not experience differences were: first year of study, overweight or obese, smokers and those in the pre-contemplation stage. these four groups spent the most time sitting at the first data collection point when compared with the rest of their cohort; in other words, sedentary behaviour was already high before lockdown and there were no significant differences at the second data collection point. some researchers believed that lockdown would cause inactivity and an increase in sedentary behaviour and that measures would need to be taken to prevent these effects [ ] . in fact, during lockdown, people modified their lifestyles, with an increase in sitting time due to people spending more time at home, and there was also a reduction in the amount of time spent on physical activity [ ] . in our study, the initial hypothesis was partially confirmed: there was an increase in sitting time, but unexpectedly, there was also an increase in both the amount of time spent doing physical activity and the number of days on which participants were active. we expected to find an increase in sitting time due to the restrictions on movement; however, we also thought that the increase in screen time would reduce physical activity time, since in previous studies conducted in the spanish university population, more screen time was associated with higher inactivity levels [ ] . we do not know the exact reasons why physical activity increased, and we do not know if the effects on physical activity habits would have been maintained if the lockdown had gone on for longer. the environment in which students live affects their sedentary behaviour patterns [ ] , and it seems that the characteristics of health sciences students' environments do not facilitate physical activity. rather than being an obstacle, restricted social relations and not having access to the built environment in their community increased the number of days and minutes students spent doing physical activity. in the case of health sciences students, another factor to consider is that their training in promoting healthy habits may have influenced their decision to exercise at home. no changes in physical activity were found in men. perhaps men and women had different motivations and the environment influences one gender more strongly. in previous studies on motives for physical activity by gender [ ] , some variables that motivated men but not women were elements related to the environment, such as competition or social recognition, while weight control was the main motivation for women. in our study, women accounted for more than % of the sample, so the lack of results may also be due to the fact that there were fewer male participants. the effect of the built environment is yet to be determined for those with a high bmi [ ] . the data in this study show that in overweight or obese students, there were no changes in time spent doing physical activity or sitting time. as we have seen, healthy habits that are ingrained in the population are not affected by the lockdown: this is the case of the mediterranean diet [ ] . in this study, we observed that students that ate a mediterranean diet spent more time doing physical activity and that their physical activity patterns did not change significantly. this suggests that those that lead a healthy lifestyle pay attention to both diet and exercise and persist with their habits regardless of the environment. conversely, those with unhealthy habits stick to them and experience no changes during lockdown. this is the case for smoking and sedentary behaviour. grouping of healthy and non-healthy factors is habitual in university students [ , ] : those that are more sedentary are also more likely to smoke or spend a lot of time watching screens, while those that exercise regularly tend to eat more fruit and vegetables and drink less alcohol. contrary to what we expected, smokers did spend more time doing physical activity during lockdown. it would be interesting to investigate the reasons for this. in our sample of the population, the percentage of smokers was very low, and the number of cigarettes smoked per day was also low, so we believe more research is needed in a sample with more smokers. in our results, we also found differences based on year of study. among final-year students, physical activity did not vary significantly. this group also spent the least time doing physical activity at both time points analysed. in their meta-analysis, keating et al. indicate that with regard to year of study, the majority of studies find no differences in physical activity, but that some studies suggest that higher years of study are less active [ ] . as for sedentary behaviour, it was observed that first-year students spent more time sitting and that lockdown did not bring about any significant changes. some studies, contrary to the findings of our study, observed that students in higher years of study were more sedentary due to a higher workload [ ] . in health sciences students, most of the theoretical workload is in the first year, while in their final year students spend most of their time on placement. another possible factor could be that first-year students might have practiced sport in secondary school and kept up the habit. it would have been interesting to ask students about their sports histories. in this study, we evaluated stages of change, one of the central concepts of the transtheoretical model of change. this model was initially used to treat tobacco and alcohol problems, but it was later adapted to other aspects of health such as physical activity and sedentary behaviour [ ] [ ] [ ] . the analysis of the stages of change and how they affected the participants was very interesting. participants in the first two stages did not experience any changes, and neither did those in the last stage. the behaviour of participants that exercised as part of their routine remained practically the same, as did the behavior of those that did not do any exercise. however, for those that were motivated but had not yet made exercise a regular habit, lockdown was a good opportunity to increase their dedication. in line with these findings, di renzo et al. [ ] observed in a recent study that lockdown increased activity among people that did sport occasionally because they had more time at home, but those that did not do any exercise did not use the situation as an opportunity to start. overall, the results show that minutes of physical activity increased, as did minutes of sitting time. although the results during lockdown are positive in terms of physical activity, it is necessary to recognise that this population might suffer from health issues in the future due to an increase in sedentary behaviour. it would be interesting to find out what the reasons were for students having this behaviour. perhaps they realised that their sitting time increased (they were not walking to class, walking to their car, going shopping, standing up, going to their jobs etc.) and compensated for this with some high-intensity exercise. another aspect that could have affected the results is that the students were involved in the health sciences field, so they may have been more prone to exercising during the pandemic than students in other majors such as engineering or literature. this is why we cannot exclusively consider the limitation of the environment during lockdown to be the cause of the changes in physical activity and sedentary behaviour. it would be interesting to continue studying the elements related to university students' physical activity/sedentary behaviour and their surroundings in order to plan strategies that promote an increase in physical activity levels in this group. our study has various limitations that should be considered. firstly, it is an observational study and all study subjects volunteered to participate in the questionnaire, so there may be a selection bias. secondly, we did not measure whether there was any risk of exposure to covid- infection, a factor that could have influenced our assessment of physical activity and sedentary behaviour. another limitation is the use of a self-administered questionnaire to evaluate physical activity and sedentary behaviour. it would have been more interesting to perform a real assessment of physical activity using accelerometry and also investigate their sports history. this could be a future line of research. finally, the lack of significance in some of the strata analysed could be due to a lack of statistical power because of the low number of subjects in some groups. furthermore, we do not know if these changes in physical activity would have been maintained if lockdown had gone on longer. as for the strengths, this is the first study to look at physical activity and sedentary behaviour in university students studying health sciences both before and during lockdown. in this study, we observed the behaviour of health sciences students when deprived of their usual social and community environment. participants spent more time doing physical activity and also spent more time sitting. university students' social environment may be a barrier to building an exercise habit, especially among women, and motivation seems to have a significant bearing on whether university students engage in physical activity. more efforts should be made to create strategies that motivate students to lead a healthy lifestyle in all aspects (diet, avoiding harmful substances, mental health etc.), with a particular emphasis on engaging in physical activity and reducing sitting time. programs and policies that promote positive youth development and prevent risky behaviors: an international perspective health benefits of physical activity: the evidence health benefits of physical activity: a systematic review of current systematic reviews world health organization. global recommendations on physical activity for health sedentary behavior and cardiovascular morbidity and mortality: a science advisory from the american heart association world health organization. global action plan on physical activity - : more active people for a healthier world levels and patterns of objectively assessed physical activity and compliance with different public health guidelines in university students determinants and patterns of physical activity practice among spanish university students sedentary behavior among spanish children and adolescents: findings from the anibes study how sedentary are university students? a systematic review and meta-analysis correlates of physical activity: why are some people physically active and others not? cultural factors associated with physical activity among u.s. adults: an integrative review physical activity and incident depression: a meta-analysis of prospective cohort studies physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies determinants of health-related lifestyles among university students nouri-aria, k. changes in student physical health behaviour: an opportunity to turn the concept of a healthy university into a reality toward a better understanding of the influences on physical activity: the role of determinants, correlates, causal variables, mediators, moderators, and confounders an ecological perspective on health promotion programs an ecological approach to creating active living communities the resilience of the spanish health system against the covid- pandemic recommendations for physical inactivity and sedentary behavior during the coronavirus disease (covid- ) pandemic. front. public health effects of covid- home confinement on eating behaviour and physical activity: results of the eclb-covid international online survey the impact of isolation measures due to covid- on energy intake and physical activity levels in australian university students exploring lifestyle habits, physical activity, anxiety and basic psychological needs in a sample of portuguese adults during covid- aguilo-pons, a. clustering of lifestyle factors in spanish university students: the relationship between smoking, alcohol consumption, physical activity and diet quality the spanish version of euroqol: a description and its applications a -item mediterranean diet assessment tool and obesity indexes among high-risk subjects: the predimed trial stages and processes of selfchange of smoking:toward an integrative model of change validation of three short physical activity questionnaires with accelerometers among university students in spain how to deal with covid- epidemic-related lockdown physical inactivity and sedentary increase in youth? adaptation of anses' benchmarks cluster analysis of health-related lifestyles in university students neighborhood built environment and socioeconomic status are associated with active commuting and sedentary behavior, but not with leisure-time physical activity, in university students college students' motivation for physical activity: differentiating men's and women's motives for sport participation and exercise role of built environments in physical activity, obesity, and cardiovascular disease eating habits and lifestyle changes during covid- lockdown: an italian survey a meta-analysis of college students' physical activity behaviors role of counseling to promote adherence in healthy lifestyle medicine: strategies to improve exercise adherence and enhance physical activity application of the transtheoretical model to sedentary behaviors and its association with physical activity status levels of physical activity, motivation and barriers to participation in university students funding: this research received no external funding. the authors declare no conflict of interest. key: cord- - trdf authors: jeong, hyun-chul; so, wi-young title: difficulties of online physical education classes in middle and high school and an efficient operation plan to address them date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: trdf this study examined the difficulties of running online physical education classes in the context of coronavirus disease (covid- ) and used the findings to develop an efficient operation plan to address these difficulties. six middle and high school physical education teachers participated; three were experts in online physical education and active in the korea council school physical education promotion, and three were recommended teachers making efforts to improve the online classes offered by the korea ministry of education. a qualitative case study method employing phenomenological procedures to collect and analyze the data was used. the difficulties of operating middle and high school online physical education classes for the first time included ( ) the monotony of the classes within their limited environmental conditions and limited educational content that did not adequately convey the value of physical education, ( ) trial-and-error methods applied nationwide, resulting from a lack of expertise in operating online physical education classes, and ( ) very limited evaluation guidelines proposed by the korea ministry of education, which made systematic evaluation with online methods impossible. to address the identified problems and facilitate the efficient operation of online physical education classes, changes in strategic learning methods are needed to understand online physical education characteristics and thereby better communicate the value of physical education. it is also necessary to cultivate teaching expertise through sharing online physical education classes, where collaboration among physical education teachers is central. in addition, evaluation processes should be less formal to encourage active student participation. the entire world is currently facing a catastrophic situation resulting from the coronavirus disease (covid- ) pandemic, which has affected the daily lives of people worldwide. since the world health organization declared a pandemic on march , avoiding face-to-face activities and engaging in social distancing have become a part of everyday life. the pandemic has also induced changes in many countries' educational environments as they began instituting online classes, including south korea (hereinafter korea), whose schools failed to begin the regular school year in march, for the first time in history. despite this unprecedented situation, korea is actively responding to social changes by offering a diverse school curriculum through online classes and developing new approaches to education. the changes required by the crisis may present an opportunity to adapt to the education needs of the incipient fourth industrial revolution. in many studies preceding covid- , the possibility of online classes has been examined as a part of future education, in that online classes can provide highly efficient and diverse elective classes to self-directed students [ ] [ ] [ ] [ ] [ ] [ ] . physical education centers on physical activity and is clearly distinct from general knowledge-based subjects. therefore, online physical education classes require special preparation and operation to communicate and practice the values of physical education well. currently, as in-person school attendance and online classes are occurring in tandem around the world, there is a need to examine whether online physical education classes are being held and conveying the values of physical education appropriately. prior studies on the efficiency and potential of online physical education classes, however, are limited [ ] [ ] [ ] . one such study focused on physical education textbooks published by the university of north carolina at greensboro and suggested employing direct and indirect experiential activities in addition to physical activities [ ] . it further proposed a teaching and learning strategy for the management of interaction and motivation, learner-centered classes, and the application of a blended learning strategy in middle school physical education classes [ ] . however, most existing studies have only examined the efficiency of college classes, within limited areas; to the best of our knowledge, no studies have investigated the difficulties or efficient operation plans of middle and high school online physical education classes. thus, there is a need to identify the existing practices of and best directions for future online physical education classes, both during and after the pandemic. this study identifies the difficulties of middle and high school online physical education classes and suggests ways to efficiently manage future online physical education classes. the results may serve as basic material to help revitalize online physical education classes in the future. the study employed a qualitative case study method using phenomenological procedures to collect and analyze the data [ ] . "turning to the nature of lived experience" of research participants' online physical education classes, the study explored the experience of conducting these classes, discussed and reflected on their efficient operation and difficulties experienced therein, and examined the data by "writing and rewriting". to find a generalized representation of middle ( - years old) and high ( - years old) school online physical education classes in korea, the researcher selected six participants for this study, who were recommended by the korea ministry of education and the council for school physical education promotion, which pursues the revitalization of physical education in korea. three participants were middle and high school physical education teachers who were experts in online physical education; the other three had worked to improve the three types of online classes offered by the korea ministry of education. all participants provided informed consent to participate in the study, which was approved by the korea jeonbuk national university high school. table shows the characteristics of the research participants. as a physical education teacher at "s" middle school in the th year of his educational career, he runs a "physical enhancement program", an interactive pe class of about students, utilizing zoom. he is a training instructor for online pe content for physical education teachers nationwide and has a good understanding of the pros and cons of interactive pe classes. "i" high school ( classes) female a as a physical education teacher for "i" high school in the th year of her educational career, she runs a "home training and yoga program" using microsoft teams, for a class of . while operating interactive teacher/student physical education classes, she tries to motivate student participation by using various video content and constantly strives for immediate feedback and interaction with students by asking questions via video. content-oriented physical education class "j" middle school ( classes) female b as a physical education teacher for "j" middle school in the th year of her educational career, she runs a content-oriented physical education class using ppt and open broadcaster software (obs studio) programs for a class of . she switched to a content-oriented physical education class after initially running an interactive pe class, in which many students found it difficult to participate. "j" high school ( classes) male b as a physical education teacher at "j" high school in the th year of his educational career, he runs a content-oriented physical education class using youtube and videos he has produced for a class of . he runs a class that combines theory and practice using physical education textbooks. he also works as a lecturer for the j-region physical education research association. assignment -oriented physical education class "h" middle school ( classes) male c as a physical education teacher at "h" high school in the rd year of his educational career, he runs an assignment-oriented physical education class using basic lecture-type content for a class of over . in addition to physical activity assignments, he offers online group learning assignments to students and provides feedback during class. currently, he works as a lecturer in the operation of assignment-oriented physical education classes nationwide. "g" high school ( classes) female c as a physical education teacher at "g" high school in the th year of her educational career, she runs an assignment-oriented physical education class for students. the class is interactive and includes feedback from the teacher and focuses on "national health gymnastics" and "creative gymnastics" developed and practiced by students. the class uses google classroom and is equipped with assignment videos and explanations. pe, physical education. the collected data included material directly produced by the research participants and online videos of their physical education classes. in-depth individual and group interviews were conducted to examine experiences emerging in the participants' journals. we examined the participants' personal diaries and their online physical education class operations. five in-depth individual participant interviews lasting - min were conducted between march and june . the interviews began with participants describing individual operation plans and were centered on the operation of these cases. five group interviews lasting - min were also conducted from april to june , focused on difficulties that were encountered and overcome in the online physical education classes. the group interviews were comprised of open discussions among the research participants, which allowed collaborative and interpretive reflection within a seminar format. an inductive category analysis was employed, focusing on open coding, axial coding, and core coding [ ] . the researcher worked to understand the overall flow and true meaning of the material through repeated reading. the meanings were classified and grouped by subject and analyzed through technical, reflective, and interpretive writing; then, the relationships between the essential elements of the results were identified to determine the overall structure. finally, an iterative process of reinterpretation, modification, and integration was applied to ensure that the generated categories reflected the purpose of the study. to enhance the validity of the study and test the consistency of the findings, a triangulation technique cross-verified data through an in-depth description from various angles using the collected data and the researcher's notes. the derived results were reviewed by the participants to ensure that their meanings were accurately expressed. the quality of the study was ensured through continuous feedback from two qualitative research experts (professor "s" of "j" university and professor "l" of "s" university), who reviewed the entire study process. difficulties in conveying the value of sports in online physical education classes remained in the modified technical practice. this value included maintaining health through physical activities, cultivating community consciousness through physical activities with friends, and developing sports etiquette through sports participation. students engaged in online physical education classes often cannot secure enough space to effectively take part in physical activity and also have limited access to supplies and equipment needed to follow online physical education classes. thus, the participants running the online physical education classes used supplies that were readily available at home, which necessarily reduced the physical education units that could be taught. this led to a shift in focus from competition, which is a major part of in-school physical education, to health and physical activity challenges in online instruction. teacher "a": in online physical education classes, students had to participate alone and use the supplies at home, so it was inevitable that classes were limited. however, it was easy for me to give feedback because i run a real-time interactive class and students practice it immediately in line with my fitness program. teacher "c": real-time interactive classes can be effectively used in a small class, but it seems inefficient in a class of about students. thus, i used lecture-type content to provide explanations and demonstrations, present assignments, and give feedback. teacher "b": i run a content-oriented class, but i had doubts about whether the values of physical education that we wanted to deliver were being conveyed well, given the limited environment and the fact that students had to practice alone. teacher "c": i agree. i had actually planned a class in the competition area, but i could only do classes in the health area. i was worried that the students would feel too complacent about physical education through such classes. teacher "a": i had no choice but to run really monotonous classes like juggling and "challenging" stay-at-home challenges that could be done in students' own houses. (from the first group interview). in contrast to the general knowledge focus of core subject courses, physical education focuses on physical activity, an emotional domain. all participants had concerns about how to convey physical activities in online physical education classes and how to make the online physical education class a meaningful educational activity. in a study of physical activity limitation, kim et al. [ ] reported that various physical educational activities geared toward health should be included in an online class, as most participants, despite various ages and genders, had health problems. it is possible that online physical education classes can be made more efficient if students receive feedback through viewing their own or their classmates' actions. this is in contrast to face-to-face physical education classes, where students can immediately receive feedback on their motor skills or their success completing physical activities. in contrast, students cannot modify their own activities by viewing a video of them, so they receive limited feedback. immediate feedback is needed to motivate students to learn and strengthen their active class attitude. the participants tried to provide feedback across time and space through online media; however, this was difficult, because basic rapport between the teacher and the students and among the students themselves was not able to develop well through the online approach. in addition, the lack of interaction between the teacher and students in online courses made it difficult to convey the value of physical education. there was an interaction between teachers and students when the teacher provided feedback by checking students' online assignment performance. this interaction became an advantage of interactive physical education classes and assignment-oriented physical education classes. however, this was difficult because basic rapport was not developed through the online approach. in addition, the lack of interaction between the teacher and students in online courses made it difficult to convey the value of physical education. (from the in-depth interview of teacher "a"). like the result of the in-depth interview with teacher "a," the interaction between the teacher and the student becomes an important factor for the realization of the value of physical education. this experience suggests that attempts to convey the value of physical education should be initiated later in the semester, after rapport has been developed between the teacher and their students and after the technical skills for various sports have been reviewed [ ] . online physical education classes, instituted nearly worldwide during the pandemic, were a wholly new experience for both teachers and students. the sudden shift to online classes left teachers unprepared and struggling with unfamiliar teaching methods, forcing them to resort to trial-and-error approaches. inadequate online teaching strategies and low teacher and student readiness for online classes made the transition difficult [ ] . i had to think about the content of physical education classes that i could do online with the start of online classes due to covid- , and about the content of the class that could be evaluated when students came to school later. the content of online physical education classes were selected based on individual sports that can be done while maintaining social distancing after school starts. however, as the use of various evaluations (individual evaluation, group evaluation, etc.) was limited due to restrictions on class activities by group, i was very worried about what to do. (from the in-depth interview of teacher "b"). the filming and production of online class materials by the physical education teacher himself took two to three times longer to prepare (e.g., production and editing) than the existing physical education classes. even if various content (youtube, internet materials, etc.) was used, it took a lot of time and effort to search for videos and materials that matched the teaching content of the physical education teacher's class. (from the in-depth interview of teacher "c"). the participants' principal concerns about running online physical education classes centered on the lack of efficient content and difficulties in using the content. they worried about the students' ability to participate in sufficient physical activities given space restrictions and the online course content they created, and whether the course content was educationally meaningful. the availability of media to capture and edit various physical activity photos and videos was absolutely essential for online course preparation. the participants experienced considerable confusion in their initial attempts at online instruction, although the ministry of education and the municipal and provincial education offices provided guidance and training on operating online classes and copyright issues after the switch to online classes. i feel that it is more important than anything else for physical education teachers to develop their ability to efficiently use content in the areas where various aspects of physical activity are expressed and where the content of explanation, demonstration, and feedback is provided. this is an important point that i realized while lecturing in the content utilization training course due to the fact that physical education is unlike the general subjects. i believe that my experience in online physical education classes will definitely be an opportunity. (from the research journal of teacher "a"). the physical education teachers had to revise their education plans, courses, and evaluations several times in their online physical education classes. it is true that it is very confusing. i am going through a lot of difficulties because it is my first time using the content of online physical education classes and making evaluations. (from the in-depth interview of teacher "b"). physical education teachers who were familiar with online content could easily incorporate it. however, others had difficulties even with simple tasks, such as uploading lectures and linking videos from different sites. those who developed their own lectures experienced difficulties preparing for online physical education classes, because they lacked the necessary equipment (cameras, microphones, laptops, etc.), had no access to software for editing images and coding video files, and/or lacked experience in using such software. to maximize the efficiency of online physical education classes, both teacher effort and collaboration with online experts were essential [ ] . the ministry of education presented guidelines for evaluating online classes [ ] , which specified that teachers were to refrain from conducting evaluations unless they could be done face-to-face and recommended conducting evaluations after the return to in-class instruction to the extent possible. participants found it difficult to apply evaluations to online physical education classes. it seemed unreasonable to evaluate students on what they had learned in school following a long period of online classes-especially if these were conducted solely through lectures and assignments without the students actually performing and practicing the activities to be evaluated-particularly because the proportion of the evaluation based on physical activity was high, given the nature of the subject of physical education. this differs from general subject evaluations, where written examinations based on online course work can be administered after the return to in-school classes. although students could submit physical education performance evaluations in the form of videos and written assignments, it would be very time-consuming for large schools to determine whether students had submitted the evaluation materials and then to actually evaluate those materials. in order to evaluate a gymnastics movement, i asked the students to take a picture of themselves doing the gymnastics movement and upload it. however, there were limits in uploading the entire gymnastic movement, and so the evaluation was made in partial movements. in addition, there was too much restriction in providing feedback and evaluation for all images. (from the in-depth interview of teacher "c"). it has been a while since online physical education classes started, but i don't believe that the performance evaluation proposed by the ministry of education is a concrete plan yet. evaluations must be done in terms of efficiency and expandability of online physical education classes. (from the in-depth interview of teacher "b"). teacher "c", who had been conducting performance evaluations based on assignments, found it difficult to complete the evaluations, because performance assessment was not conducted in real time. in addition, she felt that the diversity and specificity of the evaluation was very poor because they were limited to evaluating individual activities through videos. each study participant completed evaluations according to the type of online physical education classes they conducted, and all participants described encountering specific difficulties in completing the evaluations. teacher "a": it is very difficult to check the performance of what students practiced in real-time interactive classes. teacher "a": the home training and yoga practice scenes were evaluated in real time, but the evaluation took too long. teacher "b": the performance assignment was checked through simple quizzes and discussions during the content-oriented class, but there were many difficulties in evaluating the actual activities and conducting detailed evaluations. teacher "b": i believe that the evaluation is essential for online physical education classes. for self-directed learning, the evaluation parts associated with the assignment should be presented in various forms. teacher "c": many teachers spend too much time giving feedback and evaluations in assignment-oriented classes. systematic supplementation is needed online. teacher "c": since there is a very limited amount of information that can be recorded in the student record in the existing evaluation, a new evaluation method that can evaluate and record the learning process should be introduced. (summary of the discussion on evaluations in the second and third group interviews). in the second and third group interviews, participants discussed the difficulties of the evaluation and argued that evaluation concepts and practices for online physical education classes should be re-established based on the current evaluation results. they likewise argued that these concepts and practices should include measures that confirm whether students actively participated in the online physical education classes. in addition, physical activity content that can be viewed online needs to be expanded. online physical education classes need to teach the value of physical activity as an important element of health [ ] . however, before teaching students the value of physical education, teachers should focus on physical education concepts while preparing students to actively participate in the online class. online physical education classes should teach students to subjectively develop future physical activity plans and self-directed competencies. although the internet delivers classes without time and space constraints that nearly everyone can access, such classes are ineffective and inefficient if students do not actively and responsibly participate. in other words, the students' attitude toward self-directed learning is an important factor in the efficient operation of online physical education classes. therefore, teachers need to develop educational strategies for online classes that help students form a learning attitude. engaging and motivating students to participate in physical activities can help convey the value of physical education [ ] . teacher "b": when conducting training for teachers, the issue was raised that no matter how much effort is made by the teacher to conduct a good class, it will be of no use if the students are not willing to listen. in such a case, the plan needs to be re-examined. teacher "c": yes, that is correct. if the online physical education class begins and no assignments are given, it would not be possible to check if the student is listening to the online class. actually, some students do assignments without listening to assignments, which means you can set a group for the class and complete the group work outside of class. thus, i have tried interactive classes among students to complete a set of assignments as a group. teacher "a": that's a good idea. before discussing the value of physical education, it should be preceded by many educational devices and materials so that students can listen to online classes with an attitude toward self-directed learning. teacher "b": yes, i agree. the value of physical education should be naturally achieved in class, and a good class will be meaningless if the students do not have active learning attitudes. teacher "c": yes, i have tried to make changes in the existing physical education class by making students submit reports and videos based on their activities to make them actively participate in class. (from the fourth group interview). in the group interviews, participants discussed the buzz learning method as a way to increase student participation in online classes [ ] . changes are essential for developing and applying group assignments that encourage student participation to overcome the disadvantage of online physical education classes [ ] . new assignment content needs to be developed in the future that will allow teachers to identify an individual student's learning status, just as the research participants developed different educational strategies to increase the value of the class. physical activity does not necessarily need to be central in the actual class to establish the value of physical education; park et al. [ ] reported that the establishment of the value of physical education based on various types of materials is necessary in online physical education classes, as various audiovisual aids and activity equipment are provided to support the positive health behavior of university students. there is a need to develop ways to link the emotional areas while expanding the cognitive and defining areas, which can be an advantage of online physical education classes. teacher "b" made great efforts to motivate and interest students by using physical education textbooks to explain theoretical aspects and presenting images to help students understand the material. indirect experience based on direct experience of physical activity and the value of physical education were delivered through intensive classes in cognitive areas using physical education textbooks. (analyzing the content of teacher "b's" online physical education class). i do not think that it is necessary to teach the value of physical education centered on physical activity. rather, i think that by running this online physical education class, i was able to deliver the value of integrating various topics through theoretical classes in physical education textbooks. i tried to convey the value of physical education by using various video images, arguments, discussions, and reporting that were not well utilized in existing physical education classes. (from the in-depth interview of teacher "b"). online physical education classes are clearly different from traditional physical education classes. participants made changes while running online physical education classes and conveyed the value of physical education in different ways. participants pointed out that one change driven by online physical education classes was the active progress made by physical education teachers through collaboration, which provided training and help to teachers who had difficulty creating content in the early stage of online classes. this collaboration naturally expanded as they produced class videos and shared ideas on assignment methods and structures and class content. this collaboration was driven by the power of collective intelligence within the physical education community and demonstrated a culture of sharing based on the autonomy of the physical education research society and networks among colleagues [ ] . considering that this is my first online class this year, the most distinguishing feature is that there is a place where physical education teachers from a variety of schools share the materials, content, and concerns regarding online physical education classes. would you say that we were tightly united in a crisis? it seems to have served as an opportunity for physical education teachers to reduce the trial-and-error and to develop better physical education classes. (from the in-depth interview of teacher "c"). the research participants' videos showed that physical education teachers collaborated on making demonstrations and teaching, thereby producing more professional content by producing a joint video that fit the class subject. (from the researcher's journal) . the importance of the teacher learning community is reported in many studies on the development of teacher expertise [ ] [ ] [ ] . physical education class videos continue to be produced and teachers continue to cultivate their expertise as they develop and produce these class videos. research participants continued to develop their expertise by searching for educational materials, including carefully examining materials from the council school physical education promotion and the physical education research society, while developing online physical education classes. they further developed their expertise by producing and editing their own videos. the results of their efforts provide a good example of how to effectively prepare for future physical education. i was at a loss when i first started preparing for online physical education classes, but i received a lot of help from the teachers at the physical education research society. in addition, it really helped me cultivate my expertise while reflecting on my class. it was also very helpful to be able to view the classes of other physical education teachers, which used to be hard to see before. (from the in-depth interview of teacher "a"). it was great to be able to look at the really valuable materials in the council school physical education promotion and the national physical education teacher group's "katokbang". it was good to see many physical education teachers collaborate and build their expertise in "an opportunity that lies in a crisis". that is why i became confident in my class, too. (from the in-depth interview of teacher "c"). physical education teachers who strive to improve their expertise give students faith in the subject. faith creates interdependence through communication between the teacher and the students and also acts as an "invisible bridge" in physical education classes [ ] . faith between the teacher and students can also be indirectly formed by the teacher's demonstrating instructional content and expertise while running an online class. efforts are needed to cultivate professional and practical knowledge suitable for online physical education classes through changes in teaching and learning methods, interaction with students, a broad understanding of the area, and expanded knowledge. online physical education performance is difficult to evaluate. traditional evaluations are extremely limited, including online and offline integrated evaluations, process-oriented evaluations, and physical activity-oriented evaluations. the research participants adapted their evaluation methods to determine whether the student achievement standards were met and whether advancement to the next class was appropriate. teacher "a": teacher evaluation is conducted by looking directly at the student's activities. peer evaluation is conducted by students looking at one another. teacher "a": our evaluation method entails showing various videos that fit the topic of the class and talking about the feelings they elicit in real time. teacher "b": there is no direct evaluation, and the achievement standards are reviewed by looking at the class and simply writing the overall content in the form of a report. teacher "b": a self-assessment is conducted to determine whether the student has participated in class with an attitude toward self-directed learning, and whether the student has completed the assignments, but they are not reflected in the student's score. teacher "c": evaluations cannot be made because it is an assignment-oriented class. images of the student's physical activity are used to deliver feedback through student self-assessment and teacher evaluation. teacher "c": based on the attached content of assignments carried out by the student, the course is recorded in the physical education section of the student's study record. (summary of evaluation discussion in the fourth and fifth group interviews). one characteristic of online education is that students can develop unique thinking through learning activities that meet their needs and cultivate creativity through the process of thinking [ ] . evaluation methods need to be improved to capture the process of verbalizing students' thoughts. it is necessary to conduct evaluations in the form of an inspection to understand the educational value of online physical education classes, much like the way in which the research participants expanded the evaluation to assess diagnosis, formation, and achievement in addition to performance. the above student faithfully carried out the assignments regarding national health gymnastics during online physical education classes, understood and analyzed teacher and peer evaluation feedback, and faithfully participated in the assignments. (from the examples of study records by teacher "c"). teacher "a" evaluated interactive lessons in real time, but emphasis was placed on the students who delivered feedback and made corrections according to the feedback. in addition, a peer evaluation method was applied to the class in which feedback was provided by watching videos that in real-time interactive class, meaning other students watch the monitor video between students through informal evaluation. (analyzing the content of teacher "a's" online physical education class). research participants used informal evaluations to record student participation in the study record as a way to induce active participation. this was done while using the performance evaluation content required in physical education classes as a learning strategy. evaluation of the online classes, which was conducted for the first time in , is not yet concrete, and efficient evaluation methods and content should be examined in future studies. this study examined the difficulties teachers experienced in running online physical education classes following the start of online schooling in korea in the context of covid- and presented an efficient operation plan for future online physical education classes. the difficulties of operating online middle and high school physical education classes included monotony related to limited environmental conditions and educational content, which ultimately decreased the effectiveness of conveying to students the value of physical education. it is necessary in this light to discuss the value of physical education during online classes. second, physical education teachers across the country lacked expertise in employing online content and had to resort to trial-and-error methods. to address problems like these, we expect that effective content will develop in various directions due to the covid- outbreak. third, student evaluations conducted in accordance with the evaluation guidelines proposed by the korea ministry of education were very limited, and a systematic evaluation was not possible because of the online nature of the classes. there is a possibility that a new evaluation method that can be operated effectively in online classes will need to be constructed. in addition, to develop effective online physical education classes, strategic learning methods that incorporate online physical education characteristics are needed to help teachers communicate the value of physical education. in delivering the values of physical education, which is the goal of physical education in korea, addressing the psychodynamic domain and affective domain, which are lacking in online classes, will certainly improve the efficiency of online physical education classes. second, physical education teachers need to prepare for the future methodology of physical education and acquire professional practical knowledge through sharing online physical education content. this collaboration among physical education teachers is central and should incorporate expertise from the korea physical education research society. third, it is necessary for students to make an effort to actively participate in online physical education classes and record the process in their life record books through discussion of evaluation methods and methods suitable for an online physical education class. in this study, the research participants did not have extensive experience in information and communication technology coming into the pandemic and the advent of online education, but they nevertheless actively participated in online physical education classes and played the role of representatives of korea, making the active efforts required by the times. finally, the need is apparent to explore various cases of online physical education, teachers' and students' experiences, and their meaning, to improve the generalizability of the lessons learned. the study findings had several implications. first, it is necessary to study the state of different countries' experiences in online instruction physical education instruction, comparing and analyzing how online physical education classes are conducted worldwide. accordingly, there is a need to review and systematize approaches to online physical education classes that highlight each country's cultural and educational characteristics and to examine the effectiveness of online physical education classes as a whole. second, there is a need to explore the potential of online physical education classes linked to face-to-face physical education classes to examine their respective effectiveness and potential possibilities in light of physical education teachers' increased expertise gained through their operation of online physical education classes. third, future studies should establish a theoretical framework for online physical education classes by examining the educational value of modifying existing pedagogical methods, content, evaluations, and so on to more effectively teach online physical education classes. fourth, future studies should also examine the efficiency and affordances of different online platforms employed by physical education teachers and evaluate their generalizability across actual school sites, especially as novel tools are developed. interaction and presence in the virtual classroom: an analysis of the perceptions of students and teachers in online and blended advanced placement courses study on application of online instruction for enhancing rights for learning: focusing on high schools a study on college students' perception on convenience in online courses the effects of the flipped learning sensory integration therapy class using online learning platform on learning participation on-line classroom visual tracking and quality evaluation by an advanced feature mining technique. signal process providing high school students with online instruction for optional curriculum development and application of e-learning contents to pre-service physical education teacher education a case study on structure and possibility of online courses in physical education a study on teaching and learning plan of physical education in middle school using blended learning strategy linked researching liver experience basics of qualitative research: grounded theory procedures and techniques differences in causes of activity limitation by sex and age determination of china's online physical education object an investigation of design constraints in the process of converting face-to-face course into online course guidelines for attending, evaluating and recording remote classes to respond to corona instructional strategies for secondary school physical education inquiry on justification of the physical education on the view of value theory the need of buzz learning in real-time distance education developing a model of health behavior intentions and actual health behaviors of korean male university students exploration of culture and meaning of participation in secondary physical education study group a case study of using an online cafe in a physical education teacher learning community an investigation of the impacts and factors influencing elementary teachers' participation in a physical education teacher learning community teacher communities as a context for professional development: a systematic review. teach. teach a self-study on the management experience of learner-centered physical education characteristics of online teaching in post-secondary, formal education funding: this research received no external funding. the authors declare no conflict of interest. key: cord- -sbieo s authors: oni, tolu; micklesfield, lisa k.; wadende, pamela; obonyo, charles o.; woodcock, james; mogo, ebele r. i.; odunitan-wayas, feyisayo a.; assah, felix; tatah, lambed; foley, louise; mapa-tassou, clarisse; bhagtani, divya; weimann, amy; mba, camille; unwin, nigel; brugulat-panés, anna; hofman, karen j.; smith, joanne; tulloch-reid, marshall; erzse, agnes; shung-king, maylene; lambert, estelle v.; wareham, nicholas j. title: implications of covid- control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries date: - - journal: global health action doi: . / . . sha: doc_id: cord_uid: sbieo s at the time of writing, it is unclear how the covid- pandemic will play out in rapidly urbanising regions of the world. in these regions, the realities of large overcrowded informal settlements, a high burden of infectious and non-communicable diseases, as well as malnutrition and precarity of livelihoods, have raised added concerns about the potential impact of the covid- pandemic in these contexts. covid- infection control measures have been shown to have some effects in slowing down the progress of the pandemic, effectively buying time to prepare the healthcare system. however, there has been less of a focus on the indirect impacts of these measures on health behaviours and the consequent health risks, particularly in the most vulnerable. in this current debate piece, focusing on two of the four risk factors that contribute to > % of the ncd burden, we consider the possible ways that the restrictions put in place to control the pandemic, have the potential to impact on dietary and physical activity behaviours and their determinants. by considering mitigation responses implemented by governments in several lmic cities, we identify key lessons that highlight the potential of economic, political, food and built environment sectors, mobilised during the pandemic, to retain health as a priority beyond the context of pandemic response. such whole-of society approaches are feasible and necessary to support equitable healthy eating and active living required to address other epidemics and to lower the baseline need for healthcare in the long term. in rapidly urbanising low-and middle-income countries (lmic), the realities of large overcrowded informal settlements, a double burden of infectious and non-communicable diseases (ncds), malnutrition and the precarity of livelihoods [ ] have raised added concerns about the potential impact of the covid- pandemic. control measures implemented in these settings include closing of national and state/county borders, and schools, restricted movement (including frequency of shopping), working from home, provision of water in informal settlements for hand hygiene, physical distancing and the banning of large gatherings. these measures have been shown to slow down transmission, buying healthcare systems preparation time [ ] . however, there has been less of a focus on the indirect impacts of these measures on health behaviours and consequently health risks, particularly in the most vulnerable. these restrictions have the potential to impact ncd risk factors such as dietary intake and physical activity behaviours [ ] , by limiting access to healthy foods and to environments conducive to physical activity. while many of the interventions to curb the pandemic are intended to be temporary, they have exposed existing inequities in disease vulnerability and access to care. the amplification of these inequities is resulting in poorer disease outcomes and negative impacts on livelihoods among the poor and marginalised. this debate piece will describe how the implementation of restrictions to limit the spread of the pandemic may impact diet and physical activity behaviours, as well as their determinants. we also reflect on the experiences from mitigation interventions mobilised by several governments to respond to this pandemic, and the potential for these to be leveraged beyond covid- in order to retain health as a priority. with the implementation of measures to prevent further spread of covid- infections, lmics are experiencing two inter-related pandemics. our public health response to the covid- pandemic may be exacerbating behaviours such as unhealthy food consumption, physical inactivity and sedentary behaviour. these aforementioned behaviours are considered the key drivers of obesity epidemic globally, and obesity is a risk factor for adverse outcomes of covid- infection [ ] . external dimensions of the food environment include the availability, price, vendor and product properties, and promotional information. by comparison, personal dimensions of the food environment are the accessibility, affordability, convenience and desirability of food sources and products. these food environment exposures, which vary considerably between and within high-, middle-and lowincome countries, influence food choices, dietary habits, and food security [ , ] . the covid- -related closures of national borders threaten food supply especially in countries already facing food insecurities and those largely dependent on food imports. as a result, maintaining adequate food production, import, storage and transportation can be precarious for both external and personal dimensions of the food environment. the dynamics of purchasing and consumption of healthy food in this context, driven by limited access to fresh foods and refrigeration, has highlighted the growing wealth inequality within countries. for many, the new reality of shelter-in-place measures has resulted in an increase in cooking and eating at home. on one hand, this presents an opportunity for preparing more healthy meals at home. however, a lack of nutritional knowledge and cooking skills, increased snacking behaviour, unavailability and increased costs of healthy foods [ ] , and the lack of guidelines to ensure nutritional quality of food parcels to the poor [ ] may result in a shift to more unhealthy processed food consumption. this is particularly important for lower-income households without the means, or in some cases, the access to refrigeration, to stock up on fresh food supplies. in addition, school closures result in interrupted access to food for children from households that depend on school-feeding programmes, adding to the financial burden and household food insecurity. these measures are also resulting in a staggering loss of jobs and livelihoods that further impact on people's ability to afford healthy foods. the predominance of the informal economic sector and absence of robust social safety schemes in lmics further compound food affordability. in these circumstances, without social welfare measures, the most vulnerable are left with no choice but to defy social distancing measures to avoid hunger. covid- control measures inevitably disrupt routine daily activities and may have positive or negative consequences on physical activity behaviours. stay-at-home orders and curfew measures result in reduced travelling, which in many cases includes walking, potentially reducing the opportunity for physical activity. reduced regular physical activity alone, or compounded by unhealthy eating may result in an increased risk or worsening of chronic conditions such as obesity, diabetes, hypertension and cardiovascular disease [ , ] , which are increasing in prevalence in lmics [ ] . these are the very conditions that have also been associated with an increased risk of hospitalisation and death from covid- [ ] . some evidence from other emergencies suggests that the deleterious effects of physical inactivity and sedentarism that begin during an outbreak may continue for some time after the end of the outbreak [ ] . conversely, this new reality may encourage more physical activity as people seek respite from being stuck at home, particularly if the reduction in traffic makes built environments more conducive to physical activity in public spaces. as such, it would be important to mitigate indirect negative consequences to encourage safe physical activity. while doing this at home would be ideal, it is important to recognise that for the majority of the urban poor, particularly in the context of informal settlements [ ] , this will not be practical. furthermore, outdoor physical activity has been associated with greater enjoyment and increased likelihood of achieving the recommended levels of physical activity [ ] . this highlights a critical need for guidelines on safe physical activity outdoors at the different alert levels of pandemic response. many governments in lmics have implemented measures to minimise covid- risk while working to address underlying social inequities that further increase vulnerability to disease. in so doing, the emergency has highlighted the possibility of previously considered impossible or unfeasible actions [ ] . we note the following reflections from these pandemic responses that could be applied to current and future epidemics and pandemics to support equitable access to healthy diets and physical activity: ( ) wide-ranging multisectoral action to reduce inequalities is possible at pace when there is social and political will. the response to the covid- pandemic has seen unprecedented multisectoral action compared to responses to the ongoing obesity pandemic. of note, governments have led coordination of multisectoral responses, removing bureaucratic processes that could hinder support for vulnerable communities. for example, in kenya, the ministry of agriculture has partnered with county governors to aggregate information on the volumes and prices of staples and nutritious foods in order to ensure affordability [ ] . county governors have also prioritized identifying vulnerable families to ameliorate food insecurity [ ] . beyond this pandemic, mapping access to nutritious foods and governing their equitable distribution can be utilised to improve dietary behaviours, especially for the urban poor. the implementation of riskcontainment strategies has also required effective partnerships at the community level, with community health volunteers and grassroots organizations constituting the last mile of distribution of health information, rapid testing, healthy food and other supplies. beyond an acute emergency response, continued collaboration with these same partners can ensure that physical activity and healthy diets remain accessible. in another example of government-led strategies to support food security, the state commissioner for agriculture in nigeria established makeshift neighbourhood food markets in schools in lagos which were closed due to the lock down [ ] . in a megacity where fresh food markets are often centralised in large markets, like mile market [ ] , this intervention brought fresh food supplies closer to neighbourhoods to mitigate the impact of the closure of centralised markets and movement restrictions across the city. in jamaica, with the closure of international borders and the sudden loss of the demand for food from the tourist industry, the government introduced community-based cashless farmers markets and distribution of fixed priced 'vegetable baskets' though community organizations to reduce the waste of perishable agricultural items and help support this sector [ ] . larger food manufacturers also increased capacity for fruit preservation though production of purees and manufactured new fruit blends [ ] . beyond this pandemic, it would be important to reflect on and evaluate the experience of these endeavours to inform longer term strategies to make fresh foods more locally available within neighbourhoods. ( ) covid- has revealed significant flaws in our existing urban infrastructure. these flaws include economic systems that reduce resilience to food insecurity, and streets that prioritize motorised traffic, making physical activity for leisure or travel unsafe. understandably, the majority of emergency mitigation responses have focused on food security. however, some settings such as bogota, colombia have created new space for walking and cycling [ ] while the jamaican ministry of health and wellness has shifted focus to television and social media-based exercise programmes [ ] . given that physical distancing measures are likely to be recommended for some time, contextually relevant research to encourage and support safe accessible physical activity for all should inform recovery plans related to the built environment. ( ) there is a need for public health interventions jointly to reinforce democracy, the rights of the individual and the collective good. in the context of acute response to emergencies, varying approaches have been adopted including extensive tracing using big data and deployment of the police to enforce movement restriction measures. if rights are side-lined, these measures potentially compromise data privacy and individual rights if applied in a discriminatory manner. this highlights the importance of a rights-based approach to public health, recognising that the right to health is dependent upon other human rights (such as food, housing, information and participation) and that even well-intended enforcement could bring harms. a rights-based approach could similarly be applied to addressing the obesity pandemic. for example, governance of urban space could ensure that organizations charged with enforcing lockdown measures are thoroughly oriented in equitable governance approaches, and partner with community stakeholders to improve access to neighbourhood resources including safe spaces for physical activity. additionally, it can include collaboration with key actors to facilitate access to space for urban agriculture for the poor. while the impacts of these interventions are yet to be evaluated, these examples hint at the potential for whole-of-society approaches to building stronger systems for health and lower the baseline need for healthcare. in the long term, it is vital that the economic, political, food and built environment sectors mobilised during the pandemic are encouraged (and governed) to retain health as a priority. societies that support and enable healthy eating and active living are vital to reduce vulnerability to covid- and other diseases and pandemics in the long term. urban health research in africa: themes and priority research questions how will country-based mitigation measures influence the course of the covid- epidemic? fact sheet on noncommunicable diseases. geneva: world health organization world health organization. covid- and ncds concepts and critical perspectives for food environment research: a global framework with implications for action in low-and middle-income countries nutrition amid the covid- pandemic: a multi-level framework for action pmbejd media statement: food prices and public health messages in a time of covid- food aid parcels in south africa could do with a better nutritional balance physical inactivity and cardiovascular disease at the time of coronavirus disease (covid- ) covid- related school closings and risk of weight gain among children opensafely: factors associated with covid- -related hospital death in the linked electronic health records of million adult nhs patients physical activity and sedentary behaviour among children and adolescents living in an area affected by the great east japan earthquake and tsunami for years slum health: arresting covid- and improving well-being in urban informal settlements does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? a systematic review covid- )-inducedre-imagination: things we knew but could do nothing about until we could and did state seeks to ensure food security in covid- war joho sets aside sh million to help cushion residents of mombasa from cessation order lagos holds makeshift food markets in schools thursday mile market booming sales at kingston and st andrews farmers markets agriculture and fisheries. agri ministry collaborates with tru-juice to process excess produce bogotá expands bike lanes to curb coronavirus spread jamaica moves encourages home exercise to led the conceptualisation, initial drafting, and the overall drafting process of the manuscript.lkm and pw co-led drafting of significant components of the manuscript and overall drafting process.coo, jw, em, fao, fa, lt were responsible for drafting and editing of subsections of the manuscript.lf, cmt, db, aw, cm, nu, abp, kjh contributed to the editing and finalisation of the manuscript.js, mtr, ae, msk, evl, njw contributed to final edits of the manuscript. no potential conflict of interest was reported by the authors. not applicable. in urban populations with inadequate access to sanitation, food and physical activity, and growing obesity and ncd burden, covid- control measures can widen health inequities. addressing the pandemic while mitigating this vulnerability calls for a rights-based approach to governance of urban space. multisectoral government covid- responses in these cities to address social inequities highlight the feasibility of economic, political, food and built environment sectors, mobilised during the pandemic, to support healthy eating and active living. key: cord- -ubw chrf authors: newbold, stephen c.; finnoff, david; thunström, linda; ashworth, madison; shogren, jason f. title: effects of physical distancing to control covid- on public health, the economy, and the environment date: - - journal: environ resour econ (dordr) doi: . /s - - - sha: doc_id: cord_uid: ubw chrf physical distancing measures are important tools to control disease spread, especially in the absence of treatments and vaccines. while distancing measures can safeguard public health, they also can profoundly impact the economy and may have important indirect effects on the environment. the extent to which physical distancing measures should be applied therefore depends on the trade-offs between their health benefits and their economic costs. we develop an epidemiological-economic model to examine the optimal duration and intensity of physical distancing measures aimed to control the spread of covid- . in an application to the united states, our model considers the trade-off between the lives saved by physical distancing—both directly from stemming the spread of the virus and indirectly from reductions in air pollution during the period of physical distancing—and the short- and long-run economic costs that ensue from such measures. we examine the effect of air pollution co-benefits on the optimal physical distancing policy and conduct sensitivity analyses to gauge the influence of several key parameters and uncertain model assumptions. using recent estimates of the association between airborne particulate matter and the virulence of covid- , we find that accounting for air pollution co-benefits can significantly increase the intensity and duration of the optimal physical distancing policy. to conclude, we broaden our discussion to consider the possibility of durable changes in peoples’ behavior that could alter local markets, the global economy, and our relationship to nature for years to come. in the initial months of the covid- pandemic, most nations have attempted to control the spread of infections by reducing the rate of contacts between people who carry the virus and those who have not yet been exposed. the various methods to achieve such reductions in contacts are referred to generically as "physical distancing" measures-also known as "social distancing" or "spatial distancing" (abel and mcqueen ) . while physical distancing can reduce the death toll of the pandemic, it also can impose large costs on society as exemplified by the sharp declines in gdp and employment in the months following the initiation of physical distancing measures in the united states (sachs ; u.s. department of labor ) . this suggests there could be substantial gains from properly calibrating the intensity and the timing of physical distancing restrictions. in this study, we characterize the time path of physical distancing that minimizes total economic damages from controlling the covid- epidemic in the united states, accounting for a potentially important category of environmental co-benefits. we develop an integrated epidemiological-economic model that includes a standard model of disease transmission, the monetized value of covid- deaths averted and lives saved from exposure to air pollution, and the short-and long-run costs of physical distancing. the model includes the main features of the disease spread process and the economic trade-offs associated with broad-based physical distancing measures that represent the main approach to controlling the spread before a vaccine or effective treatments are available. we expand the model used in on our earlier benefit-cost analysis of physical distancing in several ways (thunström et al. ) . first, we explicitly connect the intensity and timing of physical distancing to both lives saved from the infection and the income lost from reduced work hours and lowered productivity. second, we incorporate the co-benefits of reduced mortality risks from declines in air pollution during the period of physical distancing. this extension is motivated by a striking side-effect of physical distancing, as indicated by visibly reduced levels of ambient air pollution in many areas around the world (iea ; venter et al. ) . globally, outdoor air pollution is responsible for around . million premature deaths per year (world health organization a), and recent estimates for the u.s. range from around , to , premature deaths per year attributable mainly to pm . (burnett et al. ; bowe et al. ; goodkind et al. ) . adding an air pollution component to our model allows us to account for the lives saved from reductions in pollution emissions as a co-benefit from physical distancing measures whose primary purpose is to control the spread of infections. third, we include a putative link between air pollution and the virulence of covid- . several recent studies have attempted to identify an interaction effect between air pollution and covid- transmissibility or case fatality ratios ogen ; persico and johnson ) . initial results of these studies suggest that airborne particulate matter could have a significant positive mediating influence on covid- fatalities, so we use our model to explore the potential effect of this link on the optimal physical distancing policy. our study draws on a mature literature that integrates economics and epidemiology to examine a wide variety of infectious diseases in humans (e.g. gersovitz and hammer ; rowthorn et al. ; perrings et al. ; fenichel et al. ; gersovitz ; fenichel ; philipson ) . we also add to a growing collection of recent studies that apply optimal control theory or computational dynamic optimization techniques to the covid- outbreak in particular (e.g. acemoglu et al. ; alvarez et al. ; eichenbaum et al. ; farboodi et al. ; gonzalez-eiras and niepelt ; kruse and strack ; piguillem and shi ; toxvaerd ) . a comprehensive review of these studies would take us too far afield, so here we briefly describe several closely related studies to highlight points of comparison between our work and that of others in the literature. farboodi et al. ( ) develop a continuous-time optimal control model with a vaccine backstop and endogenous physical distancing by optimizing individuals. they show that without regulation, individuals choose a sub-optimal level of physical distancing, reducing economic activity too late to achieve the socially optimal level of disease suppression. the optimal policy is characterized by an initial rapid ramp-up and a long duration of an intermediate level of physical distancing until a vaccine is developed. the authors apply a calibrated version of the model to the covid- epidemic in the united states, which shows that the optimal policy delays the peak of infections to buy time for a vaccine. eichenbaum et al. ( ) examine macroeconomic impacts of pandemics by modeling the behavioral responses of individuals to the evolving tradeoff between consumption and health risks during an infectious disease outbreak. they assume that the risk of infection increases with consumption, which leads to a decline in both market demand and supply during a pandemic, resulting in an economic recession. alvarez et al. ( ) and kruse and strack ( ) also study the optimal timing of physical distancing, accounting for both deaths due to infection and the economic costs of physical distancing, assuming that a vaccine or fully effective treatment will be developed within one year. in both cases, the optimal policy response allows infections to rise until they are close to the medical system capacity, and then physical distancing measures are rapidly implemented to keep the number of infections below the medical system's capacity constraint for a period of time that dampens or eliminates a second wave of infections. acemoglu et al. ( ) include multiple risk groups in a pandemic control model, where the groups are characterized by differing interaction behaviors and by age, which affects their fatality risk if infected. the authors use the model to examine the effects of targeted lockdowns, and find that differentiated lockdown policies will outperform those that are uniformly applied to the whole population. gonzalez-eiras and niepelt ( ) consider the implications of non-optimally timed physical distancing programs, and find that the net benefits of the policy can be drastially reduced if controls are initiated too early or kept in place too long. toxvaerd ( ) characterizes the equilibrium (unregulated) behavior of individuals in a model of infectious disease spread with no risk of death but with reduced flow utility in the infected state and with a linear cost of physical distancing. the equilibrium path of physical distancing has the effect of flattening the curve of infections at a characteristic level of infections determined by a combination of epidemiological and economic parameters. our model differs in the details but shares many of the same basic features as those reviewed above, including a traditional epidemiological model of disease spread and a representation of the influence of physical distancing on deaths from the infection and economic output or income. our main modeling innovation is to incorporate a link between physical distancing and air pollution, as well as the interaction between pollution and the covid- fatality rate. to our knowledge, our study is the first to examine this link in an optimal control framework, which allows us to assess a potentially important category of co-benefits from physical distancing. a final note before proceeding to the details of the model. we view our approach, like the studies described above, as closer to the "streamlined" than the "elaborated" end of the spectrum of possible models. we include the main features of the system relevant to our primary research questions, but otherwise we intentionally simplify as much as possible. we agree with pindyck ( ) that calibrated sir models applied to the covid- outbreak should be viewed as only rough approximations to reality and taken with a grain of salt. at the same time, even if they cannot provide precise forecasts and definitive policy prescription, we believe that strategically simplified models roughly calibrated to the stylized facts can be useful for developing qualitative insights and for generating preliminary comparisons of alternative control scenarios. to project the number of infections and deaths under various physical distancing policies, we use a discrete-time sir compartment model (kermack and mckendrick ; hethcote ) . we modify the standard model to represent the influence of physical distancing on the contact rate and the endogeneity of the case fatality ratio as the health care system becomes overwhelmed by a surge of infected individuals seeking medical care. we include a link between physical distancing and mortality from air pollution, as well as an interaction between air pollution concentrations and the covid- case fatality ratio. the shortand long-run economic costs of physical distancing depend on the average distancing fraction prior to the arrival of a vaccine and the assumed speed of economic recovery. the equations of motion for susceptible, infected, and recovered individuals are and in eq. ( ), is the contact rate without physical distancing, and x t is the fractional reduction in the number of potential transmission encounters that all individuals-both susceptible and infected-have in period t (alvarez et al. ) . we refer to x t as the "distancing fraction," which will serve as the control variable in the regulator's optimal control problem. in eq. ( ), is the rate of recovery from infection (the reciprocal of the average duration that individuals remain infected and able to spread the virus), and d t is the number of deaths due to infection in period t. denoting the case fatality ratio by t , the number of infected individuals who die in period t is note that t is the probability of dying from the infection before recovering, not the per period probability of death for infected individuals (keeling and rohani , p ) . we model the case fatality ratio as endogenous to the system, and indirectly responsive to the physical distancing policy through its influence on the evolution of infections. as the number of infected individuals requiring medical care increases, the health care system becomes stressed. this leads to infected individuals receiving a lower standard of care as scarce medical resources are spread ever more thinly. we represent this feedback by a logistic function of infections, ( ) where lo is the lower-bound case fatality ratio, which will obtain when i t is much lower than a critical value of infections, Ĩ (corresponding to the inflection point of the logistic function), and hi is the upper-bound case fatality ratio, which will obtain when i t is much higher than Ĩ . the parameter k controls the steepness of the logistic function, so for high k the relationship approaches a step function with lo for all i t <Ĩ and hi for all i t >Ĩ , as assumed in thunström et al. ( ) . we assume that recovery from infection yields immunity to the virus, although this has not been firmly established for covid- . while a number of studies find that people develop antibodies from the infection, the extent of protection from subsequent infections is still uncertain (world health organization b). equations ( )-( ) comprise the modified sir model with physical distancing and endogenous case fatality ratio. we use this model to project the number of infections and deaths under various physical distancing policies represented by the time path of the distancing fractions, x t . the regulator's task is to find and enforce the sequence of x t 's that minimizes the total damage from the outbreak, which includes the value of lives lost due to infection, minus the value of lives saved due to reduced pollution, plus the value of current and future income lost due to the reduced economic activity associated with physical distancing. we account for the value of lives saved from air pollution in the period of physical distancing due to lower emissions from reduced economic activity. to do so, we use a proportional hazard model (cox ; harrell ) , which implies that the number of deaths averted in a time period due to a reduction in pollution concentration from z to z is where m is the initial deaths from all causes in the time period, z is the initial level of air pollution, z is a lower level of pollution due to reduced economic activity caused by physical distancing, and is the air pollution hazard coefficient. to compress notation in what follows, we define the fractional reduction in the average pollution concentration during the period of physical distancing as z x , so z − z = z x z . air pollution emissions increase with overall economic activity, with an especially strong link to activity in the transportation sector. to represent this linkage, we assume that air pollution emissions on day t are a possibly non-linear function of the physical distancing fraction, x t . specifically, the fractional reduction in the average pollution concentration during the period of physical distancing is where days are indexed by t, and t is the duration of the physical distancing policy in days. the exponent controls the shape of the response of pollution to physical distancing. = is the linear case, for which z x = t ∑ t t= x t , while < ( > ) implies a sub-linear (supra-linear) response of emissions to distancing, in which case the fractional reduction in pollution with physical distancing would be less than (greater than) the distancing fraction. to understand how a non-linear response could arise, suppose that the average individual's inter-personal contacts are evenly split between contacts with co-workers at the workplace and contacts with friends and neighbors close to home. also suppose that commuting to and from work accounts for more (less) than half of the average individual's vehicle miles travelled and associated pollution emissions. if early increments of physical distancing mainly involve work-from-home policies, then, under the prior suppositions, the average person's inter-personal contacts would be reduced by half while her pollution emissions would be reduced by more (less) than half, which implies > (<) . here we use = , which we view as natural default assumption. several recent studies have examined possible links between air pollution and covid- related deaths. long-term exposure to air pollution contributes to many of the underlying health conditions that put people at higher risk for severe consequences from covid- , particularly respiratory diseases. such respiratory conditions also might be exacerbated by contemporaneous air pollution concentrations, which could compromise the body's ability to mount an effetive immune response to covid- . focusing on the u.s., find that a g ⋅ m − higher long-term average concentration of pm . (between the years - ) is associated with an % increase in the covid- fatality risk. other researchers have examined the possibility that airborne particulate matter (pm) facilitates the transmission of sars-cov- through the air (martelletti and martelletti ; di toppi et al. ; setti et al. ) , which could increase force-of-infection for repiratory disease transmission (tang et al. ). persico and johnson ( ) used the suspension of u.s. environmental protection agency enforcement activities as a natural experiment to estimate the impact of short-run decreases in pollution on covid- fatalities at the county level, and find large effects. to examine the potential importance of such a link for the optimal physical distancing policy, we include an interaction between air pollution and the covid- case fatality ratio, which appears in eq. ( ) above. this allows us to compare the overall deaths from infection and lives saved from air pollution between otherwise equivalent model runs with and without the interaction included. when the interaction is included, the case fatality ratio in each period is adjusted by a factor that depends on the overall reduction in air pollution due to physical distancing, i.e., where is the air pollution-infection interaction coefficient. to value lives saved from infection or air pollution, we use a central estimate of the "value per statistical life" (vsl). this quantity represents the average marginal willingness to pay for reducing the probability of death in a time period, i.e., the marginal rate of substitution between money and mortality risk (viscusi ). here we use a constant vsl, though some authors use age-adjusted vsl values, typically declining for older individuals (e.g. greenstone and nigam ) , and others value the expected loss of life-years rather than expected deaths (e.g. hall et al. ). pindyck ( ) also suggests that a lower average vsl value should be used when the number of deaths averted is large, due to diminishing marginal willingness to pay for risk reductions. the influence of age on the vsl has been examined in a number of previous studies (e.g. shepard and zeckhauser ; kniesner and viscusi ; evans and smith ; hammitt ) , but no clear consensus on a ( ) � t = t e − z x z , singular strategy to adjust for age has yet emerged in the literature. in the meantime, we follow u.s. federal agency recommendations and use a fixed central value of the vsl for all ages in our benchmark runs ( the relationship between the extent of physical distancing and lost income in society is typically taken to be linear (e.g. alvarez et al. ; toxvaerd ; kruse and strack ; piguillem and shi ; bolzoni et al. ; hansen and day ; lee et al. ). yet the possibility exists that the amount of income lost may be lower or higher than the physical distancing fraction. we introduce flexibility into the physical distancing cost function by allowing for non-constant returns to the rate of interpersonal contacts; specifically, we assume that per capita income on day t is a possibly nonlinear function of contacts, i.e., y t ∝ ( − x t ) , where = is the linear case and < ( > ) implies decreasing (increasing) returns, in which case the fraction of income lost with physical distancing would be less than (greater than) the distancing fraction. if mixing can be reduced initially by some people working remotely, traveling less, minimizing face-to-face meetings, etc., without being furloughed or losing their jobs, then would be less than . considering that some fraction of the workforce can reduce mixing with relatively little loss of productivity, we view = as a conservative benchmark assumption. we account for both the short-run and long-run cost of physical distancing. the shortrun cost is the present value of lost income during the period of physical distancing, where y is aggregate income per day with no physical distancing, and r ′ is the daily discount rate. the long-run cost of physical distancing is the present value of lost income after the period of physical distancing, which will depend on the speed of economic recovery after the initial decline in aggregate income. to represent the long-run cost, we assume that income growth will be temporarily elevated as the economy recovers from the shock, and the post-outbreak growth path will asymptotically approach the counterfactual no-outbreak growth path at a constant rate . based on these assumptions, and discounting future income at a constant rate r, the present value of lost income after the period of physical distancing is is the fractional loss of aggregate income during the period of physical distancing, y is aggregate annual income before the outbreak, and r is the annual discount rate. combining the relevant elements specified above, the total damage function is equation ( ) combines the value of covid- deaths, the value of averted air pollution deaths, and the value of lost income in the short-run and the long-run. note that the control variables, x t , are implicit in eq. ( ), through the definitions of z x , y x , v, and v, and through the dependence of the d t 's on the x t 's as determined by eqs. ( )-( ). following thunström et al. ( ) , we use r = . (liu et al. ; ferguson et al. ; aronson et al. ), = / . (liu et al. ; lauer et al. ) , lo = . , and hi = . (riou et al. ; wilson ; yang et al. ; dorigatti et al. ; unwin et al. ). in a sensitivity analysis, we use r = . , which is closer to the more recent estimate reported by sanche et al. ( ) . to specify the inflection point of the case fatality ratio function, Ĩ , we assume that if × hospital beds are occupied by covid- patients-roughly half of the . × staffed beds in u.s. hospitals (american hospital association )-then the case fatality rate would be at the mid-point of its possible range between lo and hi . wu and mcgoogan ( ) reported that % of covid- cases in china were "critical," so we assume that % of covid- infections will require the use of a hospital bed. this gives Ĩ = × . ÷ . = infected individuals. that is, if on any given day million people are infected by the virus, then a fraction ( lo + hi )∕ would not be expected to survive. we set the steepness parameter, k, to give a pronounced s-shape but not a severe step function. to calibrate the air pollution hazard coefficient, , we rearrange the proportional hazard function in eq. ( ) in our benchmark model we do not include an interaction between air pollution and the covid- case fatality ratio, so we set = . a causal link between these variables could have a profound impact on the optimal physical distancing policy, so we examine the implications of such a link in model variations using two preliminary estimates of this association. first, persico and johnson ( ) find that a short-run increase in pm . of g ⋅ m − is associated with a doubling of the covid- case fatality ratio, so in a "strong link" model variation we set = ln ( ) . second, find that differences in long-run average pm . concentrations among u.s. counties of g ⋅ m − is associated with an percent increase in the covid- case fatality ratio, so in a "weak link" model variation we set = ln ( . ). to quantify the benefits of lives saved, we use a benchmark vsl value of $ million. this is a central estimate from hedonic wage studies of the value per statistical life (viscusi ; kniesner and viscusi ) , and is consistent with u.s. federal agency benefit-cost guidelines (u.s. environmental protection agency ; u.s. department of transportation ). in a sensitivity analysis we use a lower value of $ . million, which is consistent with the average age-varying vsl used by greenstone and nigam ( ) to monetize the impact of physical distancing in the u.s. to specify , which controls the long-run costs of physical distancing, we make an assumption about the time required for aggregate income to recover to its counterfactual no-outbreak path. specifically, we define the recovery time, t r , as the time required for the gap between the actual gdp path and the no-outbreak path to shrink by %, i.e., e − t r = . , so = −t − r ln ( . ) . we assume t r = years, double the average recovery time among all bear markets since (sachs ), which gives = . yr − . finally, to compute the present value of future income losses, we use a u.s. federal agency recommended discount rate of r = . to solve the model, we use a numerical policy iteration approach (bertsekas ) . first, we initialize the distancing fraction to zero for the entire time horizon, x t = ∀t . then we compute the gradient of the objective function ( where Δ is a suitably small step size), and repeat for i = , , , ..., i max iterations. for consistency and reproducibility we use i max = , which appears to be sufficient to achieve convergence for all cases examined in this paper. we use the model to characterize the optimal timing and intensity of physical distancing to control the covid- outbreak in the u.s., and to examine the influence of air pollution co-benefits on the optimal physical distancing policy. considering the uncertainty surrounding many aspects of the system, our benchmark parameters described above and shown in table are meant to serve mainly as a point of comparison for alternative cases. to maintain continuity with previous work, our benchmark parameters are largely consistent with thunström et al. ( ) , aside from the new model features. three key parameters that drive the model results are the basic reproduction number, r , the value per statistical life, vsl, and the curvature of the physical distancing cost function, . results for our benchmark case and two additional cases involving variations in one or two of these key parameters are presented in figs. , , and table . the graphs in fig. show results for our benchmark case, which uses our preferred central parameter values and most closely resembles our prior analysis (thunström et al. in all four air pollution variations, the optimal policies shown in panel (a) are initiated with an abrupt increase in the distancing fraction just in time to arrest the early rapid spread of the pathogen and prevent the number of infections from exceeding the critical threshold of the health care system. as i t approaches the threshold, it is optimal to nearly instantaneously increase the physical distancing fraction from to around . , which in our benchmark case is initiated on day . ignoring air pollution altogether (solid line), after the immediate rapid increase the physical distancing fraction is then reduced nearly linearly until around day . the policy then increases again, modestly and temporarily, before finally decreasing to zero by day . at the other extreme, when air pollution co-benefits and a strong link between pollution and covid- deaths are included (dotdashed line), the policy begins with nearly identical timing and intensity but is maintained at a higher intensity for a longer duration, decreasing to zero by day . qualitatively, the optimal policies in all four air pollution co-benefit variations involve an early rapid increase in the distancing fraction, then a gradual decline over the course of nearly a full year. the influence of air pollution co-benefits on the shape of the optimal policy is negligible if no link between pollution and covid- is included, but is prominent if the link is strong. the horizontal line in panel (b) corresponds to Ĩ , the inflection point of the case fatality ratio function, and the vertical line corresponds to n( − ∕r ) , the herd immunity threshold for susceptible individuals. the phase diagram in fig. shows that all four controls lead to similar s−i curves, each turning down shortly before the critical threshold is reached and extending to just beyond the herd immunity level, which serves to prevent a second wave of infections after physical distancing restrictions are lifted. the rapid increase in the distancing fraction for all variations shown in panel (a) flattens the curve of infections, as shown in panel (b). the general pattern is similar to those found in other optimal control studies, including alvarez et al. ( ) and kruse and strack ( ) . key outcomes for the benchmark case are provided in the first column of table . using our benchmark parameters, the uncontrolled outbreak results in just over million covid- deaths. this is a result of nearly million cases of infection and the elevated case fatality ratio due to the critical threshold of the health care system being exceeded for a large portion of the duration of the uncontrolled outbreak. the controlled scenarios all save nearly . million lives or more relative to a no-distancing scenario, depending on the influence of air pollution in each variation. when air pollution co-benefits are excluded altogether, . million covid- deaths are averted by physical distancing, which also leads to an initial decline in gdp of nearly . percent. when air pollution co-benefits are included but with no link between air pollution and covid- deaths, the control policy becomes slightly more stringent, as indicated by the slightly larger immediate decline in gdp of . percent. in addition to the . million covid- deaths averted, , air pollution deaths due are averted due to the temporarily reduced levels of pm . during the period of physical distancing. this is roughly percent of the baseline air pollution deaths ( , ), so the lives saved from air pollution are roughly proportional to the immediate decline in gdp. in the third variation, which includes a weak link between air pollution and covid- deaths ( = . , based on , the control policy is now discernably altered from the "no air pollution" variation. with a weak link, . million covid- deaths are averted, which includes an additional , averted deaths due to the interaction between air pollution and the covid- fatality risk. this is nearly ten times larger than the , deaths averted due to the direct effects of air pollution on mortality. the final variation includes a strong link between air pollution and covid- deaths ( = . , based on persico and johnson ). in this case more than million covid- deaths are averted, including more than . million due to the interaction with air pollution, and , deaths are averted due to the direct effects of air pollution. the stronger interaction between air pollution and covid- deaths in this variation leads to a control policy that is sustained at a higher stringency and for a longer duration, which in turn leads to a larger immediate decline in gdp of . percent. in all four air pollution variations the optimal control policy concludes well before the time horizon of the model, which is years ( days). this suggests that if a vaccine will not be available before that time, then the vaccine would not affect the optimal physical distancing policy. the vaccine still would be useful in reducing the risk of future infections from imported cases, but it would not be necessary to eliminate the risk of a future outbreak due to community spread because the number of susceptible individuals would have already been decreased below the herd immunity threshold. childhood vaccinations also might be warranted after this time to prevent the number of susceptible individuals from climbing back above the herd immunity threshold over time as immune individuals die and new cohorts enter the population without immunity. and if infection does not confer lifelong immunity, then the role of a vaccine increases further still. results for the second case are shown in fig. and the second column of table . in this case, all parameters are held at their benchmark values except the curvature of the physical distancing cost function, which is here set to = . . this implies a concave relationship between interpersonal contacts and income, which means that the first increments of physical distancing, which involves a reduction in the rate of interpersonal contacts, are less costly than later increments. in this case the proportional decline in income is less than the physical distancing fraction. the effect of this assumption is to make physical distancing less costly overall, which leads to an optimal policy that is more stringent and of longer duration than our benchmark case, as shown in panel (a) of fig. . here the control policies start around day and conclude between days and . with a less costly physical distancing technology, the influence of including air pollution co-benefits is more pronounced. even the variation with no interaction between pollution and covid- fatalities is discernible in panel (a), and the variations with a weak and strong link extend the duration of the policy roughly months and months, respectively. the quantitative differences in outcomes can be seen in table . when air pollution co-benefits are excluded entirely, more covid- deaths are averted ( . million) at a lower immediate decline in gdp ( . percent) relative to our benchmark case in column . accounting for air pollution co-benefits reveals that an additional , deaths are averted due to reduced air pollution exposure, but otherwise the outcomes are nearly identical to the no air pollution variation. assuming a weak link between air pollution and covid- deaths, the policy adjusts to avert . million covid- deaths, which includes , deaths averted due to the interaction with air pollution. assuming a strong link with air pollution leads to a dramatic increase in the duration of the policy and the number of deaths averted for about the same cost as in the benchmark case, as reflected in the nearly equivalent immediate gdp decline of . percent. in addition, given the increased stringency and duration of the program, the relative influence of air pollution co-benefits is magnified. panel (a) in fig. demonstrates the significant difference in optimal physical distancing with and without air pollution cobenefits, and the cumulative numbers of pollution deaths averted increases significantly. while total costs in this case increase, the increased numbers of deaths avoided more than compensates and therefore extends the duration of physical distancing measures. by comparison to our benchmark case, these results suggest that large gains in efficiency could be achieved if the cost heterogeneity of component physical distancing measures is high, and if we are able to deploy the component measures in decreasing order of their cost-effectiveness (newell and stavins ) . results for the third and final case we examine in this paper are shown in fig. and the third column of table . in this case we vary two parameters: r is increased to . [closer to the estimate reported by sanche et al. ( ) ], and vsl is decreased to $ . million [to match the average value used by greenstone and nigam ( ) ]. the optimal control policies and associated outcomes are qualitatively different in this case. relative to our first two cases, here the optimal policy rapidly increases to a much higher level of stringencybetween . and . -but is sustained for a much shorter duration-between about and days. as a result, the curve of infections is not immediately flattened as in cases and . in this case, it is optimal to let infections exceed the medical system threshold before initiating physical distancing. infections are allowed to grow past million in the variation with no air pollution co-benefits, and past million in the variation with a strong link between infection fatality risk and air pollution. when physical distancing restrictions are initiated, the high stringency of the measures quickly reduces the number of infections back below the medical system threshold. thereafter, physical distancing measures are gradually released until herd immunity is achieved. when air pollution co-benefits are included and a strong link between pollution and covid- deaths is assumed, the peak of infections under the optimal control policy is just over one third of the uncontrolled peak. here again we see that a strong link between pollution and covid- deaths has a large influence on the shape of the optimal control policy, but even in this variation the curve of infections is not completely flattened below the critical threshold of the health care system. the optimal policy fails to flatten the curve in this case for two reasons. the obvious reason is that with a lower vsl the demand for saving lives is lowered. assigning a lower value to mortality risks reduces the implied damage to society from the outbreak and results in reduced net benefits of the control policy. the less obvious reason is that with a higher r , physical distancing is less effective at stemming the spread of the virus: reducing r from a very high level to a high level prevents fewer infections than reducing r from a high level to a medium level (thunström et al. ). these two effects combine to yield an optimal policy that allows a much larger number of deaths than cases and . (in other cases not reported here, we found that the infection curve is flattened with r = . and vsl = $ million, and is nearly flattened with vsl = $ . million and r = . .) physical distancing has so far been the most widely used policy to control the spread of sars-cov- . while the benefits to physical distancing are large, given the substantial number of lives saved, such measures also impose significant private and social costs. in this study we characterized the intensity and timing of physical distancing that minimizes total economic damages from controlling covid- , and we examined the co-benefits of lives saved from air pollution and a potential link between air pollution and covid- fatalities. our model jointly considers physical distancing that results from policies (mandates or recommendations) and individual decisions to self-protect, independent of policies. benefits from physical distancing are recorded as lives saved, while costs are measured as the loss of income in both the short run (during the period of physical distancing) and the long run (as the economy recovers from the initial shock). on the benefit side, lives saved result both from averted covid- deaths and averted air pollution deaths. in our integrated epidemiological-economic model of covid- in the u.s., deploying a physical distancing policy with optimal timing and intensity saves millions of lives and generates significant net benefits in comparison to an uncontrolled scenario with no physical distancing. we also find that thousands more deaths are averted due to the reduction of air pollution emissions from physical distancing, and hundreds of thousands more covid- deaths are averted if we assume a strong causal link between air pollution concentrations and the covid- fatality risk, which is suggested by some preliminary evidence of this association. more than million deaths from infection are predicted in the uncontrolled scenarios, and even in the optimally controlled scenarios more than million deaths are predicted. to provide some context for these results, fig. shows the imputed time path of the effective reproduction number, r e , which is proportional to the contact rate as it changes over the course of the outbreak (aronson et al. ) , and the physical distancing fraction, x t , from march through june , in the united states. the graphs are based on u.s. centers for disease control and prevention (cdc) reports of the cumulative number of infections (cdc ), assuming that the spread of the virus evolves according to an sir model similar to the one used in our optimal control scenarios (see the "appendix" for details). the the number of infections and deaths relative to a counter-factual scenario with no physical distancing. compared to the number of cases so far reported in the u.s., which provide the basis of the graphs shown in fig. , the optimal control paths shown in figures , , and allow a much larger number of infections to accumulate early in the outbreak before the rapid escalation of physical distancing [consistent with other recent studies, e.g. alvarez et al. ( ) and kruse and strack ( ) ]. this strategy provides a head start on achieving herd immunity while still preventing the number of people who are infected at any one time to exceed the critical threshold of the health care system. if aggressive physical distancing measures are implemented before many infections have occurred and are maintained at a sufficiently high intensity to keep the number of infections very low over time, then when physical distancing measures are relaxed a second wave of infections will occur because the number of susceptible individuals would still be very high. at least two categories of control options not considered here could change the character of this result. either the widespread use of cloth masks (eikenberry et al. ; howard et al. ) , or a program of diagnostic testing and self-quarantine (piguillem and shi ; taipale et al. ; allen et al. ) , or a combination of these, might allow the relaxation of physical distancing and avoid a second wave of infections while awaiting the development of a vaccine or effective treatment. if a vaccine or treatment were to become available before the optimal distancing policies in figs. , , and are concluded, then a higher intensity and shorter duration physical distancing policy may be optimal. cloth masks and testing and self-isolation measures might also serve as effective substitutes for physical distancing restrictions at all stages of an outbreak, so incorporating these additional control measures into our model would be a useful extension in follow-up work. several other limitations of our model also should be highlighted. first, we value only the reduction in the fatality risks from infection to the exclusion of all other adverse health outcomes short of death. in benefit-cost studies of environmental regulations, fatality risk reductions typically comprise percent or more of the monetized health benefits (e.g. cropper et al. ), but it is not clear whether this will apply to covid- cases. second, the narrow peaks of the infection curves in figs. , , and are characteristic of a single well mixed population. in reality, the u.s. may be better represented as many connected population centers in a spatially explicit model of disease spread, which could produce a series of overlapping and interacting infection curves more closely matching the observed patterns of cases (unwin et al. ) . we also do not distinguish between individuals of different ages or pre-existing health conditions that may make them more vulnerable to covid- (acemoglu et al. ) , nor do we distinguish between symptomatic and asymptomatic cases (stock ) . we also do not model the un-coordinated physical distancing responses of individuals in an unregulated scenario. rather, we compare the optimal physical distancing policy to a completely uncontrolled epidemic, in which individuals engage in no self-protective behaviors. (as might occur if covid- were widely but erroneously viewed as no more dangerous than the seasonal flu.) standard economic theory predicts that if the true risks are known then people would choose to distance themselves to a degree that their individual net benefits are maximized (toxvaerd ). with high enough infection and fatality risks, we would expect some voluntary physical distancing, but generally less than the economically efficient level. because our net benefit estimates presented in table are calculated with respect to a no-physical distancing counterfactual scenario, they provide an upper bound on the net benefits of externally imposed physical distancing restrictions. we also ignore a number of other potentially important side-effects of physical distancing, which may include increased incidence of domestic abuse as families spend more time at home (van gelder et al. ), increased fatality rates from other adverse health conditions as people delay treatment to avoid infection in hospitals (lazzerini et al. ) , reductions in crime rates (mohler et al. ) , adverse mental health effects of school closures (lee ) , and increased rates of suicide due to social isolation (gunnell et al. ) . finally, we focus on economic efficiency and do not address the equity implications of the disease risks or the economic effects of physical distancing. like for covid- related deaths, the adverse health effects of air pollution are asymmetrical across race and income (e.g. bowe et al. ) , and we would expect the economic costs of physical distancing also to be borne disproportionately by marginalized groups and low income households. to conclude, we discuss some potential environmental implications of the pandemic beyond the links between covid- , physical distancing, and air pollution examined in our optimal control model. our aim in this closing section is two-fold: to acknowledge the narrow focus of our control model, and to highlight opportunities for further research by environmental economists going forward. our brief discussion here is complementary to helm ( ) , iges ( ), and barbier ( ) , who provide broader discussions of the potential long-run environmental impacts from covid- . a key question highlighted by these articles is whether the necessary fiscal stimulus implemented to accelerate the economic recovery will have the effect of re-entrenching the status quo or helping societies "build back better" by improving economic resilience and environmental quality in tandem. we organize our closing discussion by considering possible long-run changes in how people will work, rest, eat, and play after covid- . first, among the most important components of physical distancing measures widely adopted during the early months of the pandemic are work-from-home policies, reduced international and domestic travel for in-person meetings, and distance education. to the extent that technical change involves learning by doing, this could lower the cost and thereby increase the long-run prevalence of remote work and online learning. this could in turn reduce polluting emissions from ground and air traffic and make durable a portion of the short-run decline in emissions observed in the early days of the pandemic, thereby slowing the rate of climate change and reducing the incidence of adverse health effects due to pollution. covid- also could accelerate the contraction of globalization, reducing the trade of goods and services and the movement of people among nations. this re-animates a large literature on the impacts of globalization on the environment (boyce ; gallagher ). another possibility, likely to vary considerably among nations, is that the cost of economic recovery could crowd-out existing environmental regulations. if there is a de facto constraint on the overall size and scope of government regulations in a country, then an expanded role for government in the provision of public health may lead to a diminished role in the provision of environmental protection. closer to home for readers of scholarly journals like this one, we wonder about the implications of this episode for the conduct of economic research and science communication, including the publication and promotion through popular media of rapid results prior to formal peer review. we see pros and cons of the current emergency response by academics to the pandemic. rapid dissemination of pre-prints may allow for more timely and actionable science to reach the decision-makers who need it, but also might lead to a higher rate of false results (e.g. freedman ; joseph ; majumder and mandl ). striking the right balance between false positives and false negatives in published results during normal times is a complicated (and we think understudied) problem, and it is not clear whether and how the balance should change in times of a public health crisis like covid- . second, will covid- have a lasting influence on where people choose to rest-that is, where they choose to live? if large cities are engines of economic growth-a conventional but not a consensus view (e.g. annez and buckley ; parkinson et al. ; frick and rodríguez-pose )-but also come be known as engines of infectious disease outbreaks (stier et al. ) , what are the implications for the optimal spatial patterns of human settlements? any such influence would have important long-run implications for the environment (newman ) . for example, if the covid- pandemic helps to slow or reverse the trend of migration from rural areas to urban centers in the u.s. (harris poll ), this would in turn change the overall amount and the spatial pattern of pollution and habitat loss. if compact human settlements are better for biodiversity, then a reversal of the trend toward agglomeration in urban centers could have adverse effects on nature and the provision of valuable ecosystem services. this would increase the importance of learning how to design dispersed human settlements that are closely connected to nature with minimal environmental impact, rather than reducing impact by concentrating human settlements into smaller areas. third, will covid- have long-run implications for food production and consumption? the pandemic could reduce both the demand and the supply of meat products due to increased concerns about safety on the part of consumers and increased costs of production if stricter safety regulations are imposed on producers. shifting away from animal to plant based proteins has the potential to significantly reduce impacts on the environment, including carbon dioxide emissions (tukker et al. ) . preferences for domestically produced food also might increase, as the covid- crisis highlights the urgency for securing a sufficient domestic food supply as a means of enhancing the resilience of local economies in the face of heightened risks of pandemics or other large scale disruptions in the future. whether this will positively or negatively affect land conservation or the climate depends on the policy choices made about the changes to food supply. finally, will the pandemic have a lasting influence on how people spend their leisure time? if people become motivated to shift a portion of their time use to outdoor recreation activities-which might pose lower risks of infection than leisure activities indoors or outdoors in large crowds (rice et al. ; venter et al. ; samuelsson et al. )-this could increase the instrumental value of a clean environment and untrammeled wilderness areas. it also could expand the health benefits from exercise outdoors (lippi et al. ; mattioli and ballerini puviani ; gössling et al. ) and the more general well-being benefits from spending time in nature (bratman et al. ; white et al. ). on the other hand, if people withdraw from travel both abroad and at home and spend more time indoors watching screens, or if yet another case of a pathogen jumping from an animal species to humans (zoonosis) (andersen et al. ; berry et al. ) makes some people more fearful of close contact with nature, the health benefits of outdoor recreation might contract rather than expand. the results from our control model presented in this paper suggest that there may be important environmental side-effects that could alter the optimal intensity and duration of physical distancing policies used to manage the covid- epidemic. many interventions designed to affect consumer behaviors have been shown to work in the short run, but people typically revert back to their prior behaviors after the intervention is removed (e.g. nisa et al. ) . so the safe bet may be that the salutary environmental side-effects of physical distancing will dissipate as fast as economic activity resumes after the outbreak. on the other hand, some past public health crises have led to lasting and high-impact changes in behaviors. these include long distance migrations in the united states during the th century to escape unhealthy living conditions in eastern cities (baur ; abrams ) , and improved personal and public hygiene practices that today we take for granted such as regular health care visits and hand washing habits (agüero and beleche ; foss ) . if covid- leads to behavioral changes as durable as those spurred by past epidemics, the environmental implications of the outbreak may extend far beyond the short-term air pollution impacts examined here. the covid- pandemic calls for spatial distancing and social closeness: not for social distancing! on the road again: consumptives traveling for health in the american west, - a multi-risk sir model with optimally targeted lockdown health shocks and their long-lasting impact on health behaviors: evidence from the h n pandemic in mexico roadmap to pandemic resilience: massive scale testing, tracing, and supported isolation (ttsi) as the path to pandemic resilience for a free society a simple planning problem for covid- lockdown fast facts on u.s. hospitals the proximal origin of sars-cov- urbanization and growth: setting the context when will it be over?": an introduction to viral reproduction numbers, r and r e greening the post-pandemic recovery in the g the health seeker in the westward movement, - the allocation of time and risk of lyme: a case of ecosystem service income and substitution effects value and policy iterations in optimal control and adaptive dynamic programming optimal control of epidemic size and duration with limited resources burden of cause-specific mortality associated with pm . air pollution in the united states green and brown? globalization and the environment nature and mental health: an ecosystem service perspective global estimates of mortality associated with long-term exposure to outdoor fine particulate matter euthanizing the value of a statistical life covid- ): cases in the u expected health effects of reduced air pollution from covid- social distancing regression models and life-tables valuing mortality risk reductions: progress and challenges novel coronavirus: how atmospheric particulate affects our environment and health report : severity of -novel coronavirus (ncov). imperial college london the macroeconomics of epidemics to mask or not to mask: modeling the potential for face mask use by the general public to curtail the covid- pandemic do we really understand the age-vsl relationship? shimer r ( ) internal and external effects of social distancing in a pandemic economic considerations for social distancing and behavioral based policies during an epidemic adaptive human behavior in epidemiological models impact of non-pharmaceutical interventions (npis) to reduce covid mortality and healthcare demand how epidemics shaped modern life a prophet of scientific rigor-and a covid contrarian big or small cities? on city size and economic growth economic globalization and the environment the economics of infection control the economical control of infectious diseases bear essentials: a guide to navigating a bear market fine-scale damage estimates of particulate matter air pollution reveal opportunities for location-specific mitigation of emissions ) pandemics, tourism and global change: a rapid assessment of covid- does social distancing matter? suicide risk and prevention during the covid- pandemic trading off consumption and covid- deaths valuing changes in mortality risk: lives saved versus life years saved optimal control of epidemics with limited resources regression modeling strategies: with applications to linear models, logistic and ordinal regression, and survival analysis amid the covid- pandemic, urbanites are eyeing the suburbs the environmental impacts of the coronavirus three basic epidemiological models rimoin aw ( ) face masks against covid- : an evidence review global energy review implications of covid- for the environment and sustainability. institute for global environmental strategies studies, including one that raised safety concerns about malaria drugs modeling infectious diseases in humans and animals containing papers of a mathematical and physical character the value of a statistical life life-cycle consumption and the age-adjusted value of life optimal control of an epidemic through social distancing. cowles foundation discussion paper the incubation period of coronavirus disease (covid- ) from publicly reported confirmed cases: estimation and application delayed access or provision of care in italy resulting from fear of covid- mental health effects of school closures during covid- . the lancet. child & adolescent health optimal control for pandemic influenza: the role of limited antiviral treatment and isolation sanchis-gomar f ( ) physical inactivity and cardiovascular disease at the time of coronavirus disease (covid- ) the reproductive number of covid- is higher compared to sars coronavirus early in the epidemic: impact of preprints on global discourse about covid- transmissibility air pollution and the novel covid- disease: a putative disease risk factor covid- pandemic: the effects of quarantine on cardiovascular risk impact of social distancing during covid- pandemic on crime in los angeles and indianapolis estimating mortality risk reduction and economic benefits from controlling ozone air pollution cost heterogeneity and the potential savings from market-based policies the environmental impact of cities meta-analysis of randomised controlled trials testing behavioural interventions to promote household action on climate change assessing nitrogen dioxide (no ) levels as a contributing factor to the coronavirus (covid- ) fatality rate city size and economic performance: is bigger better, small more beautiful or middling marvellous? merging economics and epidemiology to improve the prediction and management of infectious disease deregulation in a time of pandemic: does pollution increase coronarirus cases or deaths? in: iza institute of labor economics discussion paper series economic epidemiology the optimal covid- quarantine and testing policies covid- and the welfare effects of reducing contagion the covid- pandemic is changing the way people recreate outdoors: preliminary report on a national survey of outdoor enthusiasts amid the covid- pandemic adjusted age-specific case fatality ratio during the covid- epidemic in hubei, china optimal control of epidemics in metapopulations urban nature as a source of resilience during social distancing amidst the coronavirus pandemic high contagiousness and rapid spread of severe acute respiratory syndrome coronavirus the potential role of particulate matter in the spreading of covid- in northern italy: first evidence-based research hypotheses survival versus consumption what's in a name? a search for alternatives to "vsl covid- attack rate increases with city size. mansueto institute for urban innovation data gaps and the policy response to the novel coronavirus population-scale testing can suppress the spread of covid- . medrxiv measuring the impact of air pollution on respiratory infection risk in china the benefits and costs of social distancing to flatten the curve for covid- toxvaerd f ( ) equilibrium social distancing. cambridge-inet working paper series environmental impacts of changes to healthier diets in europe state-level tracking of covid- in the united states. imperial college covid- response team employment insurance weekly claims guidance on treatment of the economic value of statistical life (vsl) in us department of transportation analyses- adjustment circular a- : regulatory analysis covid- : reducing the risk of infection might increase the risk of intimate partner violence urban nature in a time of crisis: recreational use of green space increases during the covid- outbreak in oslo spending at least minutes a week in nature is associated with good health and wellbeing case-fatality risk estimates for covid- calculated by using a lag time for fatality world health organization ( a) air pollution immunity passports" in the context of covid- . scientific brief exposure to air pollution and covid- mortality in the united states: a nationwide cross-sectional study characteristics of and important lessons from the coronavirus disease (covid- ) outbreak in china: summary of a report of , cases from the chinese center for disease control and prevention mortality in the united states early estimation of the case fatality rate of covid- in mainland china: a data-driven analysis to produce the graphs in fig. of the main text, we assumed that the spread of the virus evolved according to an sir model with an effective contact rate that varies over time with changes in physical distancing . referring back to equations ( )-( ), the effective contact rate on day t is t = ( − x t ) , and the number of new infections on day t is t s t i t , where is the contact rate with no physical distancing, and x t is the distancing fraction on day t. the u.s. centers for disease control and prevention (cdc) reports the cumulative number of infections since january , (cdc ). denoting the cumulative number of infections reported prior to day t as c t , we can write c t+ − c t = t s t i t . ignoring deaths for simplicity, this leads to the following sequential procedure for imputing t , r e,t , and x t based on the reported values for c t and an assumed value of : key: cord- -aft agxx authors: mittal, vijay a.; firth, joseph; kimhy, david title: combating the dangers of sedentary activity on child and adolescent mental health during the time of covid- date: - - journal: j am acad child adolesc psychiatry doi: . /j.jaac. . . sha: doc_id: cord_uid: aft agxx nan while the impact of the coronavirus disease (covid- ) pandemic, subsequent quarantine, and social distancing on physical activity has been covered extensively, there has been limited focus on the resulting sedentary behaviour on existing and emerging psychopathology. this is particularly disconcerting regarding children and adolescents, who rely on the ability to play to meet developmental milestones and require more exercise than adults. youth populations have been significantly disrupted by school closures and home confinement and are in developmental periods that overlap with the emergence of serious mental illness. therefore, it is important to consider the mental health consequences for youth, and also explore ways to combat sedentary activity for this vulnerable population. participation in individual and group exercise has been found to be a robust pro-health activity, both in terms of building social support structures and resiliency factors, as well as in engaging mechanisms driving the onset and persistence of serious mental illness. there is now a large body of literature showing that physical inactivity increases the risk of mental illness. for example, while the relationships between physical activity and mental health have potential for reverse causality, well-powered mendelian randomization studies (which can determine causal relations), using objectively-assessed physical activity, have convincingly demonstrated that high levels of physical inactivity exert a casual effect on increased depression risk. alongside this, longitudinal data supported the protective effect of physical activity on depression and anxiety, which are highly ubiquitous in childhood and adolescence, with benefits more pronounced in youth than adult samples. likewise, sedentary behaviour has been found to correlate with risk markers in adolescents at clinical high-risk for psychosis. the current reality of widespread covid- infections in many countries pose a substantial challenge to remediating this state, especially with concerns about a looming j o u r n a l p r e -p r o o f additional waves. however, potential solutions do exist -these can be seen in terms of public space, school, and home-based strategies. public space options are numerous, though some of the more promising strategies would require cooperation from government and adaptive public policy. for example, at the neighbourhood level local leaders might work to allow staggered and monitored playground access with hand sanitizer availability. streets might be closed so that children and teens can play in a social distanced fashion in their community. with close cooperation, these strategies could be easily adapted to meet the constraints and needs of lockdown/stay-at-home orders versus periods of social distancing. where outdoor school infrastructure is available, teacher-or trainer-led group physical activities can be conducted safely, as individual physical distancing can be impact of covid- pandemic on children and adolescents' lifestyle behavior larger than expected effects of exercise on anxiety and depression disorders: review of meta-analyses and neurobiological mechanisms an exposure-wide and mendelian randomization approach to identifying modifiable factors for the prevention of depression physical activity and mental health in children and adolescents: a review of reviews physical activity level and medial temporal health in youth at ultra high-risk for psychosis can active video games improve physical activity in adolescents? a review of rct all statements expressed in this column are those of the authors and do not reflect the opinions of the journal of the american academy of child and adolescent psychiatry. see the instructions for authors for information about the preparation and submission of letters to the editor orcid vijay a. mittal, phd: https://orcid.org/ - - - joseph firth, phd: https://orcid.org/ - - - david kimhy, phd: https://orcid.org/ - - - all authors contributed to the conceptual planning, drafting, and revision of the manuscript. all authors give final approval on the version to be published and agree to be accountable for all aspects of the work. key: cord- - kdmljoq authors: sepúlveda-loyola, w.; rodríguez-sánchez, i.; pérez-rodríguez, p.; ganz, f.; torralba, r.; oliveira, d. v.; rodríguez-mañas, leocadio title: impact of social isolation due to covid- on health in older people: mental and physical effects and recommendations date: - - journal: j nutr health aging doi: . /s - - - sha: doc_id: cord_uid: kdmljoq objectives: to review the impact of social isolation during covid- pandemic on mental and physical health of older people and the recommendations for patients, caregivers and health professionals. design: narrative review. setting: non-institutionalized community-living people. participants: . individuals from ten descriptive cross-sectional papers. measurements: articles since to published on pubmed, scielo and google scholar databases with the following mesh terms (‘covid- ’, ‘coronavirus’, ‘aging’, ‘older people’, ‘elderly’, ‘social isolation’ and ‘quarantine’) in english, spanish or portuguese were included. the studies not including people over were excluded. guidelines, recommendations, and update documents from different international organizations related to mental and physical activity were also analysed. results: documents have been included in this narrative review, involving a total of . individuals ( % women), from asia, europe and america. articles included recommendations and addressed the impact of social distancing on mental or physical health. the main outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. cognitive strategies and increasing physical activity levels using apps, online videos, telehealth, are the main international recommendations. conclusion: mental and physical health in older people are negatively affected during the social distancing for covid- . therefore, a multicomponent program with exercise and psychological strategies are highly recommended for this population during the confinement. future investigations are necessary in this field. the covid- pandemic due to sars-cov- has rapidly spread all over the world since last december. although its prevalence in the community is uncertain due to the asymptomatic cases, all age groups seems to be similarly affected ( ) . however, older people are at higher risk of suffering negative outcomes, which can lead to an elevated rate of mortality, being five times higher than the global average for those older than years old ( ) . over % of fatalities due to covid- in europe and around % in china have included people older than years-old ( , ) . in the us, % of deaths were among adults and over ( ) . hence, health strategies to avoid spread of coronavirus (such as quarantine and social distancing) are important ( , ) . the world health organization (who) describes a close relationship between physical and mental functions with the level of self-governance and social participation in the community [ ] . social participation has been defined as active participation in a religious, sports, cultural, recreational, political, and volunteer community organizations ( ) ( ) ( ) ( ) . various studies have reported protective effects of social participation for the health of the elderly, being considered as a stimulus to increase the level of physical activity and cognitive functions ( , , ) . the social participation has been associated with a better quality of life, more muscle mass, balance, cognition and lower comorbidities and disability in older people ( , , ( ) ( ) ( ) ( ) ( ) ( ) . participating in social meetings and activities are stimuli that increase the level of physical activity as well as the interaction with other older adults stimulating sensory systems, self-esteem, affectivity, emotional and psychological support ( , , ) . as a preventive measure during the covid- pandemic, community organizations have closed. old people are constrained from visits with family members, therefore the social participation have been restricted ( ) . thus, the decreasing of social interaction produced by social distancing could have a negative impact on mental and physical health in older people ( ) ( ) ( ) , since it has limited the social participation in community organizations and in family activities ( , ) . who defines the 'intrinsic capacity' as the 'composite of all the physical, functional, and mental capacities of an individual' ( ) ( ) ( ) , changing the focus from a negative aging (disability) towards a positive one (optimal aging), being related to the onset of autonomy decline, falls and death ( ) . physical activity has a positive impact on the health and quality of life, reducing the risk of functional and cognitive impairment, falls and risk of fractures, depression, disability, risk of geriatrics syndromes, hospitalization rates and, consecutively, mortality in older people ( ) . not only the physical activity is affected during quarantine, but also mental health. several studies have described mental health consequences in previous quarantines, such as higher risk of depression ( ) , emotional disturbance ( ) , stress ( ), low mood ( ), irritability ( ) , or insomnia ( ) , being also associated with higher rates of suicide in elderly population ( ) . however, the effects of covid- quarantine on the health of older adults have not yet been broadly studied. hence, the aim of this review is to analyse the potential effects of social isolation caused by covid- pandemic on mental and physical health in older adults. additionally, we have analysed the recommendations and proposed activities to avoid mental and functional decline to carry out at home. in this narrative review, the literature search was performed by three authors (wsl, irs and rt). pubmed, scielo and google scholar databases were consulted using the following terms ('covid- ', 'coronavirus', 'aging', 'older people', 'elderly', 'social isolation' and 'quarantine'). articles of any type of methodological design published from to (may th), in english, spanish or portuguese were included. articles that did not include subjects > years old were excluded. additionally, we have searched papers, guidelines, recommendations and update documents from different international organizations related to mental and physical activity. the lists of articles in the databases were downloaded in "bib format" and stored in mendeley for analysis of duplicate articles, title, and abstract reading. the content of the review was divided into two main areas: ) effect of the reduction of social participation produced by quarantine for covid- on mental and physical health in elderly people, and ) recommendations for mental and physical health of older people during the covid- quarantine. a detailed summary of the literature search is provided in figure . six hundred and ninety unique records were identified through database and handsearching, resulting in ten articles involving . participants included in the final review (women %) from asia, europe, and america. of these, adopted a cross-sectional design, and was a qualitative design. all of them are descriptive studies. additionally, articles from experts and authors about recommendations were considered in the full-text review. a summary of the characteristics of the included studies is presented in table . selection process of studies our results are based on summary data from eight crosssectional studies ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) . the prevalence of anxiety ranged from . %, . % and . % to . % ( , ) ; corresponding values from depression were . %, . %, . %, . % and . % ( ) ( ) ( ) . finally, sleep disturbances were observed in . % ( ) and . % ( ) among the participants. six of them ( , ( ) ( ) ( ) ( ) ( ) pointed out an increased level of psychological stress defined as higher anxiety ( , ( ) ( ) ( ) ( ) , depression ( , ( ) ( ) ( ) ( ) and loneliness ( ) levels and poorer sleep quality ( ) during the lock-down by coronavirus. nevertheless, in one study ( ) isolation period by covid- turned out in a mild stressful impact. additionally, only one study ( ) showed that people during quarantine had lower anxiety levels, but more sleep disturbances. risk factors associated to these results varied across the studies. being female ( , , ) , having a negative selfperception of aging ( ) , healthcare workers ( ) , family and personal resources ( ) , time devoted to covid- information ( ), having an acquaintance or a family member infected with covid- or a previous history of medical problems ( ) seem to act as potential risk factors. the impact on physical health of the social distancing was studied for two authors ( , ) (table ). goethals et al ( ) reported that covid- pandemic has affected the number of seniors attending group physical activity programs. additionally, castañeda-babarro et al ( ) observed that the physical activity was highly decreased during confinement in all population, especially the vigorous activities and walking time. there are several recommendations related to the patient to deal with this social isolation (table a) such as strengthen social connections ( , - ) (using internet apps, video chat ( , ) ), telephone support lines or support groups ( , , ) , changes on lifestyle (regular sleep-wake up circle ( ), physical activity and nutrition habits ( , ) ) and cognitive stimulation (using apps or stimulating mental exercises, especially in those people with previous cognitive impairment ( ) ( ) ( ) ). caregivers have an important and crucial role guaranteeing the physical and mental well-being. to reduce anxiety and feeling of usefulness, letting the person participate in adapted daily activities depending on the cognitive status is recommended ( ) . the exposure to media must be regulated ( ) , avoiding doing it in excess and only from official sources ( , ) , managing to control the effect of news with traumatic content ( ) . explaining clearly ( ) or accompanying information with illustrations ( ) may help, especially in people with cognitive impairment. to improve older people resilience, a combination of health education and psychological counselling could be useful. reinforcing that being quarantined is helping to keep others safe ( , , , ) , adopting inclusive language when talking about the elderly, valuing older people's contributions and avoiding negative emphasis on risk ( ) could increase also elderly's resilience. during this covid- crisis, healthcare system have had to change completely implementing virtual consultations and telemedicine (video-tools, telephone hotlines or online consultations ( ) , guaranteeing rapid access to health care ( , ) . additionally, the scorare ga, an assessment tool, has been proposed for doing a telematic geriatric assessment ( ) . in order to minimize isolation related stress, quarantine should be as short as possible. giving good quality information, using channels that older people use like traditional media is also important for reducing stress ( ) . the social distancing has reduced the levels of physical activity, which could have a negative impact on physical health ( , ) . in this review, we include recommendations about increasing physical activity levels from the following eight global organizations: american college of sports medicine (acsm) ( ), american heart association (aha) ( ) , american physical therapy association (apta) ( ) , international association of physical therapists working with older people (iptop) ( ), world health organization (who) ( ), world confederation for physical therapy (wcpt) and international network of physiotherapy regulatory authorities (inptra) ( ) . they recommended - minutes per week of moderate-intensity aerobic physical activity and two sessions per week of muscle strength training ( , ) . additionally, exercise circuit at home with cardio and strength exercises in short bursts of seconds for up to three minutes. finally, coordination, mobility and cognitive exercises are also necessary ( ) ( table b ). the role of caregivers during the quarantine is to supervise the exercise in those patients with unstable chronic diseases ( ) . for health professionals, the principal elements to consider when designing an exercise program for older people confined at home are exercise modality, frequency, volume, and intensity ( ) . it is recommended the telehealth using online videos, apps online platform for phones and tablets through the internet system ( , , ) . iptop has recommended a list of apps[ ] such as "otago exercise programme", "clock yourself" and "iprescribe exercise". apta, acsm and aha recommended different online videos and websites ( , , ) (table b ). this review suggests a general negative effect on mental health in general population during social isolation for covid- . this implies higher levels of anxiety and depression as well as poorer sleep quality. the prevalence of anxiety and depression during covid- outbreak, varies across the studies, having a wide range from . % ( ) to . % ( ) for anxiety or . % ( ) to . % ( ) for depression, in consonance with previous studies of other epidemics. for instance, % of prevalence of anxiety was observed in france due to avian influenza ( ); % of the general population in sierra leone experimented symptoms of anxiety or depression year after ebola outbreak ( ); in hong kong due to the sars epidemic, % and % of individuals presented low mood and irritability (respectively) ( ) , as well as depression in . % of quarantined persons for sars epidemic in ( ) . the lower rates of anxiety and depression observed in some studies of our review during activities to improve the mental and physical health at home coronavirus pandemic could be explained for several reasons. the first one is that, based on previous epidemics, strong and quickly measures to keep mental health could have been taken by the governments, avoiding a bigger psychological impact. as time goes by, there was more information about sars-cov- , which could also lead to a better management of the situation. however, data were collected in a very earlier stage of the pandemic, hence, these results should be taken with caution. some of the risk factors associated to a higher risk of psychological distress have been also described in previous literature. after ebola outbreak, people who knew someone quarantined due to ebola or with any ebola experience were at higher risk of anxiety, depression and post-traumatic stress disorder ( ) . additionally, being older than or worried about the recurrence of sars have been also found as risk factors in previous studies ( ) . however, we cannot conclude the same in this review, where a more intense effect on older people has not been reported. another parameter that should be taken into account is the duration of isolation, since it is related to the severity of psychological symptoms. a non-significant impact on patients' well-being has been demonstrated during short-term isolation ( ) . health providers need to be aware that older adults are at higher risk of having mental health concerns during isolation, and they may have less resources to mitigate them. they should encourage old adults and their families to contact each other daily, as much as they can, to reduce isolation in this population. additionally, maintaining a positive life-style behavior such as regular sleep and meal times, keep a healthy diet, cognitive stimulation and perform physical activity need to be recommended. also, relaxation techniques which may include diaphragmatic respirations or muscular relaxation, practicing a regular routine, alternating with different activities during the day could be useful. it is important for people to be informed by reliable sources and spending a limited time for searching information, maximum once or twice per day. information given to the elderly should be simple, frequent, and displayed in appropriate media. this review has reported that social distancing because of the covid- pandemic could lead to negative consequences for the physical health of older adults. this is caused by the decrease of physical activity levels due to the total or partial restriction of social participation in community groups and family activities during the pandemic ( , , ) . social participation has several positive effects on physical health in elderly people ( ) . studies have reported that older adults who were enrolled into social activities presented better dynamic balance and muscle strength, healthy lung function and lower disabilities and chronic inflammation compared to those without social participation ( , ) . for this reason, attending social activities is an important component for successful aging ( , ) . the relationship between social interaction and physical health may operate through different pathways ( , ) . a possible explanation for these findings is that participating in meetings or social activities stimulates the musculoskeletal, cardiovascular, respiratory and nervous systems through physical activity and social interaction ( ) . physical activity generates benefits for the physical health of older adults, stimulating muscle contraction, energy expenditure, decreasing systemic inflammation and oxidative stress, reducing prevalence of chronic diseases, and geriatric syndromes such as sarcopenia, osteosarcopenia and frailty ( ) . as expected decreasing or total restriction of social interaction could generate negative consequences for the health of elderly people, especially in those with chronic diseases, disabilities and geriatric syndromes ( , ) . evidence has demonstrated a relationship between social isolation and loneliness with disability, chronic diseases, risk of mortality and physical inactivity in elderly population ( , , ( ) ( ) ( ) ( ) ( ) . however, the effect of increased sedentary behavior and decreased physical activity on elderly people during the covid- pandemic is unclear. isolated older people have less physical activity and more sedentary behavior than those non-isolated [ ] . physical activity is described as any body movement using skeletal muscle that results in energy expenditure > . metabolic equivalent of task (met), while sedentary behavior is defined as any waking behavior characterized by an energy expenditure . or less met while in a sitting, reclining or lying posture ( , ) . increased sedentary behavior has been associated with the prevalence of different comorbidities in elderly people ( ) . since a direct association has been reported between sedentary time and time spent at home in elderly people ( ) , recommendations have to be made to prevent health consequences in people with social isolation associated to the pandemic covid- . the global expert organizations included in this review have highlighted the importance of increasing or maintaining the physical activity levels during the pandemic ( - ). although those organization recommended different types of activities or exercises, they are in agreement of using online videos, apps online platform for phones and tablets through the internet system ( , , ). acsm and who recommended - minutes per week of aerobic physical activity and sessions per week of muscle strength training ( , ) . however, recommendations for people with social isolation could consider studies that have reported benefits of replacing sedentary time with physical activity. for example, replacing sedentary behavior with minutes of light physical activity and minutes of moderate to vigorous physical activity could have beneficial effects on all cause mortality ( ) . in addition, replacing minutes per day of sedentary time with moderate to vigorous physical activity has been associated with a decreased frailty in older people ( ) . this information could be used to recommend physical activity as appealing and feasible ( ) . additionally, balance, coordination, mobility and cognitive exercises to stimulate neurological system are recommended for older people to reduce the risk of falls and cognitive declining ( ) . in those older adults with geriatrics syndromes or unstable chronic diseases, it is recommended the supervision of caregivers to avoid falls, exacerbations and injuries during the exercise ( ) . in addition, the health professionals should design the exercise program for older people confined at home with a specific exercise modality, frequency, volume, and intensity ( ), using online videos, apps online platform for phones and tablets through the internet system ( , , ) . finally, the quarantine implied a radical change in the lifestyle of elderly people, reducing the social interaction, participation in exercise group, religious or spiritual group which have negatively affected the mental and physical health in this population ( ) . therefore, to maintain an active lifestyle at home is important for the health of older adults, especially those with chronic diseases and geriatrics syndromes. to summarize all the recommendations and articles included in this review, we have proposed different activities to improve the mental and physical health at home in figure . to the best of our knowledge, this is the first review that includes assessing the physical and mental effects of social isolation by covid- among older people. however, this study has some limitations, which deserve to be mentioned. studies included in this review were cross-sectional design and not specific in elderly population. as all of them are descriptive studies, no control group was used. additionally, there is also a lack of evidence regarding the most appropriate psychological and physical recommendations and most of the interventions suggested are based on expert opinions and not on high evidence studies. future investigations should consider a longitudinal or cross-sectional design in older individuals, with larger sample size and different outcomes related to mental and physical health. in conclusion, our study suggests that the mental and physical health in older people are negatively affected during the social distancing for covid- . the main mental and physical outcomes reported were anxiety, depression, poor sleep quality and physical inactivity during the isolation period. experts organizations and who have given different recommendations to keep older people mentally and physically healthy. therefore, an integrated and multidisciplinary assessment between geriatricians, psychiatrists and physiotherapists could be needed. history in a crisis -lessons for covid- world health organization. covid- strategy up date who. statements, press and ministerial briefings. the epidemiological characteristics of an outbreak of novel coronavirus diseases (covid- ) in china. epidemiol work gr ncip epidemic response, chinese cent dis control prev severe outcomes among patients with coronavirus disease (covid- ) -united states the covid- generation": a cautionary note social distancing" amidst a crisis in social isolation and loneliness the international classification of functioning, disability and health effects of an exercise model based on functional circuits in an older population with different levels of social participation social participation and healthy ageing: an international comparison using share data social capital and health among the aged: comparisons between the united states and germany association between social participation and hypertension among older people in japan: the jages study social participation as an indicator of successful aging: an overview of concepts and their associations with health social participation is associated with better functionality, health status and educational level in elderly women the association between social support and physical activity in older adults : a systematic review association between social participation and hypertension among older people in japan: the jages study social participation reduces depressive symptoms among older adults: an -year longitudinal analysis in taiwan social vulnerability as a predictor of mortality and disability: cross-country differences in the survey of health, aging, and retirement in europe (share) social relationships and mortality risk: a metaanalytic review social participation and self-rated health among older male veterans and non-veterans social participation and the prevention of decline in effectance among community-dwelling elderly: a population-based cohort study social participation and depression in old age : a fixed-effects analysis in european countries the psychological impact of quarantine and how to reduce it: rapid review of the evidence covid- and older adults covid- and the consequences of isolating the elderly the world report on ageing and health: a policy framework for healthy ageing prediction of adverse outcomes in nursing home residents according to intrinsic capacity proposed by the world health organization redesigning care for older people to preserve physical and mental capacity: who guidelines on communitylevel interventions in integrated care global physical activity levels -need for intervention social isolation, loneliness and health in old age: a scoping review system effectiveness of detection, brief intervention and refer to treatment for the people with post-traumatic emotional distress by mers: a case report of community-based proactive intervention in south korea factors influencing compliance with quarantine in toronto during the sars outbreak the experience of sarsrelated stigma at amoy gardens the impact of epidemic outbreak: the case of severe acute respiratory syndrome (sars) and suicide among older adults in hong kong impact of the covid- pandemic on mental health and quality of life among local residents in liaoning province, china: a cross-sectional study comparison of prevalence and associated factors of anxiety and depression among people affected by versus people unaffected by quarantine during the covid- epidemic in southwestern china comparison of the indicators of psychological stress in the population of hubei province and non-endemic provinces in china during two weeks during the coronavirus disease (covid- ) outbreak in generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey a nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors stress , anxiety , and depression levels in the initial stage of the covid- outbreak in a population sample in the northern spain symptoms of anxiety and depression during the outbreak of covid- in paraguay. symptoms anxiety depress dur outbreak covid- paraguay we're staying at home". association of selfperceptions of aging, personal and family resources and loneliness with psychological distress during the lock-down period of covid- impact of home quarantine on physical activity among older adults living at home during the covid- pandemic: qualitative interview study impact of covid- confinement on the time and intensity of physical activity in the spanish population smartphone apps for older adults to use while in isolation during the covid- pandemic covid- lockdown: a perfect storm for older people's mental health. j psychiatr ment health nurs multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science. the lancet psychiatry policy brief : the impact of covid- on older persons mental health interventions during the covid- pandemic a conceptual framework by early career psychiatrists alzheimer's disease chinese, psychogeriatric interest group of chinese society of psychiatry et al. expert recommendations on mental health and psychosocial support for persons with cognitive disorders and their caregivers during the covid- outbreak development of a telehealth geriatric assessment model in response to the covid- pandemic older people and epidemics: a call for empathy multidisciplinary research priorities for the covid- pandemic: a call for action for mental health science. the lancet psychiatry potential lethal outbreak of coronavirus disease (covid- ) among the elderly in retirement homes and long-term facilities role of telehealth in outbreaks -where the classic healthcare systems fail active during the coronavirus pandemic create a circuit home workout infographic apta stay physically active during self-quarantine physical exercise as therapy to fight against the mental and physical consequences of covid- quarantine: special focus in older people combating physical inactivity during the covid- pandemic home exercises from a physical therapist perception of epidemic's related anxiety in the general french population: a cross-sectional study in the rhne-alpes region impact of ebola experiences and risk perceptions on mental health in sierra leone sars control and psychological effects of quarantine population-based post-crisis psychological distress: an example from the sars outbreak in taiwan depression, anxiety, and moods of hospitalized patients under contact precautions association between social participation and -year change in instrumental activities of daily living in community-dwelling elderly adults the level of physical activity affects the health of older adults despite being active criteria for social isolation based on associations with health indicators among older people. a -year follow-up of the aichi gerontological evaluation study associations between social isolation, loneliness, and objective physical activity in older men and women social isolation, c-reactive protein, and coronary heart disease mortality among community-dwelling adults loneliness and risk of mortality: a longitudinal investigation in alameda county loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies social isolation and physical inactivity in older us adults: results from the third national health and nutrition examination survey sedentary behavior research network (sbrn) -terminology consensus project process and outcome physical activity, exercise, and physical fitness: definitions and distinctions for health-related research sedentary behavior and health outcomes among older adults: a systematic review physical activity in non-frail and frail older adults replacing sedentary time with physical activity: a -year follow-up of mortality in a national cohort reallocating accelerometer-assessed sedentary time to light or moderate-to vigorous-intensity physical activity reduces frailty levels in older adults: an isotemporal substitution approach in the tsha study the feasibility and longitudinal effects of a home-based sedentary behavior change intervention after stroke covid- , mental health and aging: a need for new knowledge to bridge science and service declaration of conflict of interest: none.declaration of sources of funding: co-financed by the european regional development funds (rd / ) and the centro de investigación biomédica en red en fragilidad y envejecimiento saludable-ciberfes (cb / / ).author's contribution: study concept and design: all authors. data collection: wsl, irs, rt. draft of the manuscript: wsl, irs, ppr, fg, rt. full access to all of the data in the study and responsibility for the integrity of the data: wsl, irs. study supervision: lrm. all authors reviewed the manuscript for important intellectual content and approved the final version. key: cord- -aslvqymx authors: rahman, md. estiar; islam, md. saiful; bishwas, md. sajan; moonajilin, mst. sabrina; gozal, david title: physical inactivity and sedentary behaviors in the bangladeshi population during the covid- pandemic: an online cross-sectional survey date: - - journal: heliyon doi: . /j.heliyon. .e sha: doc_id: cord_uid: aslvqymx this study aimed to determine the prevalence of physical inactivity and sedentary behaviors during the covid- pandemic among bangladeshi people. an online survey was conducted among , people over a period of days on june, during the covid- pandemic at a time that the number of newly diagnosed cases was increasing, lockdown was still in place. survey questions included socio-demographics and an adapted version of the ipaq-sf to assess physical activity and sedentary behaviors. the prevalence rates of physical inactivity (< met–minutes/week) and high sedentary behaviors (≥ h/day) among bangladeshi people were . % and . %, respectively. regression analyses revealed that young age, being a student, from a middle-class family, or upper-class family, living with nuclear family, urban living, and suffering from no chronic diseases were all associated with physical inactivity and high sedentary behaviors. moreover, physical inactivity and high sedentary behavior were strongly interrelated. however, many of the univariate risk factors exhibited interdependency. during the covid- pandemic coinciding with lockdown measures a sizeable proportion of bangladeshi people were physically inactive and reported sedentary behaviors ≥ h/day. public campaigns and media-based interventions encouraging home-based physical activities should be promoted to attenuate the impact of lockdown measures during a pandemic. the outbreak of coronavirus disease (covid- ) caused by severe acute respiratory syndrome coronavirus (sars-cov- ), has become a global public health threat [ , ] . the outbreak was first revealed in wuhan city, in the hubei province of china, in late december [ ] . since then, the virus has spread worldwide, with millions of covid- cases and related deaths being recorded globally [ ] . the first case of covid- was confirmed in bangladesh on march , [ , , ] , and more than , confirmed cases of covid- and , deaths have been recorded by september , [ ] . physical activity (pa) is regarded as a critical component of a healthy lifestyle and disease prevention [ ] . conversely, physical inactivity increases the risk of many chronic diseases, such as hypertension, coronary heart disease, stroke, diabetes, depression, and risk of falls [ ] . regular physical activity helps maintain a healthy weight, reduces the risk of developing obesity, and strengthens the immune system [ , ] . physical activity also reduces feelings of depression and improves mental health [ ] . considering the health benefits of regular physical activity, the who recommends that individuals aged - years should engage in > min of moderate-intensity or > min of vigorous-intensity physical activity per week or an equivalent combination of moderateand vigorous-intensity activity [ ] . sedentary behavior refers to any waking behavior characterized by an energy expenditure not exceeding . metabolic equivalents (mets), while in a sitting or reclining position [ , ] . like the vast majority of the affected countries around the world, bangladesh initiated a lock-down policy to ensure spatial distancing, selfisolation, or quarantine, as part of the efforts to limit the spread of covid- . the government declared a nationwide lockdown from march to may , with a th extension being recently announced [ , ] . previous studies investigated the impact of covid- on physical activity in different age clusters and in different regions [ , , ] . reports have indicated that the covid- pandemic-related public health restrictions appear to have led to reductions in physical activity [ , , , ] . we hypothesized that the extended periods of lockdown in bangladesh may have adversely impacted physical activity and increased sedentary behaviors in the population. we aimed to determine the prevalence of physical inactivity and sedentary behaviors during the covid- pandemic among bangladeshi people. we adopted an online cross-sectional survey approach to assess the levels of physical activity and sedentary behaviors among bangladeshi citizens during the covid- pandemic. the survey was carried out between june to june , , when the number of newly diagnosed cases increasing, and the government continued to impose lockdown restrictions to limit the spread of covid- . the target population was the general bangladeshi population. inclusion criteria were being (i) a bangladeshi residence, (ii) aged years or older, and (iii) being able to read bangla. participants were recruited from various social media platforms (e.g., facebook, whatsapp), using convenience sampling. data were collected by means of an anonymous online questionnaire. the questionnaire was translated into bangla (the native language of participants), and then back-translated to english by different experts to assess validity. the most widely used standardized procedure (i.e., beaton et al., ) was used to perform the back translation for this questionnaire [ ] , which has been previously used in bangladesh [ , ] . a pilot test was conducted on samples to test the validity of the questionnaire. the data from the pilot survey were not included in the final analysis. the online survey was conducted using a survey link created on google form. a total of , people completed the online survey. of these, were excluded as they were below years of age. therefore, the final sample consisted of , participants. socio-demographic variables included in the survey were age (later categorized: young [ - years] , and adult [ þ years]), gender (male vs. female), marital status (unmarried, married, and divorced/widows/ widowers), education levels (secondary/below, higher secondary, and graduation/above), occupation (student, housewife, employed, businessman, and unemployed), monthly family income (later categorized: lower-class [< , bangladeshi taka (bdt)], middle-class [ , bdt] , and upper-class [> , bdt]), family type (nuclear vs. joint), and current place of residence (village, sub-district town, district town, and divisional town). other variables included were self-reported physical health (good, moderate, and poor), chronic diseases (yes vs. no), and cigarette smoking currently (yes vs. no). physical activity level was assessed using the international physical activity questionnaire short form (ipaq-sf) [ ] . the ipaq-sf is a valid and reliable tool for physical activity surveillance across a range of populations [ , , , , ] . validity of the ipaq-sf has been assessed across countries, and showed that acceptable properties for use in many settings and in different languages [ ] . the ipaq-sf consists of items providing information on time spent in walking, moderate-and vigorous-intensity activities during a typical week. walking activities are defined as "walking at home and at work, walking to travel from place to place, and any other walking done solely for recreation, sport, exercise, or leisure". moderate-intensity activities are defined as "those that take moderate physical effort and produce a moderate increase in respiration rate", and included examples such as carrying light objects, working in the garden, cycling at a regular pace, or doing prolonged physical work at home. vigorous physical activities are defined as "those that take hard physical effort and produce vigorous increases in respiration rate' such as lifting heavy objects, hoeing the earth, practicing zumba, cycling on an exercise bike, or running on a treadmill at high speed" [ ] . for each of walking, moderate-and vigorous-intensity activities, individuals were asked to report the number of days per week that they performed the targeted activity for at least min at a time, and then asked to report how much time they usually spent on one of those days doing the targeted physical activity. according to the ipaq data analysis guideline, all activity data were converted to metabolic equivalent task (met), the standard unit used to express the intensity of physical activities. for all three types of activities (i.e., walking, moderate-and vigorous-intensity activities), met-minutes per week were calculated as follows: walking ¼ ( .  walking min  walking days); moderate activity ¼ ( .  moderate activity min  moderate activity days); vigorous activity ¼ ( .  vigorous activity min  vigorous activity days). physical activity levels for each participant were classified into categories based on the met-minutes/week of the total weekly energy expenditure (i.e., the sum of walking, moderate-and vigorous-intensity physical activities): (i) low (< met-minutes/ week); (ii) moderate active (! met-minutes/week); (iii) high active (! met-minutes/week) [ ] . for ease of regression analysis, physical activity level was later categorized: inactive (low active) and active (moderate/high active). the ipaq-sf has an additional item, namely "during the last week, how long in total did you spend in sedentary activities on a typical day?" to assess sedentary behavior. sedentary activities were defined as "those activities in a sitting, reclining, or lying position (except sleep) requiring very low energy expenditure" and examples included sitting/lying down reading or watching tv, computer use, video games, etc. sedentary behaviors for each participant were categorized as: < h/day and ! h/day (high), as used in previous studies [ , ] . this categorization is based on a previous cohort study that reported a detrimental association between sb ! h/day and all-cause mortality [ ] . statistical analysis was performed using microsoft excel and statistical package for social science (spss) version (chicago, il). microsoft excel was used for data entry, editing, and sorting. continuous data were presented as mean and standard deviation (sd), and categorical data as frequency and percentage. the chi-square test was applied for categorical variables. logistic regression (both unadjusted and adjusted models) was performed with a % confidence interval to determine the significant associations between categorical dependent and independent variables. analyses were univariate, yielding crude odds ratios, followed by multivariable analyses with predictors combined, with the exception of sedentary behavior and physical inactivity in the models of each other, and yielding adjusted odds ratios. the association of variables was considered statistically significant if the two-sided p-value was less than . . the present study was carried out in accordance with the guidelines of the helsinki declaration, . in addition, the formal ethics approval was granted by the ethical review committee, the faculty of biological sciences, jahangirnagar university, savar, dhaka- , bangladesh (ref no: bbec, ju/m ( ) ). participants were well informed about the procedure and purpose of the study, and confidentiality of their information. informed consent was ensured by each of participants. furthermore, all data were collected anonymously and analyzed by using the coding system. a total of , participants were included in the final analysis. of these, . % were male, the mean age was . years (sd ¼ . ) and age ranged - years. the majority were single ( . %), had graduation or above level education ( . %), and were students ( . %). a sizeable majority were from middle-class families ( . %), came from nuclear families ( . %), and were from village areas ( . %). good physical health reported in . % of responders, with nearly one-fifth of participants indicating chronic diseases ( . %), and the majority ( . %) did not smoke currently (table ) . figure represents the interrelation between physical activity level and sedentary behaviors among bangladeshi people during the covid- pandemic. the proportion of physical inactivity was significantly higher among (i) young ( - years) young people were . times more likely to be physically inactive (or pi ¼ . ; % ci ¼ . - . , p < . ), and . times more likely to develop high sedentary behaviors (or sb ¼ . ; % ci ¼ . - . , p < . ) compared to adults (table ). other predictors of physical inactivity (pi) and high sedentary behavior (sb) were being students (or pi ¼ . ; % ci ¼ . - . , p ¼ . , and or sb ¼ . ; % ci ¼ . - . , p ¼ . ), being from middle class families (or pi ¼ . ; % ci ¼ . - . , p < . , and or sb ¼ . ; % ci ¼ . - . , p ¼ . ), being from upper-class families (or pi ¼ . ; % ci ¼ . - . , p < . , and or sb ¼ . ; % ci ¼ . - . , p < . ), living with nuclear families (or pi ¼ . ; % ci ¼ . - . , p < . , and or sb ¼ . ; % ci ¼ . - . , p ¼ . ), living in urban environment (or pi ¼ . ; % ci ¼ . - . , p < . , and or sb ¼ . ; % ci ¼ . - . , p < . ), and not suffering from chronic diseases (or pi ¼ . ; % ci ¼ . - . , p < . , and or sb ¼ . ; % ci ¼ . - . , p ¼ . ) ( table ). additional risk factors of physical inactivity were being single (or pi ¼ . ; % ci ¼ . - . , p ¼ . ), having higher secondary level education (or pi ¼ . ; % ci ¼ . - . , p ¼ . ), having graduation/above level education (or pi ¼ . ; % ci ¼ . - . , p < . ), having poor physical health (or pi ¼ . ; % ci ¼ . - . , p ¼ . ); in contrast, being housewife was protective (or pi ¼ . ; % ci ¼ . - . , p < . ). likewise, additional risk factors of high sedentary behaviors were being female (or sb ¼ . ; % ci ¼ . - . , p < . ); conversely, moderate physical condition was a protective factor (or sb ¼ . ; % ci ¼ . - . , p ¼ . ) ( table ) . furthermore, the findings showed a significant association between physical inactivity and high sedentary behaviors (χ ¼ . ; df ¼ , p < . ), as well as physical inactivity (or sb ¼ . ; % ci ¼ . - . , p < . ) and sedentary behaviors (or pi ¼ . ; % ci ¼ . - . , p < . ) emerged as significant predictors of each other ( table ) . multivariable logistic regression analyses with each of the factors entered into the model revealed that most of the risk factors were interdependent and lost statistical significance (table ) . for physical inactivity, significant associations with education level, residence, selfreported physical health, and sedentary behavior emerged. for sedentary behaviors, the only significant associations retained in the model included gender, education level, self-reported physical health, and physical inactivity (table ) . to our knowledge, this is the first study that investigated physical activity patterns and sedentary behaviors among bangladeshi people during the covid- pandemic, and provides a snapshot of such issues. this survey was conducted during a -day period, while the number of newly diagnosed cases was increasing in bangladesh, and during which, substantial restrictions that included spatial distancing, home quarantine, social isolation, and travel restriction were in place. in a prior study focused on mental health conducted earlier during the outbreak in bangladesh, we reported that . % participants did not engage in physical exercise while in home quarantine, and . % browsed internet more than h per day [ ] . we also reported that those individuals who reported vulnerable mental states (i.e., depression, anxiety, and stress) were significantly more likely not to engage in physical exercise and to browse the internet for longer periods of time. physical inactivity, a major risk factor for global mortality, accounts for . million deaths each year worldwide [ ] . not getting enough physical activity, including among those individuals who have no other associated risk factors, can lead to an increased risk of heart disease. physical inactivity can also increase the likelihood of other risk factors for developing heart disease, such as obesity, high blood pressure, high blood cholesterol levels, and type diabetes [ ] . the fear of being infected and the mobility restrictions imposed during the covid- pandemic may dissuade people from attaining the recommended levels of physical activity. in the present study, we found that nearly % of participants were physically inactive during the covid- pandemic. direct comparisons with these findings are quite difficult due to the lack of studies employing a similar instrument in bangladesh. here, we found that the prevalence of physical inactivity was significantly higher among young people ( . %) compared to those individuals older than years of age ( . %). young people spend more time on electronic devices than other age groups [ ] . while confined at home because of covid- , young people could spend more time on electronic devices, leading them to increase the time spent as physically inactive. as corroboration of such assumption, single individuals (likely younger) were more likely to be physically inactive. people with higher education levels were more inclined to report physical inactivity. this finding is in conflict with previous research studies that indicated that higher education levels are associated with higher degrees of involvement in physical activity [ , ] . the discrepancies in this finding may be due to the situation imposed by covid- . indeed, the prevalence of physical inactivity was significantly higher among students ( %) compared to all other groups, and was anticipated, considering the promotion of online activities during the covid- pandemic. since all the educational institutions were closed, students would be more prone to screen exposure in the context of both social media interactions, games or even studies online, and these trends may facilitate the emergence of mental and behavioral stress. people who were living in urban settings reported higher prevalence of physical inactivity. participation in physical activity is largely determined by physical and social environmental factors that influence access, availability, and utilization [ , ] . in bangladesh, divisional cities are densely populated, and the number of covid- cases was comparatively large. accordingly, main factors favoring physical inactivity included being fearful of exposure to covid- , closed sports facilities, unavailability of friends to exercise with, and a lack of interest in pursuing physical activities during the covid- pandemic [ ] . the findings of this study also indicate that nearly % participants had high sedentary behavior (i.e., time spent on sedentary activities > hours/day) during the covid- pandemic. prolonged sedentary behavior induces adaptations that negatively decondition cardiorespiratory fitness and metabolic profiles, and are therefore intimately related to disease prevention [ , ] . it is possible that insufficient participation in physical activity over extended periods during the covid- emergency may turn into sedentary behaviors. females had higher prevalence of sedentary behaviors compared to males, similar to previous reports, possibly reflecting additional cultural and social norms [ ] . additional factors for high sedentary behaviors included being young, being a student, being from an upper-class family, and living in urban settings. since these factors were also associated with physical inactivity, it is not surprising that they also contributed to increased sedentary behaviors. the unique importance of physical activity and of restricting sedentary behaviors cannot be overstated, considering their beneficial effects on health in general, and also on specific elements related to the covid- pandemic, such as modulation of the immune system [ ] . therefore, the who and many other professional societies recommend the adoption of specific exercise programs and daily strategies including home-based exercise programs to maintain a physically active lifestyle during the pandemic [ , ] . this study has some limitations that must be considered when interpreting the results. the present research adopted an online selfreport methodology that may be susceptible to potential biases (e.g., social desirability and memory recall). in addition, the study was crosssectional in nature and therefore we cannot infer causality between any of the variables examined. furthermore, due to the online survey and convenience sampling technique, participants were predominantly educated young adults and students, which might affect the generalizability of the findings. physical inactivity is prevalent among the bangladeshi population during the covid- pandemic, and appears to be largely impacted by socio-demographic factors. moreover, one-fifth of the cohort reported high sedentary behaviors. the findings suggest that there is a need to promote regular physical exercise in the context of home quarantine measures and increase awareness to induce cogent avoidance of activities related to sedentary behaviors during the covid- outbreak. author contribution statement m. rahman: conceived and designed the experiments; performed the experiments; contributed reagents, materials, analysis tools or data; wrote the paper. m. islam: conceived and designed the experiments; performed the experiments; analyzed and interpreted the data; contributed reagents, materials, analysis tools or data; wrote the paper. m. bishwas and david gozal: contributed reagents, materials, analysis tools or data; wrote the paper. m. moonajilin: conceived and designed the experiments; wrote the paper. this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. the outbreak of coronavirus disease (covid- )-an emerging global health threat panic and generalized anxiety during the covid- pandemic among bangladeshi people: an online pilot survey early in the outbreak the origin, transmission and clinical therapies on coronavirus disease (covid- ) outbreak-an update on the status world health organization, coronavirus disease (covid- ) pandemic knowledge, attitude, and practice regarding covid- outbreak in bangladeshi people: an online-based cross-sectional study posttraumatic stress disorder during the covid- pandemic: upcoming challenges in bangladesh and preventive strategies knowledge, attitudes and practices associated with the covid- among slum dwellers resided in dhaka city: a bangladeshi interview-based survey updating the evidence that physical activity is good for health: an epidemiological review chronic disease and the link to physical activity long-term health benefits of physical activity -a systematic review of longitudinal studies health benefits of physical activity: a systematic review of current systematic reviews mental health benefits of physical activity world health organization energy expenditure during common sitting and standing tasks: examining the . met definition of sedentary behaviour shutdown won't be extended after private offices from the impact of physical activity on psychological health during covid- pandemic in italy physical activity levels and related energy expenditure during covid- quarantine among the sicilian active population: a cross-sectional online survey study impact of the covid- virus outbreak on movement and play behaviours of canadian children and youth: a national survey the covid- pandemic and physical activity combating physical inactivity during the covid- pandemic elite athletes and covid- lockdown: future health concerns for an entire sector coronavirus outbreak in italy: physiological benefits of home-based exercise during pandemic guidelines for the process of cross-cultural adaptation of self-report measures prevalence and correlates of anxiety and depression in frontline healthcare workers treating people with covid- in bangladesh validation and evaluation of the psychometric properties of bangla nine-item internet disorder scale-short form international physical activity questionnaire: short last days self-administered format criterion-related validity of the last -day, short form of the international physical activity questionnaire in swedish adults validity of four short physical activity questionnaires in middle-aged persons validity of the international physical activity questionnaire short form (ipaq-sf): a systematic review depression and comorbid panic in primary care patients reliability and validity of the international physical activity questionnaire in the nord-trøndelag health study (hunt) population of men international physical activity questionnaire: -country reliability and validity correlates of sedentary behavior in the general population: a cross-sectional study using nationally representative data from six low-and middle-income countries patterns of physical activity and sedentary behavior in a representative sample of a multi-ethnic south-east asian population: a cross-sectional study sitting time and all-cause mortality risk psychological responses during the covid- outbreak among university students in bangladesh world health organization, physical inactivity: a global public health problem shortterm decreased physical activity with increased sedentary behaviour causes metabolic derangements and altered body composition: effects in individuals with and without a first-degree relative with type diabetes interventions designed to reduce sedentary behaviours in young people: a review of reviews examining the association between education level and physical activity changes during early old age educational level is related to physical fitness in patients with type diabetes -a cross-sectional study social and environmental influences on physical activity behaviours the environment and physical activity: the influence of psychosocial, perceived and built environmental factors exercising in times of lockdown: an analysis of the impact of covid- on levels and patterns of exercise among adults in belgium sedentary behavior: emerging evidence for a new health risk sedentary behaviors, weight, and health and disease risks ale s, gender differences in physical activity, sedentary behavior and bmi in the liberec region : the ipaq study in - by immunological implications of physical inactivity among older adults during the covid- pandemic physical activity and coronavirus disease (covid- ): specific recommendations for home-based physical training exercise and fitness in the age of social distancing during the covid- pandemic the authors declare no conflict of interest. no additional information is available for this paper. key: cord- -lv mo d authors: alpalhão, vanessa; alpalhão, miguel title: impact of covid- on physical therapist practice in portugal date: - - journal: phys ther doi: . /ptj/pzaa sha: doc_id: cord_uid: lv mo d nan the physical therapy profession has been severely affected by the crisis. in portugal, regulatory rules have determined that only -urgent‖ care should be provided for the duration of the pandemic-leaving each physical therapist with the discretionary power to determine which cases could benefit the most from their intervention. although many may recognize the benefit of physical therapy in the face of this infection, many cases may fall into a gray area, resulting in asymmetrical accessibility to care. long-term care and convalescence units are particularly sensitive areas. it is hard to define -urgent‖ interventions in such settings, where the main goal is to reinstitute function and quality of life to patients in the mid to long term. we must also consider that much of the income and social value of these units derive from the rehabilitation care developed and provided by physical therapists. the sudden loss of income may represent a risk for the viability of these institutions. taking this into consideration, physical therapists continue to intervene in all settings, facing an increased risk for covid- infection due to the physical proximity involved in our usual practice as well as due to the high number of patients treated each day. furthermore, given that asymptomatic individuals have been shown to spread the infection, the exposed physical therapist might represent a risk to other patients, many of whom may be older and have significant comorbidities. some practices may be adopted to reduce these risks. first, wearing disposable personal protection equipment, which should be changed between patients, can reduce transmission of the infection; second, decreasing the number of patients and therapists in the same physical space may facilitate social distancing; and third, digital physical therapist practice, making use of technology for communicating with and guiding patients, is proposed by some international agencies. these methods, however, have a steep learning curve not suited for an immediate-need context, and many older patients may have limitations using new technologies. involving family and caregivers in the treatment session may reduce this hindrance and promote participation, particularly in patients with neuropsychiatric conditions and in pediatric patients. this strategy would require legal regulation to prevent uncertified individuals from offering health care services, even if in a virtual setting, without the appropriate accreditation and certification of expertise. if the covid- crisis lingers for a long time, physical therapists may start shifting their practice toward therapeutic exercise and away from passive techniques that require close proximity. this is far from ideal, as many benefits from an integrative approach could be lost. physical therapist interventions remain fundamental for the health of our communities and should not be avoided as a general rule. all available precautions should be taken to reduce the likelihood of infection for both practitioner and patient, and every patient should have an individual examination for risks and benefits of the planned intervention. therapeutic strategies may be adapted to reduce physical contact to a minimum while providing therapeutic benefit, and new digital strategies may become more widespread, but caution should be taken to ensure the quality of the intervention provided. there is no funding to report. physiotherapy management for covid- in the acute hospital setting: clinical practice recommendations transmission of -ncov infection from an asymptomatic contact in germany information and resources about covid- . world confederation for physical therapy website the authors declare no conflicts of interest. key: cord- -wll hpu authors: shahidi, seyed houtan; stewart williams, jennifer; hassani, fahimeh title: physical activity during covid‐ quarantine date: - - journal: acta paediatr doi: . /apa. sha: doc_id: cord_uid: wll hpu the world health organization recommends that children and adolescents aged ‐ should engage in at least minutes of moderate to vigorous intensity physical activity a day. physical activity is defined as bodily movement performed by skeletal muscles that demand energy expenditure. the physical benefits of this include musculoskeletal and cardiovascular health, a healthy body weight and neuromuscular awareness, for coordination and controlling movement. the psychological benefits include managing anxiety and building self‐esteem, which are both important for children’s psycho‐social development ( ). the world health organization recommends that children and adolescents aged - should engage in at least minutes of moderate to vigorous intensity physical activity a day. physical activity is defined as bodily movement performed by skeletal muscles that demand energy expenditure. the physical benefits of this include musculoskeletal and cardiovascular health, a healthy body weight and neuromuscular awareness, for coordination and controlling movement. the psychological benefits include managing anxiety and building self-esteem, which are both important for children's psycho-social development ( ). however, the covid- pandemic has restricted physical activity in people of all ages. in many countries, both indoor and outdoor sports and recreational facilities, such as gyms, public swimming pools and playgrounds, are closed. online communication for work, leisure and shopping is now part of daily family routines and children are using the internet for school work and social interaction. however, it is important that children participate in, and enjoy physical activity, as part of a broader set of life skills during their leisure time. in a parallel field, a new concept known as physical literacy is now renowned in many different countries. although they are related, physical literacy and physical activity are independent of each other. physical literacy is the motivation, confidence, physical competence, knowledge and understanding that people need to value and take responsibility for engaging in physical activity for life ( ) . it is a multidimensional concept that encompasses cognitive, emotional and social components that have a mutually beneficial relationship with motor skills and forms of physical activity. importantly, physical literacy does not result from physical activity. it needs to be separately developed as a life skill, preferably before adolescence. therefore, promoting physical activity alone this article is protected by copyright. all rights reserved we need to look forward to how schools can increase physical literacy after covid- . circus arts are gaining interest in physical education as one way of doing this. the suite of circus training tools includes individual and group activities, such as clowning and acrobatics, manipulation, equilibrium and aerial skills (figure ) ( ) . a canadian school-based study of children aged nine to years focused on children whose physical activity levels were increased when they were given schoolbased circus arts instruction three times a week for approximately minutes. various outcomes were compared with a control group of age-matched children who received standard physical education at schools with the same socioeconomic status. the circus arts group demonstrated statistically significant improvements in motor competence and confidence. boys typically do better than girls when it comes to motor skills, but this gap narrowed in the circus arts group ( ). creating and maintaining physical literacy in children with disabilities is particularly important, as they are under-represented in organised sport and are a vulnerable group during this pandemic. another canadian programme that was specifically created for children with autism used equipment such as boxes, bubbles, balloons, foam dice and scarves, to create simple fun games to improve children's physical activity levels, skills and confidence ( ) . clearly there are restrictions on what kind or programmes and activities children can get involved in during the pandemic, especially when quarantine and social distancing measures are in place. fun interventions like the circus arts programme and activities for children with disabilities are just some of the ideas that parents and educators may want to consider. there are several worthwhile digital platforms that show how these activities can be introduced into everyday indoor and outdoor routines. the canadian programme "playbuilder" is a cloud-based system which delivers activities that can be conducted at home, to keep children active and mentally engaged during the coronavirus pandemic (https://sportforlife.ca/). "appetite to play" is another canadian initiative designed to promote and encourage healthy eating and physical activity in early childhood. the programme offers self-assessment and planning tools, tips, recipes, games, and other activities for this article is protected by copyright. all rights reserved parents and carers (https://www.appetitetoplay.com/), the "simple movement" programme from the united kingdom, aims to help each child achieve their unique potential in reading and writing as well as in sports and playing. this easy-to-follow animated online programme promotes building developmental skills in a fun and pleasant manner (https://www.simplephysicalliteracy.com/). the pandemic has highlighted structural shifts in society that may lead to less physical activity in the future and this calls for novel approaches. it is very important that parents and educators do not allow children to adopt more sedentary lifestyles and greater screen time. if this happens it will distract them from achieving and sustaining ongoing physical literacy, both now and in the future. world health organization. world health organization global recommendations on physical activity for health physical literacy: throughout the lifecourse: routledge physical literacy and resilience in children and youth the impact of circus arts instruction in physical education on the physical literacy of children in grades and i can develop physical literacy the authors would like to thank canada for allowing us to include the circus programme image in our paper. no external funding. the authors have no conflicts of interest to declare. circus arts physical literacy programme in children. key: cord- -bittqpyo authors: scott, jennifer; abaraogu, ukachukwu o.; ellis, graham; giné-garriga, maria; skelton, dawn a. title: a systematic review of the physical activity levels of acutely ill older adults in hospital at home settings: an under-researched field date: - - journal: eur geriatr med doi: . /s - - -y sha: doc_id: cord_uid: bittqpyo purpose: the purpose of this review was to identify, evaluate and synthesise existing evidence reporting the physical activity levels of acutely ill older patients in a ‘hospital at home’ setting and compare this to patients with similar characteristics treated in a traditional hospital inpatient setting. functional changes and any adverse outcomes due to physical activity (e.g. falls) in both settings where pa was reported or recorded were also evaluated as secondary outcomes. methods: a search strategy was devised for the medline, cinahl, amed, pedro, ot seeker and cochrane databases. search results were title, abstract and full-text reviewed by two independent researchers. data were extracted from included articles using a custom form and assessed for quality and risk of bias using the appraisal tool for cross-sectional studies. results: no studies set in the hospital at home environments were identified. hospital inpatient studies met the criteria for inclusion. older patients managed in inpatient settings that would be eligible for hospital at home services spent . % of their day active and undertook only . daily steps. functional change was reported in four studies with both improvement and decline during admission reported. conclusion: there is a lack of published research on the physical activity levels of acutely-ill older adults in hospital at home settings. this review has identified a baseline level of activity for older acutely ill patients that would be suitable for hospital at home treatment. this data could be used as a basis of comparison in future hospital at home studies, which should also include functional change outcomes to further explore the relationship between physical inactivity and functional decline. electronic supplementary material: the online version of this article ( . /s - - -y) contains supplementary material, which is available to authorized users. hospital at home (hah) is a model of healthcare delivery which provides an alternative to hospitalisation by delivering acute-level hospital services in a residential setting [ ] . the hah care model has increased in prevalence in recent years, with well-established programmes providing services in western europe, north america, brazil, australia, israel and south east asia [ ] . home-hospitalisation has also been advocated during the recent covid- pandemic as a means of increasing bed capacity, facilitating quarantine and reducing disease transmission to vulnerable groups [ ] . research interest has also been growing, with a more than sixfold increase in hah-related citations between and [ ] . a recent systematic review found that hah may be a clinically effective alternative to inpatient care for some older, acutely-ill medical patients [ ] . furthermore, it suggested hah treatment may pose less risk of physical functional decline to patients than the traditional ward-based inpatient environment [ ] . functional decline is a known adverse effect of hospitalisation, affecting between and % of older inpatients between admission to hospital and discharge [ ] [ ] [ ] [ ] , manifesting as a loss of muscle mass, strength, physical function and/or ability to perform basic activities of daily living such as dressing, eating and maintaining hygiene and continence [ ] [ ] [ ] . physical inactivity while hospitalised, combined with older age, are predictors of functional decline [ ] . hospitalised patients are highly inactive, with acute medical and surgical inpatients spending between and . % of their time sitting or lying [ ] , and older patients spending as little as mins per day in an upright position [ ] . recently published draft recommendations on physical activity for inpatients have emphasised the importance of incorporating opportunities for physical activity into the daily care of older adults to improve clinical outcomes, focusing on function, independence and activities of daily living [ ] . however, there are many institutional barriers to physical activity in hospital including lack of staff support, tethering to medical devices, lack of assistive devices, and unfamiliar surroundings, as well as a fear of injury [ ] . treatment in a less restrictive home environment may overcome such barriers, providing more opportunity for patients to continue to perform regular activities of daily living [ ] , thereby lessening the risk of functional decline. this review sought to investigate the hypothesis that older, acutely ill patients treated in a hah setting may be more active than hospital inpatients with similar characteristics. the aim was to identify, evaluate and synthesise primary research studies reporting cumulative physical activity levels in these populations and, where reported, evaluate reports of functional decline or adverse effects resulting from physical activity during admission. as will be reported, no studies conducted in hah treatment settings were identified, and functional change outcomes were largely absent. the review protocol was developed in accordance with preferred reporting items for systematic review and meta-analysis protocols (prisma-p) [ ] guidelines and registered with the international prospective register of systematic reviews (prospero, registration number crd ) [ ] . the review followed the guidelines set out in the cochrane handbook for systematic reviews of interventions [ ] where applicable and complies with the prisma statement [ ] for the conduct and reporting of systematic reviews. a comprehensive search strategy was developed in accordance with the cochrane recommendations for health care review [ ] and reviewed by a specialist medical librarian. the search was initiated in july and updated january to ensure currency. search terms and appropriate synonyms were chosen in alignment with the research objective and combined using boolean operators, subject headings, truncations and wildcards where appropriate. filters limited results to peer reviewed, english language, human studies with available abstracts published since . all study designs were acceptable. the databases medline (ovid interface), central, cumulative index to nursing and allied health literature (cinahl), allied and complementary medicine database (amed), pedro and otseeker were chosen as the most relevant to the subject matter. the full search strategies with database-specific syntaxes for all sources are included in online resource . once key papers were identified, reference lists were handsearched and subject experts were approached to identify any further resources. 'grey' literature including conference abstracts, reports, unpublished data and dissertations were not included. multiple publications using the same participant dataset were excluded and the most comprehensive or recent publication used. setting studies set in either an hah or acute medical inpatient environment were included, studies did not have to compare both groups. hah was defined as 'a service that provides acute, hospital-level care by healthcare professionals in a home context for a condition that would otherwise require acute hospital inpatient care' [ ] . an acute inpatient setting was defined as 'a hospital (private or public) providing -h care for people who are unwell and had an unplanned admission' [ ] . as hah is designed to treat acute episodes of transient rather than chronic medical illness [ ] , studies set in non-medical or non-acute environments such as palliative care, respite, rehabilitation, mental health, long-term care or residential nursing home facilities were excluded. studies concerned with post-discharge hah services (e.g. 'step-down' hah), were also excluded, as the focus of the research project is hah as an alternative to hospital admission for the preservation of physical function. participants studies involving patients aged and over diagnosed with an acute-onset medical condition that would fall within the scope of a hah service were included. hah services predominantly manage non-surgical, non-critical conditions such as infection, acute exacerbations of cardiac and respiratory conditions, haematological and metabolic disturbances, and acute kidney injury [ ] . certain conditions are not appropriate for management in a home setting such as those requiring surgery (e.g. acute coronary syndromes, orthopaedics), critical care or advanced diagnostics and interventions (e.g. stroke). to ensure that intervention and comparison populations were similar, studies containing these large numbers of patients with such conditions were excluded unless these participants could be discounted from the results. a margin of ≤ % of patients under and ≤ % with excluded conditions was allowed. where numbers exceeded this margin, or other pertinent information was required, study authors were approached via email on up to occasions to request abridged results. where a custom dataset was provided, this was used in analysis over the published dataset. intervention and comparator the intervention of interest was treatment in a hah setting compared to standard inpatient acute care. as this review aimed to establish if there are differences in the cumulative activity levels of patients in each setting, trials of other interventions to increase patient activity such as exercise programmes or physiotherapy sessions over and above usual care were not suitable for inclusion unless the physical activity levels of the control group were available, as the intervention group would not be representative of the general older acute population. outcome the primary outcome measure was the cumulative level of pa performed by patients receiving standard medical care in a hah and/or inpatient setting. it was decided a priori that acceptable measures would include objective methods, such as activity monitor data, or subjective methods, such as direct observation, self-reported instruments or questionnaires. changes in functional independence (e.g. activities of daily living, dependent walking) and physical performance (e.g. handgrip test, timed up and go) from admission to discharge, as well as any adverse effects reported as a consequence of physical activity (e.g. falls) were selected as secondary outcomes. the inclusion and exclusion criteria are summarised in table . literature search results and bibliographic records were exported into refworks to facilitate deduplication and screening of titles and abstracts. articles meeting the inclusion criteria were then subjected to full-text appraisal. all records were reviewed by the lead researcher (js) and independently second-reviewed by another (ds, ua, mg or ge). the decision for inclusion or exclusion was recorded along with reasons for exclusion. where there was disagreement between reviewers on inclusion at any stage, a third reviewer was consulted. sixteen articles were selected for inclusion in the review. this process for identifying these is documented in the prisma flowchart [ ] below ( fig. ). the process of data extraction was performed using a custom template which was developed and piloted to extract: ( ) data relevant to the research question, and ( ) data required to perform a quality appraisal and risk of bias assessment using the appraisal tool for cross-sectional studies (axis) [ ] (data extraction table: online resource , axis appraisal: online resource ). the axis tool comprises questions and considers study design and reporting quality in addition to the risk of bias when appraising research studies [ ] . the data extracted were spot-checked for accuracy by the review team (ds, ua, mg or ge). where studies reported results for participants that were excluded from this review (e.g. surgical, non-geriatric) these were separated and excluded from the analysis. separate datasets were requested and received from karlsen [ ] and valkenet [ ] containing only participants that met the inclusion criteria. the physical activity outcomes of the studies were grouped according to their method of measuring physical activity levels and reporting format. in accordance with duvivier [ ] , standing and slow walking have both been categorised as physical activity and grouped together into 'active time' for the purposes of analysis. time spent sitting or lying down, including sleep time, has been classified as 'non-active' time. this classification allowed categories to emerge; ( ) active time recorded over h, ( ) active time recorded over variable timeframes, and ( ) physical activity as step count. the percentage of time spent actively was selected as a common scale to enable comparison of data across the studies. studies using step count as a measure of physical activity were reported separately. results reported in minutes were converted into a percentage of h. median and interquartile ranges were converted into mean values using the formula devised by wan [ ] to allow results to be summarised as pooled averages. summary independent t-tests were used to examine whether physical activity or step count differed significantly from the pooled averages when grouped by medical condition or studies at lower risk of bias. analyses were performed using spss v , p < . was considered significant and % confidence intervals are reported. study characteristics no suitable hah studies were identified. all included studies were conducted in single-site [ ] acute inpatient hospital environments. the studies were published between and , and the majority (n = ) were cross-sectional observational designs aiming to establish the physical activity levels of patients as a primary outcome. this design is consistent with the nature of the research question, which does not aim to evaluate the efficacy of an intervention. of the remaining three studies, two were validation/agreement studies [ , ] , and one was a randomised controlled trial (rct) [ ] . participants most studies concerned general acute medical patients (n = , mean sample size , range . five studies were exclusively concerned with patients with specific conditions; two each reported physical activity levels of patients with acute exacerbations of chronic obstructive pulmonary disease (mean sample size . , range - ) [ , ] , and heart failure (mean sample size , range - ) [ , ] and whilst one reported on patients with mixed medical conditions plus mild-moderate cognitive impairment (sample size ) [ ] . primary outcome all included studies assessed physical activity levels using objective accelerometer-based methods, except belala [ ] who used behavioural mapping. valkenet [ ] also performed behavioural mapping in addition to accelerometery (dynaport movemonitor). a variety of monitoring devices and algorithms were used, with the activpal (pal technologies, glasgow, uk) being the most commonly used device in studies concerned with posture ( uses), and the stepwatch activity monitor (modus health, washington, us) used most frequently for step count ( uses). the validity of the methods used was reported by most studies, except for the mediwalk pedometer (terumo, japan), used by ueda [ ] . the range and validity of outcome measures used is available in online resource . the included studies were assessed for risk of bias using the axis tool [ ] (online resource ) which was deemed appropriate due to the high proportion of observational studies identified. there is an inherent risk of bias in descriptive, observational study designs, which rank low on evidence hierarchies, however, a well-designed and conducted crosssectional study can be of some evidential value [ ] . the axis tool prompts consideration of selection, instrumentation and reporting bias as well as reporting and study design quality. it was also suitable for the evaluation of the methodology used to acquire and report physical activity levels in the rct included in this review [ ] . a domain-based risk of bias assessment indicates a low risk of instrumentation and reporting bias, with adequate measurement and reporting of physical activity levels, however, there is a high risk of selection bias within the identified research (fig. ) . the studies that performed better in the analysis [ , [ ] [ ] [ ] gave greater consideration to reporting information on non-responders (patients that were eligible for inclusion but declined to participate). in terms of quality assessment, overall reporting quality was high, however, study design considerations were less well evidenced, with a broad lack of consideration of sample size, and frequently vague reporting of ethics or consent protocols. active time recorded over h the level of inpatient physical activity reported as a percentage of h could be established in seven studies (table ) . when averages were pooled, the mean proportion of time spent active was found to be . % ± . (range . - . %). active time recorded over a variable timeframe three studies collected results over shorter, variable timeframes ( - h periods), during waking hours, and with different populations and measurement techniques (accelerometery and behavioural mapping), which precludes pooling of results, however, it can be seen that daytime-only levels are higher than the mean for h results, ranging from . to . % (median . %) ( table ) . physical activity as step count eight studies used pedometers or accelerometers to record h step count as a measure of physical activity ( functional change between admission and discharge was reported in studies, the results extracted are summarised in table . as will be discussed, the reported outcomes from these studies were highly heterogenous in terms of tools used, data collection protocols and presentation of data, such that no summative conclusions on of the impact of differing physical activity levels on the incidence of functional decline could be drawn from the data. adverse effects occurring during the period of monitoring were poorly reported, with only four studies reporting this outcome; two advised there were no adverse effects [ , ] and two reported one death (unrelated to physical activity) [ , ] during the course of their research. sub-group analyses were performed comparing studies at lower risk of bias (according to axis appraisal) and concerning only one medical condition to the overall physical activity and step count results. both sub-group analyses found no significant difference in results comparing these devices to the overall results (table ) , indicating the general results are an accurate representation of pa levels. the aim of this review was to identify, evaluate and synthesise the evidence on the physical activity levels of acutely ill older patients undergoing treatment in an hah vs inpatient setting. no hah studies of older adults could be identified, representing a significant gap in the literature surrounding this treatment model. despite the lack of hah research in this field, this review has provided useful data on the baseline physical activity levels that could be expected for patients suitable for treatment in a hah model of care: when monitored for h/day, such patients spend on average . % of the time active, and walk as few as . steps per day. these findings are consistent with other research on hospitalised older adults, despite the strict hah-specific inclusion/exclusion criteria applied. baldwin [ ] reviewed studies reporting the activity levels of acutely admitted medical and surgical adult patients, and found patients spent between % and . % of their entire stay sitting or lying, and that the majority of studies reported a daily step count of < . similarly, fazio [ ] , in a systematic review of standing/ walking activity in medical inpatients, found that patients were active for min per h ( . % of the time). the baseline pa values provided in this review may be suitable for use as an inpatient comparator value in future hah pa studies. the low levels of activity reflected in our findings can result in functional decline, however, in our results only four of the studies measuring physical activity also measured functional change. this represents a missed opportunity to further explore correlations between physical activity and functional decline that should be addressed in future pa studies in hospitalised and hah patients. where functional changes were reported there was high heterogeneity in results between studies. agmon [ ] established that walking less than steps when hospitalised was strongly associated with functional decline in older adults. both ueda [ ] and villumsen [ ] reported a mean step count below this threshold, and while both reported results using the barthel index, measurements were taken at different points in the studies and the results were presented differently: ueda [ ] reported the change in mean score, while villumsen [ ] reported the percentage of participants who improved. in all, six different metrics were used in the four studies reporting functional change, with high variability in measurement tools (see online resource ), data collection protocols and reporting formats, precluding meaningful synthesis of the results. assessing physical function in acutely ill older inpatients who may present with a wide range of medical conditions and functional levels is undoubtedly challenging, and research is ongoing to identify the most feasible tools to use in this patient group [ ] . a consensus-driven core outcome set for studies of functional performance in either older or hospitalised populations has yet to be developed and should be a research priority to allow evaluation and meta-analysis of the findings of studies in this field. placing the findings of this review in the wider context of physical activity research is challenging again due to substantial differences in the methods and outcome measures used. the techniques most frequently utilised in the studies in this review ( h recording, positional accelerometery) rarely feature in population or community-based research. including night-time activity is likely to present a more accurate picture of all activity undertaken, especially in a hospital setting where circadian rhythms may be disrupted [ ] , but will result in lower average activity levels than studies of day-time pa or sedentary behaviour only. this is evident in the results for the three studies that conducted monitoring over a shorter, daytime, timeframe (table ) which found physical activity ranged from . to . % of the monitoring period. as a result of these different outcome measures, recording periods and a lack of objectively established normative values for the -h physical activity of healthy free-living older adults, it is challenging to establish how much activity drops when hospitalised. however, as the continuous objective monitoring of research participants becomes easier and cheaper with developments in accelerometery and wearable digital technology, it may be the case that normative values for pa in free-living older adults can be established. this would allow more accurate evaluation of the extent to which normal pa is impeded by acute illness, in both hah and inpatient settings. a strength of this review is that it followed a systematic approach following cochrane guidelines where applicable [ ] and was reported in accordance with prisma statement, which reduces the risk of bias. a possible limitation of this review is its high specificity arising from highly refined inclusion and exclusion criteria. this led to some potentially relevant articles being excluded. for instance, two promising rcts were identified during the literature search and selection process which found that adult hah patients may around . times more active than inpatients [ , ] , however, these studies were excluded as it was not possible to isolate the results for participants aged over years-only. a further limitation of this review is the high risk of bias present in the studies identified, which may limit the representativeness of the findings. physical and functional decline, caused in part due to inactivity during hospital admission, can have a considerable impact on an older patient's health and ability to remain independent on discharge. hah may offer a treatment environment that preserves and facilitates physical activity in older patients, however, it has been demonstrated in this review that there is a lack of research evidence to confirm this. this review has provided an indication of the baseline activity levels of inpatients suitable for a hospital at home service, however primary objective research is needed in this treatment setting. this review also identified that functional change is infrequently measured along with physical activity, representing a missed opportunity to assess the impact of immobility in hospital on function. where they are reported, functional measures are highly diverse and data collection protocols vary, impeding comparisons between studies. a consensus-driven core outcome set for the investigation of functional decline in hospitalised patients would greatly facilitate the comparison and synthesis of research in this field. sedentary behaviour, defined as 'any waking behaviour characterized by an energy expenditure ≤ . metabolic equivalents (mets), while in a sitting, reclining or lying posture' [ ] , was included in the search strategy as a related field to physical activity. no studies reporting sedentary behaviour as the primary outcome met the inclusion criteria, therefore, this concept is not discussed further in this review. funding the writing of this review was funded through a joint nhs lanarkshire-glasgow caledonian university phd studentship. the funders have had no input in the writing of this review or it's conclusions. hospital at home, guiding principles for service development world hospital at home congress. societies and programs why we should expand hospital-at-home during the covid- pandemic citation report for "hospital at home". clarivate analytics admission avoidance hospital at home. cochrane database syst rev no one size fits all-the development of a theory-driven intervention to increase in-hospital mobility: the "walk-for" study the effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis trajectories and predictors of functional decline of hospitalised older patients predictors on admission of functional decline among older patients hospitalised for acute care: a prospective observational study reducing, "iatrogenic disability" in the hospitalized frail elderly the hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients rethinking hospital-associated deconditioning: proposed paradigm shift. phys therapy daytime physical activity and sleep in hospitalized older adults: association with demographic characteristics and disease severity accelerometery shows inpatients with acute medical or surgical conditions spend little time upright and are highly sedentary: systematic review daily and hourly frequency of the sit to stand movement in older adults: a comparison of day hospital, rehabilitation ward and community living groups recommendations for older adults' physical activity and sedentary behaviour during hospitalisation for an acute medical illness: an international delphi study attitudes and expectations regarding exercise in the hospital of hospitalized older adults: a qualitative study preferred reporting items for systematic review and meta-analysis protocols (prisma-p) : elaboration and explanation cochrane handbook for systematic reviews of interventions preferred reporting items for systematic reviews and meta-analyses: the prisma statement crd's guidance for undertaking reviews in health care targets for older adults' physical activity and sedentary behaviour during hospitalisation: an international delphi study development of a critical appraisal tool to assess the quality of crosssectional studies (axis) methodological quality (risk of bias) assessment tools for primary and secondary medical studies: what are they and which is better improved functional performance in geriatric patients during hospital stay measuring physical activity levels in hospitalized patients: a comparison between behavioural mapping and data from an accelerometer minimal intensity physical activity (standing and walking) of longer duration improves insulin action and plasma lipids more than shorter periods of moderate to vigorous exercise (cycling) in sedentary subjects when energy expenditure is comparable estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range assessing sedentary behavior with the geneactiv: introducing the sedentary sphere impact of oral treatment on physical function in older patients hospitalized for heart failure: a randomized clinical trial gosselink r ( ) physical activity and hospitalization for exacerbation of copd a pilot study examining activity monitor use in older adults with heart failure during and after hospitalization a pilot observational study to analyze (in)activity and reasons for sedentary behavior of cognitively impaired geriatric acute inpatients levels of evidence in medicine walking in hospital is associated with a shorter length of stay in older medical inpatients mobility activity and its value as a prognostic indicator of survival in hospitalized older patients very low levels of physical activity in older patients during hospitalization at an acute geriatric ward: a prospective cohort study ) how much do hospitalized adults move? a systematic review and meta-analysis association between steps a day and functional decline in older hospitalized patients feasibility and inter-rater reliability of physical performance measures in acutely admitted older medical patients hospital-level care at home for acutely ill adults: a pilot randomized controlled trial hospital-level care at home for acutely ill adults: a randomized controlled trial sedentary behavior research network (sbrn): terminology consensus project process and outcome stepping toward discharge: level of ambulation in hospitalized patients acknowledgements thanks to dr alexandra mavroiedi of strathclyde university for advice given during the drafting of the protocol preceding this review and to julie smith, specialist librarian within the school of health and life sciences, glasgow caledonian university for assistance with devising the search strategy. thanks also to professor jon goodwin for advice on data analysis strategy and to dr phillipa dall for assisting with the full text review stage. js was funded to write this review through a joint nhs lanarkshire-glasgow caledonian university phd studentship.author contributions js, ua, ge and ds conceived the review. all authors contributed to the development of the search strategy and participated in the screening, review and selection of the included papers. js drafted the review and all authors reviewed, provided feedback and approved the final manuscript. the authors declare that they have no competing interests.ethical approval not applicable. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/ . /. key: cord- -tl vhd s authors: levinger, pazit; panisset, maya; dunn, jeremy; haines, terry; dow, briony; batchelor, frances; biddle, stuart; duque, gustavo; hill, keith d. title: exercise intervention outdoor project in the community for older people – results from the enjoy seniors exercise park project translation research in the community date: - - journal: bmc geriatr doi: . /s - - - sha: doc_id: cord_uid: tl vhd s background: many research studies evaluate physical activity interventions for older people in the community, however relatively few successfully promote maintenance of physical activity beyond the completion of the intervention. this study aimed to implement and evaluate the effects of sustained engagement in physical activity on mental, social and physical health outcomes through the use of the seniors exercise park physical activity program for older people (the enjoy project). method: people aged ≥ years underwent a -week structured supervised physical activity program using outdoor exercise park equipment followed by months unstructured independent use of the exercise park. participants were assessed at baseline, months and months and completed a test battery evaluating physical activity, physical function and health related quality of life measures. repeated measures anova was used to compare differences between baseline, and months. results: of the participants, ( . %) completed the months supervised program, and ( %) completed the month assessment (the latter impacted by covid- restrictions). a significant increase in physical activity level was demonstrated following the weeks intervention (p < . ). significant improvements were also demonstrated in all physical function measures (p < . ), self-rated quality of life (p < . ), wellbeing (p < . ), fear of falls (p < . ), falls risk (p < . ), depressive symptoms (p = . ) and loneliness (p = . ) at months. at the months follow up, significant improvements from baseline were demonstrated in the frequency, duration and total of physical activity level (p < . ), and all physical function measures (p < . ), with no decline in these measures from to months. at months, significant changes were observed in the health related quality of life mobility and self care domains with reductions in both fear of falls and falls risk (p < . ). conclusion: the seniors exercise park may be an effective modality for improving and sustaining older people’s physical function and wellbeing and can be an important public health infrastructure investment in promoting physical activity for older people. future work should focus on wider implementation of the program and on scaling up this initiative to achieve public health benefit for the community. trial registration: trial registration number actrn , date of registration th october , https://www.anzctr.org.au/trial/registration/trialreview.aspx?id= the world's population is ageing rapidly, with the number of older people age and over projected to more than double by [ ] . the number of australians aged and over is expected to increase from around . million in to . million in [ ] . physical activity is one of the key behavioral factors to positively impact health outcomes, including reduction of risk of chronic diseases, cognitive and functional decline, and improvement in mental health [ ] . increase in physical activity can also minimise the burden on the health care system [ ] . despite the strong evidence around the importance of physical activity, older people do not regularly undertake physical activity [ ] , with less than % of older australians meeting the recommended physical activity guidelines [ ] . there has been considerable research into physical activity interventions for older people in the community, but interventions that successfully promote maintenance of physical activity beyond the completion of the intervention are limited [ , ] . various methodological challenges exist that often limit translation of physical activity programs into practice, these include: lack of evidence of transferability of trial results to the community setting, insufficient local expertise to roll out community exercise programs, and inadequate infrastructure to integrate evidence based programs into community practice [ ] . interventions that are designed to be conducted in a community setting with community engagement have the potential to be sustained beyond the trial period and have shown to be effective in increasing and promoting physical activity [ , ] . in recent years, outdoor environments and associated infrastructure features (e.g., exercise equipment) have been recognized as an important investment to promote regular physical activity [ , ] . hence, the design of an age friendly 'active environment' has been recommended as one of the strategies to increase physical activity at a population level [ ] . in we commenced our research work in the area of age friendly active spaces for older people with the utilization of outdoor exercise equipment specifically designed for older people (the seniors exercise park). the seniors exercise park program was designed to actively promote community well-being through the provision of a unique exercise and social support program. in a small week randomized controlled trial (rct), we demonstrated the effectiveness of the seniors exercise park program on improving physical function and social health in older people [ , ] . these preliminary positive outcomes indicated the need for investigation of its sustained impact on physical and social health outcomes, and its potential wider usage in the community on a larger scale with local governments' (councils') engagement. therefore, the aim of the present study was to implement and evaluate the effects of sustained engagement in physical activity on physical, mental, social and health outcomes through the use of the seniors exercise park physical activity program for older people (the enjoy project). this study was a multi-site prospective study with a pre and post intervention design and month follow up. participants underwent a -week structured supervised physical activity program using outdoor exercise park equipment followed by a month unstructured physical activity program, including ongoing unsupervised access to the exercise park. each exercise session was followed by a social gathering with morning/afternoon tea provided by the research team. participants were assessed at baseline, post intervention ( months) and months follow up time points as detailed in fig. . the study was designed according to the transparent reporting of evaluations with nonrandomized designs (trend) [ ] which complements the widely adopted consolidated standards of reporting trials (consort) statement developed for randomized controlled trials [ ] . ethical approval was obtained from the melbourne health human research ethics committee, melbourne (application id. hrec/ /mh/ , local number . ). all participants provided informed consent. the full description of the study's methods, design, and procedure can be found in the trial protocol [ ] . older people were eligible to participate in the study if they: ) were aged years and over living in the community (i.e. not living in an institution, such as a nursing home); ) had one or more falls in the previous months or were concerned about having a fall; ) were generally independent around the house (able to take care of themselves) and in the community (e.g. able to walk away from home to visit local stores, friends, and other local venues), and able to attend the outdoor exercise park; ) were able to walk outdoors and use the exercise equipment with no more gait aid support than a single point stick ) did not have cognitive impairment (abbreviated mental test score (amts) > / ) [ ] . older adults were excluded from this study if they: ) had neurological or musculoskeletal conditions limiting walking to less than one block; ) had a history of stroke, parkinson's disease, or other neurological disorder impacting on mobility; ) were unable to understand conversational english; ) were taking part in a structured resistance training and/or an organised balance training program more than once a week; ) met the australian physical activity recommendations of min of physical activity / week [ ] ; ) had any documented medical condition or physical impairment that was deemed by their medical practitioner to contraindicate their inclusion. older people were recruited from the general community in the suburbs close to the seniors exercise parks location in melbourne, australia. advertisements in local newspapers, council newsletters, posters displayed on notice boards, and flyers distributed to senior groups were used for recruitment. information was also placed online on the councils' and participating partners' websites as well as associated social media platforms (e.g. facebook, twitter). recruitment took place between october to november . participants who met the inclusion criteria attended an initial (baseline) assessment at a community centre close to their area of residence. demographic characteristics (age, gender), anthropometric measures (height and weight), previous medical history, current medication usage, socioeconomic and cultural background information (e.g. employment, level of education, country of birth, years of residency in australia) and falls history were collected at baseline. assessments were undertaken at baseline, months and months, by an allied health professional (accredited exercise physiologist and/or physiotherapist). physical activity the level of physical activity of the participants was measured using the community healthy activities model program for seniors (cham ps) [ ] . the champs provides a self-reported measure of caloric expenditure (and frequency) per week in all exercise-related activities and caloric expenditure (and frequency) per week in moderate exercise -related activities. a comprehensive suite of physical function (strength, balance, functional mobility), psychosocial (quality of life, enjoyment, social isolation, fear of falls, loneliness), and mental health outcomes (mental wellbeing, depression) and falls risk assessment were undertaken as detailed in the protocol paper [ ] , and summarized below. physical function measures physical measures of strength, balance and functional mobility were assessed using the following validated tests. (i) functional lower limb muscle strength was assessed using the -s sit to stand test [ ] ; (ii) exercise tolerance and functional mobility was assessed using the two-minute walk test [ ] ; (iii) dynamic balance was assessed using the step test [ ] , the sum of the number of steps from each limb was combined and used for the analysis [ ] ; and (iv) walking speed was assessed using the m walk test [ ] . psychosocial, mental and quality of life health outcomes psychosocial, mental health and quality of life outcomes were assessed using the following questionnaires: (i) health-related quality of life was assessed using the eq- d- l [ ] . the eq- d- l comprises five dimensions (mobility, self-care, usual activities, pain/ discomfort and anxiety/depression) as well as an overall self-rated health status (visual analog scale (vas) - ) where higher score represents better health. (ii) mental wellbeing was assessed using the five-item world health organization (who- ) wellbeing questionnaire [ , ] . the who- measures psychological wellbeing and depressive symptoms using simple questions. the raw score was calculated to obtain a percentage score, which ranges from representing the worst imaginable wellbeing and representing the best imaginable well-being. (iii)loneliness was assessed using the ucla -item loneliness scale which incorporates three dimensions of loneliness: relational connectedness, social connectedness and self-perceived isolation [ , ] . the scale gives a possible range of scores from to (higher scores indicate greater feelings of loneliness). (iv) depression was assessed using the short version geriatric depression scale (gds- ) where a score of to is considered normal and a score greater than suggests depressive symptoms [ ] . (v) fear of falls was assessed using the short falls efficacy scale international (short fes-i) questionnaire [ ] , a -item scale ranging from (no concern about falling) to a maximum (severe concern about falling). (vi) self-efficacy barriers to exercise was assessed using the self-efficacy for exercise (see) questionnaire, with scores ranging from to (a higher score indicates higher self-efficacy for exercise) [ ] . (vii) enjoyment was assessed using the -item version physical activity enjoyment scale (paces), where higher values reflect greater levels of enjoyment (values range - ) [ ] . (viii)social isolation and social support were assessed using the short version -item lubben social network scale (lsns ). the score ranges between and where higher scores indicate more social engagement [ ] . falls risk assessment (i) the falls risk for older people in the community (frop-com) risk assessment tool was used to assess fall risk. the frop-com consists of falls risk factor domains, with most risk factors scored to reflect graded risk on a -point scale (nil, mild, moderate, or severe) [ ] . the seniors exercise park the seniors exercise park equipment (lark industries (australia) and lappset group) consists of outdoor playground equipment specifically designed for older people to improve strength, balance, joint movements and overall mobility and function (fig. ). it comprises multiple equipment stations that target a specific function or movement (upper and lower limb) such as shoulder range of movement, static and dynamic balance (unstable surfaces), and functional movements (walking up/down stairs, sit to stand). the exercise park equipment was installed in two public locations and a third location in a retirement living and aged care community respectively: barry rd. community centre, thomastown, melbourne (under the municipality of whittlesea city council); central park community centre, hoppers crossing, melbourne (under the municipality of wyndham city council); and leith park, st helena, melbourne (old colonists' association of victoria). participants participated in a -week supervised exercise intervention program twice a week using the seniors exercise park. the exercise program was delivered by a qualified exercise instructor (accredited exercise physiologist or physiotherapist). participants performed exercises that focused on strength, balance, coordination, mobility and flexibility as detailed in our previous work [ ] . each session consisted of - min of warm-up exercises, followed by - min at the equipment stations, and concluded with min of cool down exercises (overall duration approximately min). the exercise classes were run as a circuit-based group program with - participants. each participant was familiarized with the exercises individually and the difficulty level was tailored to the capabilities of the participant. each session was followed by morning/ afternoon tea to encourage socialization. individual and group exercise progression each exercise station included two different exercises which were performed twice by each participant. examples of the stations and the exercises can be found at https://youtu.be/ payucmtnlyk. two participants were allocated to each station such that each participant performed one exercise for the allotted time and then swapped with their partner, repeating each exercise twice before rotating to the next station. rest periods were provided during transition to the next station. the duration of each exercise and rest period were adjusted progressively according to program progression, as detailed in the protocol paper [ ] . participation rate (adherence) and exercise monitoring during the -week supervised exercise program frequency of exercise session participation was determined using daily attendance logs kept by the exercise instructor. overall adherence to the structured exercise program was defined by the number of sessions attended: where % adherence indicated that a participant attended all available sessions. in the event of cancellation (due to weather or public holidays), participants were given alternative make up sessions to achieve the sessions. monitoring exercise uptake following the -week exercise program for monthsfob access system at the completion of the structured weeks exercise program participants were given two options to choose from to continue their physical activity. option independent unsupervised access and usage of the exercise park in participants' own preferred time. option : access to twice a week exercise sessions on the exercise park under supervision but with no formal structured group activity. adherence and exercise uptake for the months post intervention was monitored using a fob access system (citywatch security, melbourne, australia www.citywatchsecurity.com.au/) that included a card reader/scanner and a control panel at each site. participants were assigned an individual identification key (fob) which they used to tap a card reader each time they accessed the seniors exercise park at the site. their access was recorded and monitored (thereby electronically monitoring access). a separate paper will report outcomes and experiences using the fob system. weather elements in extreme weather conditions (e.g. heavy rain, extreme heat (above °c)), if deemed by the exercise instructor as unsafe to exercise, sessions were cancelled. in circumstances where sessions were cancelled, or during a holiday period, makeup sessions were organised towards the end of the program (up to two weeks or sessions). any cancellation and the associated reason were recorded in a log book kept by the researchers. adverse events joint pain/discomfort and or muscle soreness instances of joint pain or discomfort (directly related to the exercise program) during the exercise program were recorded. sessions that were missed due to pain or discomfort that had not settled and prevented a participant from attending the exercise sessions were also recorded. any falls during the delivery of the structured supervised exercise programs and during the independent usage phase of the seniors exercise park were recorded. a fall was defined as an event when the participant 'inadvertently comes to rest on the ground, floor or other lower level' (who global report on falls prevention in older age [ ] ). any report of difficulty breathing that did not settle quickly with rest, new or unrelenting chest pain, or acute changes in the level of consciousness during the session were documented. a serious adverse event was deemed if symptoms did not settle and medical emergency care was required and organised. a power analysis was undertaken using previously published data using the primary outcome measure champs for measurement of change in physical activity level over a month period [ ] . we considered a minimum meaningful change in the physical activity outcome from use of the seniors exercise park intervention to be d = . . using this standardized effect size, % power and a twotailed alpha of . , we calculated need for a sample size of participants. previous data indicates a within subject change in daily calorie expenditure for all activities of and for moderate intensity activities of when exposed to -month physical activity program [ , ] . this meant we were likely to have % power to detect a change of in total daily calorie expenditure, and in daily calorie expenditure in moderate intensity activities. we projected for a % drop-out rate, thus we sought a total sample of participants ( - per site). for the primary outcome of overall physical activity score (champs) and the physical, mental, and health secondary outcome measures, repeated measures analysis of variance (anova) were used to determine if there were differences between scores collected at baseline assessment and at month follow-up. a separate repeated measures anova (with the equivalent non parametric test for ordinal data) was used to examine the effect of the exercise program on physical activity level, physical, mental and psychosocial and health outcomes between baseline and months; and months vs months. information collected about exercise adherence were reported using descriptive statistics (% of adherence). data were analysed using spss version . (ibm corp, ny, usa). effect size, partial eta squared, ( η p ) from spss was used to determine effect size as follows: η p values greater than . were considered a large and significant effect size whereas . and . were considered small and medium, respectively [ ] . ninety-five older people living in the community who volunteered to participate were eligible to take part in the study, with a mean age of . ± . , and . % female. the majority of participants ( . %) suffered from at least one medical condition with the most common conditions reported being arthritis ( . %), hypertension ( . %) and hypercholesterolemia ( . %) ( table ) . fifteen participants dropped out between baseline and three months follow up ( . %), leaving participants available for analysis of pre-post intervention (mean age . ± . years; . % females). no significant differences existed between those who dropped out and the remaining sample with respect to their medical or demographic characteristics. recruitment and drop out breakdown are provided in fig. . interruption to data collection occurred during the covid- pandemic due to the physical distancing and lock down restrictions which prevented access to the seniors exercise park. participants were not able to access the seniors exercise parks for a lengthy period of several months (restrictions of public parks closure and no access to aged care sites as imposed by the australian state government). data of n = was impacted due to covid- and were excluded from the analysis (fig. ) . consequently, a separate analysis was conducted for the comparison of the champs primary and secondary outcomes between baseline and months follow up (n = ), in addition to the baseline vs months analyses (n = ). average adherence in the supervised -week program was %. the most frequently reported reason for absence from classes was due to illness or medical problems ( . % of the occasions of absences). only . % of sessions were cancelled due to weather (hot or wet). during the -week program, people ( %) reported pain or discomfort due to aggravation of pre-existing injury/condition, with events ( . % of all sessions) reported. five people ( . %) missed exercise sessions due to aggravation of pre-existing injury/condition with a total of sessions missed ( . % of all sessions). one fall occurred during the exercise program with no severe injury. no serious adverse events occurred during the program. a significant increase in physical activity level was demonstrated following the intervention (champs caloric expenditure, frequency per week and total time in all exercise and in moderate exercise per week, p < . , moderate to large effect sizes). significant improvements were also demonstrated in all physical function measures (p < . , small to large effect sizes), self rated quality of life (p = . , small effect size), wellbeing (p < . , small effect size), fear of falls (p < . , medium effect size), falls risk (p < . , medium effect size), depressive symptoms (p = . , small effect size) and loneliness (p = . , small effect size). no significant changes were demonstrated in socialisation and self-efficacy for exercise outcomes (p > . ) ( table ) . changes in the eq- d- l dimensions are presented in fig. with improvements shown in selfcare (p < . ) and depression (p = . ) domains. for the month follow up (n = ) significant improvements from baseline were demonstrated in the frequency, duration and caloric expenditure of moderate physical activity and all type of exercises (p < . , moderate to large effects size, table ). significant improvements in all physical function measures were demonstrated between ( ) baseline and months follow up (p < . , moderate to large effect size, table ). significant changes were observed only in the health related quality of life mobility and self-care domains (p < . , eq- d- l dimensions, fig. ). no changes were observed in the other health related quality of life measures apart from significant reductions in both fear of falls and falls risk (p < . , table ). very few changes were observed between and month follow ups as indicated in table . participation in physical activity is important for the reduction and management of chronic diseases as well as to help older people remain mobile and independent. only a quarter of older people meet the recommended national guidelines for physical activity [ ] . participation in the enjoy seniors exercise park program resulted in increases in physical activity level as well as physical and mental health benefits in the short term with sustained physical function benefit in the longer term. although there is strong evidence from randomized controlled trials to support the importance of physical activity, older people have low participation rates in physical activity programs aimed at achieving a variety of positive health outcomes, including falls prevention [ , ] . those who do commence a physical activity program as part of a research study often return to their inactive lifestyle behaviour once the study is completed, indicating that interventions that are not easy to apply in "real world" situations often do not sustain participation beyond the trial period [ ] . hence translating these studies into effective and sustained behaviour change remains a challenge [ ] . participation in the enjoy project resulted in significant improvement in physical activity level (all champs outcomes) after the weeks intervention and these improvements were sustained months later (with no decline between and months), suggesting that participants remained physically active over the longer term. importantly, the increase in the moderate exercise type (frequency and duration) indicates that participants exceeded the recommended physical activity participation of min per week of moderate intensity. the sustained engagement in physical activity provides promising results for the potential benefits of scaling up such a program in order to achieve public health benefit for older people in the community. sustained participation in physical activity at a level to maintain or improve health by older people remains challenging to achieve, with fewer than half of older adults being active enough to achieve most of these health benefits [ ] . having national and international guidelines or recommendations appear insufficient to achieve this activity [ ] . providing widely available and accessible avenues for physical activity options, such as widespread implementation of outdoors seniors exercise parks may assist improving participation levels. state and / or national policies supporting increased physical activity participation by older people may also be beneficial. loneliness and social isolation are greatest among older people and can pose significant physical and mental health risks [ , ] . loneliness, in addition to other physical and mental problems, gives rise to feelings of depression in older people [ ] . physical activity is one possible health promotion strategy that has positive effects on mental health in later life [ ] . improvement in depressive symptoms (as reported by the depression domain in the quality of life scale and the geriatric depression scale) and wellbeing were seen after the months intervention. slight improvement in loneliness (relational connectedness, social connectedness and self-perceived isolation) was demonstrated but with no changes in social isolation or social support. caution must be taken, however, in the interpretation of the results as the values reported in both scales (ucla and lsns ) did not suggest that the participants experienced severe loneliness or lack of social engagement at baseline. the physical activity program incorporated group setting exercise activity followed by a social morning tea, which facilitated social connection. enjoyment in physical activity was also significantly improved following the intervention. given that fun, enjoyment and social interaction are key motivators for older people to take part in physical activity [ ] , these aspects should be an integral part of physical activity programs for older people. consequently, the results highlight the beneficial effect of the seniors exercise park program on general wellbeing. we have previously demonstrated in a small randomized controlled trial the physical and social benefits of utilizing the seniors exercise park program for older people [ , ] . pre-post studies such as the enjoy trial may be considered to be less rigorous than randomised controlled trials, although in implementation research, especially where one or more previous randomised trials have demonstrated the approach to be effective (as in this study), this is considered acceptable [ ] . the enjoy project provides further evidence for the potential effectiveness of the physical and social activity program to improve quality of life and wellbeing on a larger scale beyond the weeks supervised program. the approach utilized in the enjoy project encompasses partnership with local governments to create an innovative enjoyable physical activity for older people with the utilization of specialized outdoor equipment. the availability of the equipment in community settings provides an advantageous set up where participants can have free access beyond the research trial. moreover, the location in outdoor settings also offers additional benefits, as exercising outdoors is known for its' health benefits for mental wellbeing [ ] . combining exercise, nature and social components may play a key role in engaging older people in physical activity and health promotion initiatives longer term. older people are at high risk of falls. exercise programs have been shown to be effective in preventing falls in community-dwelling older people [ ] . balance and strengthening exercises in particular are important to be incorporated into exercise programs to reduce falls [ ] . the seniors exercise park program integrates multimodal exercise stations that target balance (unstable/uneven surfaces), strength and functional movements. this offers an important combination of different physiological aspects to obtain broader health benefits in addition to falls prevention, and is different to what is available in most traditional outdoor exercise equipment, which is usually focused on either cardiorespiratory or strength training [ ] . the current sample population included people with high risk of falls ( . % had previous falls) as well as high fig. proportion of responses by level of severity for eq- d- l dimensions: mobility (a), usual activities (b), self-care (c), pain/discomfort (d), anxiety/depression (e) at baseline and at and months follow-ups. *significant between baseline and months. **significant between baseline and months prevalence of complex medical issues. the sustained improvements in the physical function measures as well as the reduction in fear of falls and falls risk at months suggest potential benefits to reduce the risk of falls. this study has several limitations. firstly, the spread of covid- in early and associated restrictions and lockdown prevented older people in the community to be physically active using the seniors exercise park in the latter stages of this project. this has adversely impacted on the enjoy project data collection as participants were unable to access the seniors exercise park sites as well as their ability to maintain their physical activity using this exercise modality. as such the data for the months follow up included a smaller sample which could have potentially impacted on the results, leading to underestimation of the impact of the physical activity program on various health measures. the total dropout rate (n = , fig. ) of those who ceased participation in the project was . % which is within the expected rate for exercise related interventional studies among older people [ , ] . secondly, the level of physical activity was measured using self-reported questionnaires which might not accurately reflect the actual physical activity level of the participants. however it is important to acknowledge that the champs questionnaire has been widely used in research and has been designed for use in evaluating interventions that primarily aim to increase levels of physical activity in older adults [ ] . it is a reliable and valid questionnaire that is sensitive to change of the physical activity measures derived from it. the questionnaire was also tested and found suitable to be used with older australians [ ] . finally, while our sample is representative of older australians' age, bmi and cultural background, it included a relatively high proportion of females with a small proportion of male participants. although the risk and incidence of falls are greater in females, males are commonly underrepresented in exercise intervention trials [ , ] . males have been reported to have specific preferences and characteristics of exercise interventions that are most likely to appeal to them [ ] . the specific appeal or lack of appeal of this outdoor exercise park approach will need to be explored in future research. the results suggest that the seniors exercise park may be an effective modality for improving older people's physical function and wellbeing beyond an initial supervised program, and can be an important public health infrastructure investment in promoting physical activity for older people. future work should focus on wider implementation of the program and on scaling up this initiative to achieve public health benefit for the community. new york: united nations, department of economic and social affairs, population division the ageing australian population and future health costs: - . department of health and aged care occasional papers does physical activity prevent cognitive decline and dementia?: a systematic review and metaanalysis of longitudinal studies the cost of physical inactivity: moving into the st century global physical activity levels: surveillance progress, pitfalls, and prospects physical activity in older people: a systematic review exercise-based interventions to enhance long-term sustainability of physical activity in older adults: a systematic review and metaanalysis of randomized clinical trials exercise and fall prevention: narrowing the research-to-practice gap and enhancing integration of clinical and community practice the effectiveness of interventions to increase physical activity. a systematic review community-based efforts to promote physical activity: a systematic review of interventions considering mode of delivery, study quality and population subgroups impact and costeffectiveness of family fitness zones: a natural experiment in urban public parks understanding outdoor gyms in public open spaces: a systematic review and integrative synthesis of qualitative and quantitative evidence global action plan on physical activity - : more active people for a healthier world older adults' perceptions to a novel outdoor exercise initiative: a qualitative analysis a novel exercise initiative for seniors to improve balance and physical function improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the trend statement statement: updated guidelines for reporting parallel group randomised trials exercise intervention outdoor project in the community for older people -the enjoy senior exercise park project translation research protocol evaluation of a mental test score for assessment of mental impairment in the elderly physical activity recommendations for older australians champs physical activity questionnaire for older adults: outcomes for interventions a -s chair-stand test as a measure of lower body strength in community-residing older adults two-, six-, and -minute walking tests in respiratory disease a new test of dynamic standing balance for stroke patients: reliability, validity and comparison with health elderly step test scores are related to measures of activity and participation in the first months after stroke gait speed and survival in older adults a single european currency for eq- d health states. results from a six-country study validity of the five-item who well-being index (who- ) in an elderly population regional office for europe ( ) wellbeing measures in primary health care: the depcare project developing a measure of loneliness ucla loneliness scale (version ): reliability, validity, and factor structure geriatric depression scale (gds) recent evidence and development of a shorter version the short fes-i: a shortened version of the falls efficacy scale-international to assess fear of falling testing the reliability and validity of the self-efficacy for exercise scale measuring enjoyment of physical activity in older adults: invariance of the physical activity enjoyment scale (paces) across groups and time performance of an abbreviated version of the lubben social network scale among three european community-dwelling older adult populations the reliability and predictive accuracy of the falls risk for older people in the community assessment (frop-com) tool a novel dynamic exercise initiative for older people to improve health and well-being: study protocol for a randomised controlled trial who global report on falls prevention in older age. geneva: world health organisation physical activity outcomes of champs ii: a physical activity promotion program for older adults statistical power analysis for the behavioral sciences physical activity across the life stages older people's participation in and engagement with falls prevention interventions in community settings: an augment to the cochrane systematic review participation levels of physical activity programs for community-dwelling older adults: a systematic review factors influencing the implementation of fall-prevention programmes: a systematic review and synthesis of qualitative studies global rocommendations on physical activity for health. geneva: world health organisation loneliness, social isolation, their synergistic interaction, and mortality loneliness and health in older adults: a mini-review and synthesis loneliness, depression and sociability in old age can physical activity improve the mental health of older adults? the acceptability of physical activity interventions to older adults: a systematic review and meta-synthesis effectivenessimplementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact exercise-, nature-and socially interactive-based initiatives improve mood and self-esteem in the clinical population exercise for preventing falls in older people living in the community: an abridged cochrane systematic review guidance about age-friendly outdoor exercise equipment and associated strategies to maximise usability for older people adherence to exercise programs for older people is influenced by program characteristics and personal factors: a systematic review reducing attrition in physical activity programs for older adults measurement properties of the champs physical activity questionnaire in a sample of older australians who participates in physical activity intervention trials? exercise for falls prevention in community-dwelling older adults: trial and participant characteristics, interventions and bias in clinical trials from a systematic review men's preferences for physical activity interventions: an exploratory study using a factorial survey design created with r software publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge whittlesea city council, wyndham city council and old colonists' association of victoria for their collaboration and partnership in this project. moreover, we would like to thank lark industries for the seniors exercise park equipment installation and associated advice and support. this study was funded by gandel philanthropy. this funding source had no role in the design of the study, its execution, analyses, interpretation of the data, and in writing the manuscript for publication. the datasets generated and/or analysed during the current study are not publicly available due to ethical restrictions but are available from the corresponding author on reasonable request.ethics approval and consent to participate ethical approval has been obtained from the melbourne health human research ethics committee, melbourne (application id. hrec/ /mh/ , local number . ). all participants signed a consent form prior to participation. not applicable. the authors declare that they have no competing interests. key: cord- - qf dqdg authors: ricci, fabrizio; izzicupo, pascal; moscucci, federica; sciomer, susanna; maffei, silvia; di baldassarre, angela; mattioli, anna vittoria; gallina, sabina title: recommendations for physical inactivity and sedentary behavior during the coronavirus disease (covid- ) pandemic date: - - journal: front public health doi: . /fpubh. . sha: doc_id: cord_uid: qf dqdg nan since the escalation of coronavirus disease (covid- ) pandemic, over a billion people across the world have faced restrictions due to varying degrees of confinement, and in the absence of a vaccine against sars-cov- , massive public health interventions have been implemented to contain the outbreak. the lockdown set up in many countries to combat the covid- epidemic entails unprecedented disruption of lives and work, determining specific risks related to mental and physical health in the general population, especially among those who stopped working during the current outbreak ( ) . the implementation of confinement policies to contain covid- could be a catalyst for concealed mental and physical health conditions, further enhancing the effects of psychosocial risk factors, including stress, social isolation, and negative emotions that may act as barriers against behavioral changes toward an active lifestyle and negatively impact on global health, well-being and quality of life, ultimately resulting in result in a range of chronic health conditions ( , ). the world health organization (who) classified physical inactivity as the fourth leading risk factor accounting for % of global mortality, following hypertension ( %), smoking ( %) and diabetes ( %). the relationship between physical inactivity and obesity trends was quite evident since when the london busmen study showed that bus drivers who mainly sat during work presented with larger waist circumferences, higher levels of adiposity and increased risk of coronary events than bus conductors, who walked the aisles and climbed the stairs of double-decker buses ( ). physical inactivity levels are rising in many countries with significant implications for the prevalence of non-communicable diseases and the general health of the population worldwide. the who recommends that adults accumulate at least min of moderate to vigorous-intensity physical activity (mvpa) or min of vigorous-intensity physical activity (vpa) throughout the week, cumulated in bouts lasting ≥ min. this volume of physical activity (pa) is associated with a lower risk of cardiovascular (cv) morbidity and mortality and a number of other healthcare benefits ( ). unfortunately, attained levels of daily pa are largely insufficient, especially in western countries. recent evidence suggests that sedentary behavior (sb) is independently associated with traditional cv risk factors and increased cv morbidity and global mortality, regardless of pa volume ( ). sb is defined as any waking behavior characterized by an energy expenditure ≤ . metabolic equivalents, while in a sitting, reclining or lying posture. typical sb includes "screen time" (tv viewing, videogame playing, computer use), car-driving, and reading. importantly, in a dose-response metaanalysis of studies, including , , community-dwelling participants, total sitting time volumes > h and h/day were associated with increased risk of all-cause death and cv death, respectively, in pa adjusted analyses ( ). for tv viewing time, an increased risk for all-cause and cv mortality was strongest above levels of - h/day, regardless of pa level ( ). thus, physical inactivity and sb should be considered as separate entities with their unique determinants and health consequences, but with synergistic harmful effects on cv health ( ) . while containing the spreading of the contagion as quickly as possible is the urgent public health priority, there have been few public health guidelines for the public as to what people can or should do in terms of maintaining their daily exercise or pa routines ( , ) . safeguarding psycho-physical health in a lockdown situation is paramount, and special attention should be paid to elderly and pediatric populations. with advancing age, it becomes more difficult to reverse the effects of deconditioning of the musculoskeletal system. children and adolescents have higher pa needs than adults, and these are more difficult to achieve during the quarantine period, also due to the influence of home environment ( ) . both physical and social environmental factors operating within the home space are indeed important influences on sb and pa, especially for the pediatric population ( ) . regarding adolescents, another point that warrants careful vigilance concerns the risks associated with increased total screen time, including the total hours spent on computer, tv and video gaming. who just released guidance intended for people in selfquarantine without any symptoms or diagnosis of acute respiratory illness, containing a set of practical advice on how to stay active and reduce sb while at home. who further highlights how standard recommendations of min of mvpa or min of vpa per week, or a combination of both, can still be achieved even at home, with no special equipment and with limited space. there is a robust health rationale for staying active at home in the current precarious environment, for all age groups. the following are general recommendations, unless otherwise specified. you can meet weekly recommendations performing short bouts of pa, including taking the stairs, performing domestic chores, such as cleaning and gardening, or funniest activities such as dancing. walk and stand up take every chance to walk and stand up, like walking during a call, or taking a breath of fresh air, even just at the window. try not to sit continuously for more than h, but rather to take a - min break every min. alternatively, consider active breaks every h of sb or distribute periods ≥ min of continuous aerobic activity throughout the day. light-intensity activities like mobilizing the muscular masses and the joints are fine. older people can perform them even in sitting or semi-lying position. follow online exercise classes, play with children, help the elderlies to stay active take the advantage of free, virtual exercise classes on the web, devote more time to playing with children and encourage seniors to stay safe and active choosing suitable exercises for endurance, strength, balance, and flexibility. avoid screen time while playing with children in favor of funny activities and active playing. for children and teens, it is advisable to play with sports or fitness video games with motion sensor controls. performing light-intensity activities while assisting older people protects you from sedentariness. active play rather than screen time helps you and your children to avoid snacking. be regular have regular times for main meals, sleep, and wake-up calls. your sleep should be of sufficient duration and good quality. prioritize continuity and regularity rather than the intensity of the pa and gradually increase frequency, duration, and intensity. activity trackers and smartphone apps can help in monitoring your progress. in case of poor experience and poor physical fitness, be careful. specific recommendations and tips for children, adults, and elderly are further detailed in figure . while recognizing the importance of confinement policies set up to contain covid- pandemic, we firmly recommend the relevance of home-based programs for figure | physical activity, sedentary behavior, sleep recommendations, and tips for covid- quarantine period. blue, adults; gray, older people; orange, preschooler; yellow, school-aged children and adolescents; bold, international guidelines and recommendations; italic, tips for quarantine period; pa, physical activity; sb, sedentary behavior; lpa, light-intensity physical activity; mpa, moderate-intensity physical activity; vpa, vigorous-intensity physical activity; mvpa, moderate to vigorous-intensity physical activity. in the central portion of the figure we reported recommended hours of sleep by age group. *perform strengthening activities in non-consecutive days. +, ++, + + +: relative importance of pa/exercise type for each age category. dumbbell: muscle and bone strengthening activities; running: aerobic activities; monopodalic standing: balance exercise; bending: flexibility. disruption physical inactivity and sedentary behavior as a critical behavioral strategy for the prevention of global health and consequences of psychosocial stress during the current lockdown. fr and pi drafted the manuscript. all co-authors provided critical revision for important intellectual content. unprecedented disruption of lives and work: health, distress and life satisfaction of working adults in china one month into the covid- outbreak sanchis-gomar f. health risks and potential remedies during prolonged lockdowns for coronavirus disease (covid- ) physical inactivity and cardiovascular disease at the time of coronavirus disease (covid- ) mortality, and incident type diabetes: a systematic review and dose response meta-analysis relationship of sedentary behavior and physical activity to incident cardiovascular disease: results from the women's health initiative coronavirus disease (covid- ): the need to maintain regular physical activity while taking precautions a tale of two pandemics: how will covid- and global trends in physical inactivity and sedentary behavior affect one another? prog cardiovasc dis associations between the home physical environment and children's home-based physical activity and sitting socio-cultural determinants of physical activity across the life course: a 'determinants of diet and physical activity' (dedipac) umbrella systematic literature review 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 © ricci, izzicupo, moscucci, sciomer, maffei, di baldassarre, mattioli and gallina. this is an open-access article distributed under the terms of the creative commons attribution license (cc by). the use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. no use, distribution or reproduction is permitted which does not comply with these terms. key: cord- -hvrly e authors: stanton, robert; to, quyen g.; khalesi, saman; williams, susan l.; alley, stephanie j.; thwaite, tanya l.; fenning, andrew s.; vandelanotte, corneel title: depression, anxiety and stress during covid- : associations with changes in physical activity, sleep, tobacco and alcohol use in australian adults date: - - journal: int j environ res public health doi: . /ijerph sha: doc_id: cord_uid: hvrly e the novel coronavirus (covid- ) has enforced dramatic changes to daily living including economic and health impacts. evidence for the impact of these changes on our physical and mental health and health behaviors is limited. we examined the associations between psychological distress and changes in selected health behaviors since the onset of covid- in australia. an online survey was distributed in april and included measures of depression, anxiety, stress, physical activity, sleep, alcohol intake and cigarette smoking. the survey was completed by adults (mean age . ± . years, % female). negative change was reported for physical activity ( . %), sleep ( . %), alcohol ( . %) and smoking ( . %) since the onset of the covid- pandemic. significantly higher scores in one or more psychological distress states were found for females, and those not in a relationship, in the lowest income category, aged – years, or with a chronic illness. negative changes in physical activity, sleep, smoking and alcohol intake were associated with higher depression, anxiety and stress symptoms. health-promotion strategies directed at adopting or maintaining positive health-related behaviors should be utilized to address increases in psychological distress during the pandemic. ongoing evaluation of the impact of lifestyle changes associated with the pandemic is needed. first reported in november , the novel coronavirus (covid- ) has resulted in a global health emergency. as of june , the virus has claimed more than , lives globally and infected more than . million people. the scale of the pandemic has resulted in worldwide concern, not only for the loss of life but also the social and economic impacts. there is significant concern over how the changes in the ways that people normally engage in everyday activities impact their health and well-being. this is especially relevant for those in self-isolation or quarantine, where feelings of depression, fear, guilt, and anger may manifest [ ] . in australia, similar to other countries, social distancing, travel bans, the cancellation of sporting and other mass participation events, and changes to work practices have dramatically affected daily life. the partial lockdown procedures implemented by the australian government to protect citizens and reduce the spread of the virus forced the closure of many businesses in late march saw unemployment levels rise to . %, more than three times higher than the pre-covid- predicted unemployment rate [ ] . the impact of these changes likely comes at significant personal cost, including the onset, or worsening, of mental health issues. to address the psychological distress experienced by australians in the current pandemic, more than aud million has been committed to the development and delivery of mental health and well-being support services in australia. multiple calls to ensure the preparedness of psychological services have been presented [ ] [ ] [ ] ; however, the uptake and immediate and long-term impacts of these services are unclear. the covid- pandemic may also lead to adverse changes in health behaviors, such as physical activity, smoking, alcohol use and sleep. with the enactment of social isolation and physical distancing restrictions in march , the usual places to be physically active, such as gyms and outdoor recreation facilities, were no longer accessible. although some people may have sufficient autonomous regulation of physical activity to pursue alternate activities (e.g., online fitness classes, other home-based physical activities), others may reduce their physical activity due to the lack of social support available or concerns for contracting the virus in an outdoor environment. on the other hand, those forced to work from home may have spent less time commuting, and may have seized the opportunity to create new physical activity habits. alternatively, since exercise was one of few legitimate reasons for being able to leave the home some people may have developed a walking or cycling habit as a reason to escape being housebound. as many studies have demonstrated strong positive associations between physical activity and lower psychological distress [ , ] , the commencement or continuation of physical activity during the pandemic will likely aid in reducing psychological distress. however, some concern has been expressed regarding increased risk of respiratory illness in those engaged in high-and very-high intensity exercise due to the potential for reduced immune response [ ] . in contrast to health-promoting behavior such as physical activity, some people may manage social isolation and any pandemic-related psychological distress by commencing or increasing adverse health behaviors such as smoking or alcohol use. since covid- is an acute respiratory illness, commencement or continuation of tobacco use during the covid- pandemic may lead to the worsening of outcomes for those infected with the virus [ ] . indeed, early indications suggest the proportion of current and former smokers is higher among those with severe disease and among those admitted to intensive care and requiring ventilation [ , ] . harmful intake of alcohol leads to neuroadaptations that exacerbate alcohol cravings during times of stress [ ] . hence, social isolation, coupled with changes in employment status or uncertainty about the future may trigger an increase in alcohol intake for susceptible individuals [ ] . the combined effect of changes in lifestyle behaviors; confinement to the home through government restrictions in travel; and elevated depression, anxiety and stress associated with the current covid- pandemic, may have significant negative impacts on sleep [ ] . this has been especially evident in healthcare workers, who may be required to work longer shifts in highly stressful environments [ , ] . poorer sleep quality has been associated with higher levels of depression, stress, and anxiety [ ] . maintaining sleep quality is important in strengthening immunity [ ] , hence any sleep disturbances subsequent to covid- -pandemic-induced stress, may increase susceptibility to infection, or compromise recovery in the case of infection [ ] . there is currently limited research regarding psychological distress subsequent to the covid- pandemic. two recent studies from china reported high levels of psychological distress during the initial stages of the pandemic [ , ] ; however, the association between psychological distress and health behaviors remains unclear. early evidence during the covid- outbreak suggests positive associations between increased physical activity and physical health and inverse associations between sedentary behavior and physical and mental health outcomes [ ] . a more detailed exploration of health behaviors during stages of the covid- pandemic may help direct future public health messaging to promote positive behaviors and guard against uptake or the worsening of negative behaviors in order to maintain community well-being and mental health. therefore, the present study aims to examine associations between depression, anxiety and stress and changes in health behaviors, including physical activity, sleep, smoking and alcohol use subsequent to the onset of covid- and the implementation of social isolation rules in australia. an anonymous online survey was hosted on the survey platform qualtrics and distributed using social media sources (facebook and twitter) and via institutional sources including email and public marketing. eligible participants included all australian adults aged years and over. ethical approval was granted by central queensland university's human research ethics committee (approval number ). data collection occurred between and april . at the time of survey distribution, australia was in the midst of significant personal distancing, partial lockdown and travel restrictions. social distancing measures included keeping a minimum . meters between people, a ban on any public gatherings, a limit of no more than five people at personal gatherings such as weddings and funerals, and no person was allowed to meet with more than one other person outside of their own household. lockdown restrictions also included the closure of restaurants and bars, many retail stores, and restricted access to outdoor parks. most schools were closed, with students advised to study from home while being supported by online learning platforms and materials. university campuses limited or ceased face-to-face teaching and transitioned to online learning, with most clinical placements, residential schools, and simulations postponed. inter-and intra-state travel was banned, and travel within towns and cities was only permitted for essential work/workers, or to access essential services such as medical or health care, or to shop for groceries. existing covid- surveys from china, the united kingdom and germany were reviewed to inform development of the present survey. in addition to demographic information, the survey included questions examining chronic health conditions; depression, anxiety and stress; and physical and health behaviors such as physical activity, sleep, smoking and alcohol consumption. the current paper only reports on measures included in the survey associated with the study aim. demographic characteristics included age, gender, marital status, educational attainment, income and chronic disease status. psychological distress was assessed using the well-established -item depression, anxiety and stress scale (dass ) [ ] . seven items for each component were scored on a -point likert scale ranging from (did not apply to me at all) to (applied to me very much, or most of the time). scores for depression, anxiety and stress items were summed with valid scores ranging from - for each component. symptom severity was scored according standard cut-points [ ] . physical activity was assessed using the active australia survey (aas) which comprises eight items assessing frequency and duration of walking, moderate and vigorous leisure physical activities, and vigorous gardening over the past seven days. total physical activity was calculated according to the aas guidelines, where total minutes of physical activity = minutes of walking + minutes of moderate activity + (minutes of vigorous activity × ) [ ] . a single item asked participants to report their change in physical activity since the onset of covid- , with six response options ranging from (i am much more physically active than usual) to (i have ceased physical activity altogether). sleep was assessed using two items. first, participants were asked how many hours, on average, they slept per night prior to the onset of the covid- pandemic (sleep quantity). second, participants indicated the effect of the covid- pandemic on current sleep quality using the question, "since the onset of the covid- pandemic, i...". five response options ranged from "am sleeping much better than usual" to "am sleeping much worse than usual". smoking behavior was assessed by asking whether respondents consumed cigarettes or other tobacco products prior to the onset of covid- . change in smoking behavior was examined using a single item with ten response options ranging from "since the onset of the covid- pandemic, i... smoke much more than usual", to "have not smoked (i am a non-smoker)". current alcohol use was examined using the first item of the alcohol use disorder identification test consumption (audit-c) [ ] , which asks how often alcohol is consumed. response options were "never", "monthly or less", " - times a month", " - times a week", and " or more times a week". changes in alcohol consumption was assessed using a single self-report question: "since the onset of the covid- pandemic i . . . ", with the following response options: "drink much more than usual", "drink a little more than usual", "drink about the same as usual", "drink less than usual", "drink much less than usual", "intend to reduce my drinking", "intend to cease drinking", or "have ceased drinking altogether". sas v . (sas institute inc., lane cove, australia) was used for the analysis. the descriptive statistics, including frequencies and percentages, were generated for categorical variables; means and standard deviations (sd) were generated for continuous variables. depression, anxiety and stress scores were compared based on participant's sociodemographic and health status using non-parametric analysis of wilcoxon rank-sum, the kruskal-wallis test and spearman's correlation. the responses for each behavior, i.e., physical activity, sleep, smoking and alcohol use, were recoded into negative change (− ), no change ( ), or positive change (+ ) for separate analyses of changes in each behavior. a multiple lifestyle behavior index [ ] was created by summing the scores of the four behavior change items to reflect a composite health behavior change score, ranged from - to + . the average composite health behavior change scores and sd were presented separately for each level of depression, anxiety and stress. linear regression was used to test associations between composite health behavior change score and depression, anxiety and stress. crude estimates and estimates adjusted for age, years of education, gender, marital status, household income and chronic disease status were reported with % confidence intervals (ci). logistic regression was used to test whether negative changes in individual behavior change items were associated with depression, anxiety and stress. crude odds ratios (or) (model ) and ors adjusted for age, years of education, gender, marital status, household income and chronic disease status (model ) with % ci were reported. all p-values were two-sided and considered significant if less than . . the sociodemographic and health characteristics of the study sample are presented in table . in total, people (mean age . ± . years, female) completed the survey. most (n = , . %) were married or in a relationship, and almost half (n = , . %) reported having at least one chronic health condition. the average score for depression was . ± . ; anxiety, . ± . ; and stress, . ± . . the average physical activity of participants was . minutes/week, but almost half (n = , . %) reported a reduction in physical activity since the onset of the covid- pandemic. the average sleep duration reported prior to the onset of covid- was . ± . h per night, with half (n = , . %) reporting no change in sleep quality since covid- . most (n = , . %) were non-smokers, and the majority (n = , . %) reported no change in smoking since the onset of covid- . almost one-quarter (n = , . %) reported consuming alcohol on four or more occasions per week, and just over half (n = , . %) reported no change in alcohol consumption. the depression, anxiety and stress scores in relation to different sociodemographic and health characteristics are presented in table . no significant differences were found between males and females for depression and anxiety; however, females had significantly higher stress scores compared to males. younger individuals ( - years) had significantly higher depression, anxiety and stress scores compared to their older counterparts. similarly, those who were not in a relationship had significantly higher depression, anxiety and stress scores compared to other categories of relationship status. the spearman's correlation showed a significant negative association between years of education (recorded as a continuous variable) and scores for depression, but not for the anxiety or stress scores. those in the lowest income category had significantly higher depression scores compared to higher income categories; however, no difference was observed between different weekly household incomes and anxiety and stress. respondents who had been diagnosed with a chronic illness reported significantly higher depression, anxiety and stress scores, compared to those without chronic illness. diagnosed with a chronic disease the mean changes in composite health behavior score, stratified by depression, anxiety and stress severity, are presented in table . for depression, anxiety and stress, the number of people in each symptom severity category decreased as the symptom severity increased, except for the categories of extremely severe depression and anxiety. for depression, anxiety and stress, the mean composite health behavior change score decreased as the symptom severity increased, except for the categories of extremely severe anxiety and stress. associations between depression, anxiety and stress severity and negative change in behavior are outlined in table . since adjustment for age, years of education, gender, marital status, household income and chronic disease status did not impact associations, only adjusted or's are presented. participants who reported a negative change in physical activity were more likely to have higher depression (adjusted or = . , % ci = . , . ), anxiety (adjusted or = . , % ci = . , . ), and stress (adjusted or = . , % ci= . , . ) symptoms. those who reported a negative change in sleep were more likely to have higher depression (adjusted or = . , % ci = . , . ), anxiety (adjusted or = . , % ci = . , . ), and stress (adjusted or = . , % ci = . , . ) symptoms. for those who reported a negative change in smoking, they were more likely to have higher depression (adjusted or = . , % ci = . , . ), anxiety (adjusted or = . , % ci = . , . ), and stress (adjusted or = . , % ci = . , . ) symptoms. similarly, those who reported a negative change in alcohol intake were more likely to have higher depression (adjusted or = . , % ci = . , . ), anxiety (adjusted or = . , % ci = . , . ), and stress (adjusted or = . , % ci = . , . ) symptoms. the results were consistent for composite change scores. there was a decrease of . ( % ci = − . , − . ), . ( % ci = − . , − . ), and . ( % ci = − . , − . ) points in composite change score for every point increase in depression, anxiety and stress. the present study examined the association between depression, anxiety and stress and the change in health behaviors of physical activity, sleep, smoking and alcohol use subsequent to the onset of covid- , as individual health behaviors and as a health behavior change index composite score. the main findings were that all aspects of psychological distress (depression, anxiety and stress) were significantly associated with changes in health behavior, both independently and as a composite score. numerous studies have examined the association between a range of health behaviors and psychological distress factors. for example, rebar and colleagues reported significant inverse associations between physical activity participation and depression and anxiety levels in their meta-analysis [ ] . previous work has reported significant positive associations between smoking, and depression [ ] , but not between smoking cessation and reductions in depression or anxiety [ ] . large-scale studies also demonstrate a significant association between alcohol misuse and psychological distress [ ] . taken together, the findings of previous work suggest variability in the associations between lifestyle behaviors and depression, anxiety and stress that appear to depend on the nature of the behavior under investigation. the present study also demonstrated that, as the severity of depression increased, the composite health behavior change score worsened. that is, those with normal levels of depression symptoms reported a small negative change (− . points), while for those with extremely severe symptoms, the change in composite health behavior change score was more than three times greater (− . ). for anxiety and stress, as symptom severity increased from normal to severe, so did negative changes in composite health behavior change score. linear regression showed a significant association between increased depression, anxiety and stress, and negative changes in composite health behavior change scores. logistic regression showed that, compared to no change or positive change, a negative change in all behaviors was associated with a significantly greater likelihood of increased depression, anxiety and stress. a number of reports suggest covid- is likely to have significant impacts on psychological distress [ , ] ; however, the data from the present study suggest that the mean scores for depression, anxiety and stress are mostly within the normal to mild range. moreover, the mean scores for depression and stress were only slightly elevated when compared to normative data for australian adults, and anxiety the scores were marginally lower [ ] . viewed another way, more than % of all respondents reported psychological distress within the normal range, and less than % reported severe to extremely severe scores. the mean scores for depression, anxiety and stress in the present study are all substantially lower than those reported in italy. mazza and colleagues [ ] reported mean depression, anxiety and stress scores of . , . , and . , respectively, compared to . , . , and . , respectively, in the present study. these differences may be accounted for in the timing of data collection as data from italy were collected in mid-march, differences in government responses to the pandemic, and differences in the severity of impact on the population. the prevalence of moderate to severe depression in the present study ( . %) is comparable to that reported in china ( . %) [ ] ; however, the prevalence of moderate to severe anxiety is markedly less in this study ( . %) compared to that in china ( . %). in contrast, the prevalence of moderate to severe stress reported in this study ( . %) is almost double that reported in china ( . %). the timing of data collection may account for some of these differences since the data from china were collected from residents in cities during late january-early february, one day after the world health organization declared a public health emergency. in contrast, the data for the present study were collected in early to mid-april when significant travel and social distancing restrictions were already in place. it is possible that the low prevalence of depression may also be a result of government investment in mental health support services. the lower anxiety scores in the present study may be attributed to respondents being somewhat accustomed to changes in social contact, whereas the higher stress levels may be attributed to the uncertainly about the future, particularly regarding job losses and economic stress. the total average physical activity was . ± . min/week. this is similar to recent australian bureau of statistics data based on the active australia survey, showing that australians aged and over reported min of daily activity, or min per week on average [ ] , but substantially less than the peak of min of activity per week reported by alley and colleagues using the same measure [ ] . physical activity guidelines for australian adults suggest they should accumulate - min of moderate intensity physical activity, - min of vigorous intensity physical activity, or an equivalent combination of both, per week. however, here we report total physical activity, not moderate or moderate-to-vigorous activity. the aas is known to overreport physical activity participation, but actigraphy is not practical in large samples [ ] . therefore, our data may be an over-representation of actual physical activity performed. almost half of our respondents ( . %) reported a negative change (reduction) in physical activity since the onset of the covid- pandemic, but about % also reported a positive change. this is important to note, since there has been considerable emphasis in the media on the importance of maintaining physical activity for physical and mental health benefits [ , ] . our data suggests these recommendations may have been ineffective for most people, but not all. these data are hard to interpret as there has been a visible increase in people using walking paths all over the country, as well as a strong increase in registrations to the , steps australia program [ ] . it may be that the extra people who are walking are predominantly those who were already active (e.g., gym and sports club members) prior to the covid- onset, but had to undertake different activities at different locations due to the closure of exercise and sporting facilities. the reported overall decline in physical activity is likely a consequence of social distancing, travel restrictions, the closure of usual exercise venues, or unwillingness to change previous exercise habits. nonetheless, given the psychological distress responses to covid- , [ ] and the established benefits of physical activity on psychological distress [ , ] , additional strategies to promote physical activity are needed. prior to the covid- pandemic, mean sleep duration was . ± . h, which meets the guidelines of - h for adults [ ] and aligns with a recent national study of australian adults [ ] . although half ( . %) of all respondents reported no change in sleep quality since the onset of the covid- pandemic, . % reported a negative change. this is unsurprising given the potential for psychological distress during a global pandemic, change in exercise behaviors, and employment and relationship concerns. a number of recommendations have been made to address poor sleep during covid- , including maintaining a regular sleep routine, taking time for self-reflection, limiting exposure to covid- -related news, and getting regular exercise during daylight hours [ ] . apart from these covid- -specific recommendations, most principles mirror those recommended for good sleep hygiene in usual circumstances. only % of survey respondents were smokers. this is less than the % prevalence of smoking recently reported among australian adults [ ] . overwhelmingly, respondents have not changed their smoking behavior, with almost % reporting no change or a positive change (reduction) in smoking status since the onset of the covid- pandemic. among smokers, . % (n = ) report a positive change (reduction), . % (n = ) report no change, while . % (n = ) report a negative change (increase) in smoking behavior. since covid- is a respiratory illness, and smokers are more susceptible to respiratory tract infections, there is significant potential for adverse events in this population. early evidence from china suggests either a significant association, [ ] or at least a trend [ ] toward smoking being associated with poor prognosis in covid- cases. to date, there has been limited attention in the media to smoking cessation programs or adverse risk associated with smoking. although more research is needed, health promotion efforts directed at educating the population regarding the risks for smokers during the covid- pandemic are needed. these may include higher exposure to passive smoking during periods of lockdown or relapse-preventions strategies targeting those who have recently ceased smoking. almost three quarters of respondents reported no change or a positive change (reduction) in alcohol use since the onset of covid- . a reduction in alcohol use might be driven by closures to licensed establishments such as bars and clubs and temporary restrictions on alcohol purchases. in contrast, around one quarter of respondents reported a negative change (increase) in alcohol consumption. this is consistent with research by australia's foundation for alcohol research and education [ ] reporting that % of australians increased alcohol purchases since the onset of covid- and % were drinking more than usual. worryingly, this report suggests that almost % of adults are drinking more to cope with psychological distress [ ] . concerns such as these have prompted the australian government to invest more than aud million into drug-and alcohol-related services to combat the risk of substance abuse and related harms, such as domestic violence, due to the pandemic. to the best of our knowledge, this is the first published study to report associations between health behaviors and psychological distress in australian adults during the covid- pandemic. one published study from europe reported that reductions in physical activity and increased sedentary behaviors during lockdown were associated with negative changes in physical and mental health [ ] . moreover, a number of reports have highlighted the need for rapid and comprehensive responses to increasing mental health needs during covid- [ , ] ; however, it is expected this support will need to be maintained for some years to come given the magnitude of the covid- pandemic. there are a number of strengths of the present study, including the inclusion of multiple health behaviors, a large sample size, and the timing of data collection relative to lockdown restrictions in australia. however, there are also some limitations to consider. firstly, all data are self-reported meaning responses are subject to recall bias. secondly, data are cross-sectional and therefore causality cannot be inferred. thirdly, participants in the present study are older compared to other studies examining health behaviors such as sleep [ ] , and thus the generalizability to other populations needs to be confirmed. additionally, longitudinal data are needed to observe changes over time to assess the impact of changes in social restrictions. finally, our sample was recruited conveniently and therefore the results may not be generalizable to populations with different characteristics. in conclusion, our data suggests negative changes in health behaviors are associated with increased psychological distress in australian adults during the covid- pandemic. effective health promotion strategies directed at adopting or maintain positive health-related behaviors such as targeted social media messaging and balanced media reporting, should be used to reduce the acute and chronic increases in psychological distress during these unprecedented times. ongoing evaluation of the impact of lockdown rules and social distancing (associated with the pandemic) on health behaviors is necessary to inform these targeted health promotion strategies. the psychological impact of quarantine and how to reduce it: rapid review of the evidence psychological interventions for people affected by the covid- epidemic the emotional impact of coronavirus -ncov (new voronavirus disease) the mental health consequences of covid- and physical distancing: the need for prevention and early intervention role of physical activity and sedentary behavior in the mental health of preschoolers, children and adolescents: a systematic review and meta-analysis the evidence for physical activity in the management of major mental illnesses: a concise overview to inform busy clinicians' practice and guide policy respiratory health in athletes: facing the covid- challenge covid- and smoking clinical characteristics of coronavirus disease in china analysis of factors associated with disease outcomes in hospitalized patients with novel coronavirus disease stress, dysregulation of drug reward pathways, and the transition to drug dependence alcohol use and misuse during the covid- pandemic: a potential public health crisis? lancet public health , , e dealing with sleep problems during home confinement due to the covid- outbreak: practical recommendations from a task force of the european cbt-i academy generalized anxiety disorder, depressive symptoms and sleep quality during covid- outbreak in china: a web-based cross-sectional survey the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid- ) in january and february in china changes in sleep pattern, sense of time, and digital media use during covid- lockdown in italy sleep health: reciprocal regulation of sleep and innate immunity importance of sleep for health and wellbeing amidst covid- pandemic a nationwide survey of psychological distress among chinese people in the covid- epidemic: implications and policy recommendations immediate psychological responses and associated factors during the initial stage of the coronavirus disease (covid- ) epidemic among the general population in china relationships between changes in self-reported physical activity, sedentary behaviours and health during the coronavirus (covid- ) pandemic in france and switzerland manual for the depression anxiety stress scales active australia survey: a guide and manual for implementation, analysis and reporting; australian institute of health and welfare audit-c as a brief screen for alcohol misuse in primary care cross-sectional associations between multiple lifestyle behaviours and excellent well-being in australian adults a meta-meta-analysis of the effect of physical activity on depression and anxiety in non-clinical adult populations association between depression and smoking: a global perspective from low-and middle-income countries smoking in relation to anxiety and depression: evidence from a large population survey: the hunt study gender-specific association between alcohol consumption and stress perception, depressed mood, and suicidal ideation covid and its mental health consequences percentile norms and accompanying interval estimates from an australian general adult population sample for self-report mood scales a nationwide survey of psychological distress among italian people during the covid- pandemic: immediate psychological responses and associated factors ten-year physical activity trends by location in queensland validity and responsiveness to change of the active australia survey according to gender, age, bmi, education, and physical activity level and awareness physical inactivity and cardiovascular disease at the time of coronavirus disease (covid- ) physical activity and coronavirus disease (covid- ): specific recommendations for home-based physical training every step counts: understanding the success of implementing the , steps project. in information technology based methods for health behaviours covid- and mental health: a review of the existing literature the role of exercise in preventing and treating depression physical activity protects from incident anxiety: a meta-analysis of prospective cohort studies sleep needs across the lifespan; sleep health foundation report to the sleep health foundation: sleep health survey of australian adults; the adelaide institute for sleep health australian institute of health and welfare alcohol, tobacco & other drugs in australia covid- and smoking: a systematic review of the evidence active smoking is not associated with severity of coronavirus disease (covid- ) foundation for alcohol research and education. alcohol sales and use during covid- ; foundation for the enemy who sealed the world: effects quarantine due to the covid- on sleep quality, anxiety, and psychological distress in the italian population this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license the research received no external funding. the authors declare no conflict of interest. key: cord- -ukz hnmy authors: nan title: poster date: - - journal: j frailty aging doi: . /jfa. . sha: doc_id: cord_uid: ukz hnmy nan background: frail older adults are at increased risk of postoperative morbidity compared with robust counterparts. simple methods testing frailty such as grip strength have shown promising results for predicting post-operative outcome, but there is a debate regarding the most appropriate and precise frailty assessment method. objectives: we compared the predictive value of multidimensional frailty score (mfs) with grip strength or conventional risk stratification tool for predicting postoperative complications in older hip fracture patients. methods: from january to december , older hip fracture patients (age >= years) who underwent surgery and comprehensive geriatric assessment (cga) were retrospectively included for analysis. hip-mfs was calculated based on the cga with component of sex, charlson comorbidity index, serum albumin, koval grade, cognitive function, risk of falling, mini-nutritional assessment and mid-arm circumference. grip strength was also measured before surgery. the primary outcome was a composite of postoperative complications (e.g. pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission). results: among patients (mean age . ± . years, . accordingly, grip strength could be used for screening tool to identify high-risk patients who need for further comprehensive geriatric assessment among older hip fracture patients. information and data suspected of post-operative infections. the diagnostic criteria of infection dealt with grade ii or more of clavien-dindo classification. diagnosis of infectious disease was made with reference to vital sign, blood test, imaging and bacterial test results. surgical site infection (ssi) was evaluated based on the infectious control team surveillance. results: elderly patients were registered with necessary data. the average age was . years, males and females were included. in the sarcopenia evaluation, there were cases without sarcopenia and cases with it. cases developed some infectious complications postoperatively. the types of infectious complications (including duplication) were cases of some surgical site infections including suture failures, of pneumonia, of urinary tract infection, of pneumonia and cases of sepsis in patients. infectious complications occurred in cases in the non-sarcopenia group and in the sarcopenia group (p = . ). the average postoperative hospitalization was . days overall, . in the group with postoperative infectious complications, and . in the group without sarcopenia. conclusion: in this study, there was no relation in the incidence of postoperative infections and preoperative sarcopenia. however, the postoperative hospitalization in the group with postoperative infectious complications was almost tripled. background: hypertension is one of the major risk factors for cardiovascular disease. lowering blood pressure is effective for preventing stroke, heart failure (hf), myocardial infarction and possibly dementia. in france, the prevalence of elderly people treated for hypertension rising leading to a possible increase of potentially inappropriate antihypertensive prescribing (piap) that may cause adverse drug events. objectives: to identify associated factors with potentially inappropriate antihypertensive prescribing (piap) in elderly people. methods: we conduct a retrospective observational study based on a cohort from geriatric day hospital for assessment of frailty and prevention of disability in toulouse, between january and april . piap was defined with several explicit criteria: the european list of potentially inappropriate medications, alert and control of iatrogenesis (aci) criteria by the french health authority, the french society of hypertension guidelines, screening tool of older people's potentially inappropriate prescriptions (stopp) version two and summary of product characteristics. the piap has been considered as a binary variable (logistic regression) then as a counting variable by number of nonconformities on antihypertensive drugs (negative binomial regression). results: among the patients, % had piap. frailty, polypharmacy, history of angina and hf are associated with a higher risk of piap. similarly: frailty, polypharmacy and history of angina are associated with an increase in the number of non-conformities antihypertensive drugs. analysis of subgroup of patient hf -piap indicated that % had aci criteria whose % the aci criteria " antihypertensive drugs or more" and % the aci criteria " diuretics or more". analysis of subgroup of patient history of angina -piap indicated that % had stopp criteria, focused on loop diuretics. conclusion: our work suggests that some elderly people characteristics are associated with an increase likelihood of piap. targeting these patients would be beneficial in preventing medicine-related illness. background: social frailty was reported to be associated with age, sex, income, education, marital status, and household status. however, mood status including depression and emotion was relatively less investigated. objectives: the aim of this study is to clarify the association between depression and apathy status and social frailty in community-dwelling japanese elderly. methods: a health promotion project (teng tv project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. we ran a cross-sectional analysis using baseline characteristics of all participants (n= ). demographic data, socio-economic status, comorbidities, and nutrition evaluated by mininutritional assessment-short from (mna-sf) were recorded. functional capacity was assessed by the japan science and technology agency index of competence (jst-ic). mood status including depression, and emotion was measured by geriatric depression scale (gds- ) and apathy evaluation scale (aes). social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. we defined total deficit scores of or more as social frailty, as social pre-frailty, and as robustness. we used a linear regression model to analyze the association between mood status and social frailty after adjusting for age, sex, education, marital status, comorbidities, bmi, mna-sf, jst-ic. results: at baseline, mean age of all participants ( . % men) was ± . years. a total of . % and % of all participants were categorized as social prefrailty and social frailty, respectively. the mean scores of gds- and aes were . ± . , . ± . , respectively. in linear regression model after full adjustment, participants with social pre-frailty and social frailty were associated with increased gds- scores (social pre-frailty vs. social robustness: b= . , %ci . - . ; social frailty vs. social robustness: b= . , %ci . - . ) and aes scores (social pre-frailty vs. social robustness: b= . , %ci - . - . ; social frailty vs. social robustness: b= . , %ci . - . ). in addition, jst-ic was also associated with gds- and aes scores. conclusion: social pre-frailty and social frailty were associated with greater level of depression and apathy. future studies are warranted to determine the causal relationship among mood status and social participation. inthira roopsawang , , hilaire thompson , oleg zaslavsky , basia belza (( ) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; ( ) biobehavioral nursing and health informatics, school of nursing, university of washington, seatlle, usa) background: frailty is a common geriatric condition with an impact on surgical outcomes. no research has been published on frailty assessment in hospitalized orthopedic patients in thailand. having a valid frailty measure has the potential to improve screening and could enhance quality of care. objectives: to test the ability of the reported edmonton frailty scale-thai version (refs-thai) in predicting hospital outcomes compared with preoperative assessment measures, the american society of anesthesiologists physical status classification (asa) and the elixhauser comorbidity measure (emc) in older thai orthopedic patients. methods: a prospective study was conducted at a university hospital. the hospitalized patients aged years or older scheduled for elective orthopedic surgery were recruited in this study. multiple firth logistic regression modeled the effect of frailty on postoperative complications, postoperative delirium (pod), and discharge disposition, while length of stay (los) was examined by poisson regression. the area under the receiver operating characteristic curve (auc) and mean squared errors (mse) were used to compare predictive ability of the instruments. results: two hundred participants with mean age of (range - years) were mostly female , % were frail, and % underwent knee surgery; of which . % had postoperative complications, . % developed pod, and % were unable to be discharged home. average los was days. adjusting for other variables, frailty was significantly associated with postoperative complications (or = . , p = . ), pod (or = . , p = . ), and prolonged los (relative risk [rr] = . , p = . ). applying the refs-thai alone shows good performance in predicting postoperative complications (auc = . , % ci = . - . ) and pod (auc = . , % ci = . - . ). the combination of refs-thai with asa and emc demonstrates improvement in predicting postoperative complications (auc = . , % ci = . - . and . % ci = . - . , respectively) and pod (auc = . , % ci = . - . and . % ci = . - . , respectively). conclusion: frailty assessment using the refs-thai was useful in predicting adverse outcomes in older adults undergoing orthopedic surgery. integrating the refs-thai for preoperative assessment may be useful for enhancing orthopedic care quality. anthony frioux , matthieu faure , margot de battista , benoit roig (( ) université de nîmes, france; ( ) université de france) background: the attention of the scientific community to frailty has been drawn over the past several years. frailty is defined as a state of increased vulnerability that may lead to functional disability. if this state is managed soon enough it may be reversible. in parallel, the possibilities of monitoring health status through connected objects such as smartphones are increasing. similarly, it is possible to measure the activity of the inhabitants of a house collecting usage data (water and electricity consumption). our project is in the field of smart home and aging monitoring. objectives: therefore, the objective of our work is to develop an integrative model of frailty based on the contributions of existing scientific tools (fried et al., ; mitnitski, mogilner, & rockwood, ) and current sensors to measure a person's activity. eventually, we are aiming for the detection of the frailty trajectory early on. for example, real-time activity monitoring is used to detect a fall and alert rescue. in our case, these sensors will allow us to identify as soon as possible a dimension that would be abnormal in order to intervene and propose an appropriate intervention. methods: our tool will be able to measure the five fried's frailty criteria which are currently used in clinical practice. we compare the data from the sensors with the results of the evaluation of fried's frailty phenotype. results: we expect to obtain a correlation between our data and phenotype results. conclusion: the main contribution of our tool resides in the possibility to observe deviations from an individual's normal aging trajectory. thus, the evaluation we propose would be more ecological as it will enable us to consider the individual's habits and to have a more detailed assessment of his activity evolution. in conclusion, the holistic aspect of our work will allow the practitioners to base their intervention on a wide range of health data. l. van wagenberg, r.m. wösten-van asperen (department of paediatrics, paediatric intensive care unit. wilhelmina children's hospital, utrecht, the netherlands) background: a frail phenotype is recognized in the elderly population. frailty is associated with a higher mortality for adult intensive care (icu) patients. research in oncology suggests biological age is not the key contributor to frailty, since frailty is also found in the younger population. in paediatrics frailty is an unknown concept and as a consequence, the prevalence and meaning of being frail at young age are unknown. objectives: to assess whether a possible frail phenotype can be found in a critically ill paediatric oncological population. methods: a retrospective cohort study in a paediatric oncological icu population between january and september . demographic data and need for icu resources (mechanical ventilation, inotropic support and s continuous renal replacement therapy (crrt)) were collected. since specific paediatric frailty scores are not available, we addressed patients as having a frail phenotype by textmining their electronic health records on the words "fatigue", "cachexia" and "diminished physical activities" before, during, and after paediatric icu admission. risk factors for a possible frail phenotype (cachexia, use of corticosteroids and lowest serum albumin levels) were collected. primary endpoint was mortality during icu treatment or course of illness. results: admissions were included, of which admissions had a possible frail phenotype. these admissions included unique patients. % of patients was male and the median age was years (iqr - ). patients were predominantly treated for a haemato-oncological malignancy ( %). mortality during icu-admission was %, and % died subsequently during the course of disease after picu discharge. patients were severely ill, with a mean icu length of stay of . days (± ), % on ventilator support, % receiving vasopressor or inotropic support, and % on crrt. loss of muscle function or fatigue was present in % before icu admission and in % acquired atrophy or cachexia was documented during icu treatment. % were treated with corticosteroids during picu stay. in % a serum albumin ≤ gram/dl was measured. conclusion: a possible frail phenotype is present in the oncological patient population of a paediatric icu. more research on the contributing factor of frailty on outcome of these patients is needed in the near future. john muscedere , , amanda lorbergs , jayna holroyd-leduc , anik giguere , leah gramlich , heather keller , ada tang , danielle bouchard , donna fitzpatrick-lewis , , diana sherifali , (( ) canadian frailty network, kingston, on, canada; ( ) queen's university, kingston, on, canada; ( ) university of calgary, calgary, ab, canada; ( ) laval university, quebec city, qc, canada; ( ) background: despite research evidence related to nutritional and physical activity interventions, there is a gap in provision of evidence-based care focused on preventing and managing frailty among older adults. objectives: to systematically generate evidence-based nutrition and physical activity (pa) clinical practice guidelines to improve health and functioning in older adults with or at risk of frailty. methods: we are using the agree ii guideline development protocol to generate guidelines to improve health and functioning in older adults. for each guideline, systematic review of meta-analyses was conducted by searching three databases for english language citations published since that included adults aged y and older with frailty and/or pre-frailty. nutrition or pa interventions with a comparison group were considered eligible. acceptable study designs included rcts, quasi-experimental trials, and observational cohorts with a comparison group. in a face-to-face meeting with multidisciplinary content experts, healthcare professionals, and end-users we will further appraise the quality and strength of the evidence using the grade approach. this group will use this evidence to form recommendations related to nutrition and pa in this population. results: the nutrition and pa searches resulted in and citations, with and eligible for full-text review, respectively. the results will inform guideline recommendations. knowledge translation strategies will be developed to support guideline dissemination and implementation. conclusion: the guidelines will inform health professionals by providing evidence-based nutrition and pa interventions for adults with frailty. ( background: physical and psychosocial factors play important roles in the severity and progression of frailty. frailty screening tools include measures of the more common risk factors, including advanced age, comorbidities, poor diet, weight loss, lower socioeconomic status, and physical inactivity. however, there has been limited standardization in the us on specific frailty screening measures to include in national health surveys or frailty tools/protocols for community health settings. this makes it difficult to monitor frailty incidence/prevalence in the older adult population and to best identify and treat individuals at risk. results: we reviewed the most recent versions of us national health surveys that include older adults, to identify whether frailty screening measures were included in. no national surveys had a battery of measures that would allow for frailty risk screening. most commonly, questions on weight, disability, mental health, physical functioning were included. however, physical functioning measurements such as grip strength or gait speed, measured height and weight, unintentional weight loss, dietary intake or appetite changes were not. further, we used the world health organization criteria for effective community screening programs to review published evidence of the validity, reliability, and feasibility of data-driven screening tools for frailty risk among community-dwelling older adults. of the frailty screening tools reviewed, the frail scale was identified as the most promising, based on test characteristics and cost/ease of use. more community-level s research is recommended, particularly on predictive validity of favorable outcomes following physical activity/nutritional interventions. finally, because nutrition plays a significant role in frailty risk, we surveyed registered dietitian nutritionists who work with older adult populations (n= ) to identify their awareness/use of frailty screening protocols/tools and dietitians' potential role in frailty screening. dietitians practicing in the community recognized a potential role, but few dietitians were aware of (< %) or using (< %) specific frailty screening tools. conclusion: future opportunities to better support healthy aging include: addition of frailty screening measures to national health surveys to help prioritize high-risk populations, conduct additional research to validate/recommend a common community-level screening tool, and promote engagement by dietitians and other health professionals who can establish protocols for community-based frailty screening. ming-yueh chou , , ying-hsin hsu , yu-chun wang , chih-kuang liang , , li-ning peng , , liang-kung chen , , yu-te lin (( ) center for geriatrics and gerontology, kaohsiung veterans general hospital, kaohsiung, taiwan; ( ) aging and health research center, national yang ming university, taipei, taiwan; ( ) department of geriatric medicine, national yang ming university school of medicine, taipei, taiwan; ( ) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, functional decline and mortality, and multi-domain intervention program may prevent those. objectives: the purpose of this study is to evaluate the effectiveness of multi-domain intervention program among those community-dwelling frail older people in southern taiwan. methods: a week multi-domain intervention program were provided for all participants, including physical activity, high protein diet education, medical knowledge education and cognitive simulation activity for hours per week. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds- ), cognitive condition (by mmse) and frailty status according to the definition by the cardiovascular health study (chs) . results: during jan and may , totally participants were invited for study ( . % female, mean age . ± . years). among them, ( . %) were clarified as frailty status and ( . %) as prefrailty status. after the multi-domain intervention program, their mood condition ( . ± . to . ± . , p< . ) and cognitive condition ( . ± . to . ± . , p< . ) improved significantly. in addition, the walking speed ( . ± . to . ± . m/s, p< . ) and physical activity ( . ± . to . ± . mets/week, p< . ) improved, but not handgrip strength (p= . ). for the frailty status, those clarified as frailty status decreased from . % to . % and prefrailty status from . % to . % (p< . ). conclusion: our results showed that through the week multi-domain intervention program, those frail older people could improve their mood condition, cognitive condition, usual gait speed and frailty status. sarah b. lieber , stephen a. paget , , jessica r. berman , , medha barbhaiya , , lisa sammaritano , , kyriakos a. kirou , , john a. carrino , dina sheira , mangala rajan , yingtong lyu , lisa a. mandl , (( ) division of rheumatology, hospital for special surgery, new york, ny, usa; ( ) department of medicine, weill cornell medicine, new york, ny, usa; ( ) department of radiology and imaging, hospital for special surgery, new york, ny, usa) background: frailty is a clinical phenotype that increases with age, but can occur in younger patients with chronic disease. based on few studies, frailty has been found in up to . % of patients with systemic lupus erythematosus (sle) and is associated with increased mortality. whether frailty is prevalent in other sle cohorts and associated with objective and subjective factors is unknown. objectives: we aimed to determine the prevalence of frailty in a prospective cohort of women with sle and whether inflammatory biomarkers, body composition, and patient-centered domains differed between frail and non-frail women. methods: adult women < years old who fulfilled american college of rheumatology sle criteria were recruited from one center. exclusions included pregnancy, dialysis, active malignancy, overlap autoimmune syndromes, and severe sle disease activity. frailty was measured according to fried criteria. patient-reported outcomes (pros) were measured using pro measurement information system (promis) computerized adaptive tests; lupusqol; and disability based on valued life activities. physicianreported sle disease activity and damage indices were collected. inflammatory biomarkers and sarcopenia according to dual-energy x-ray absorptiometry were assessed. differences between frail and non-frail women were evaluated using chisquare tests and kruskal-wallis tests; the association between frailty and disability was determined using logistic regression. results: women enrolled from / - / . despite age under years old, % were frail. frail women had greater disease damage (p= . ) and were more often smokers (p= . ). high-sensitivity c-reactive protein (p= . ) and interleukin- (p= . ) were higher and sarcopenia trended toward greater prevalence (p= . ) in frail women. significant differences in promis mobility, physical function, pain interference and behavior, and fatigue and lupusqol physical health and pain (all p< . ) were observed between frail and non-frail women, with frail women reporting consistently worse scores. frail women were . x more likely to be disabled than non-frail women, including after adjustment for age, comorbid conditions, and disease activity/damage. conclusion: the prevalence of frailty was high in this cohort of mid-aged women with sle. frail women had poorer health-related s quality of life than non-frail women, including substantially higher disability. if frailty is associated with worse health outcomes, it could be a potential therapeutic target. chariya sumcharoen, supreeda monkong, nuchanad sutti (ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bangkok, thailand) background: bed bound older adults need caring of physical activities, mental, mood, and social from family caregivers. family caregivers usually gets the role strain from caregiving. there are many factors associate with the caregiver role strain but have been rarely reported in bed bound older adults at home. objectives: the study examined age, adequacy of incomes, mutuality, health status, preparedness, and social support influencing caregiver role strain from caregiving activities for bed bound older adults at home. methods: caregiver role strain concept by archbold and colleagues with literature review were used to guide this study. the sample was recruited by purposive sampling consisted of caregivers aged years or older, who have cared for bed bound older adults at home in thailand. data were collected by structured interview using the questionnaires including demographic data, preparedness, health perception, mutuality, social support, and caregiver role strain from the care activities. data was analyzed using descriptive statistics, pearson's product moment coefficients, and multiple regression analysis. results: the most of participants were women ( . %), age ranging from to years (m= . , sd= . ) . the result showed that age, adequacy of incomes, mutuality, health status, preparedness, and social support jointly significantly explained . % of the variation in caregiver role strain from caregiving activities. the regression effects were strongest for health status (beta=-. , p=. ), followed by preparedness (beta=-. , p=. ), age (beta=. , p=. ), and adequacy of incomes (beta=-. , p=. ) respectively. conclusion: this finding suggests that healthcare providers should find strategies for promoting health status and preparedness of family caregivers for decrease caregiver role strain from caregiving activities. of life, and hospital admissions. objectives: we estimated the prevalence and describe the characteristics of the population with recurrent falls and fear of falling and their association with frailty, physical performance and cognitive fragility. methods: data came from the "salud, bienestar y envejecimiento" (sabe) colombia study, a cross-sectional study conducted in at the urban and rural research sites ( municipalities) in colombia. sociodemographic, health, cognitive and anthropometric measures were collected from community-dwelling adults aged years and older, representative form the total population. frailty was defined using the frailty phenotype proposed by fried. cognitive frailty was defined using the inaa/iagg consensus definition. low performance was evaluated with sppb (short physical performance battery). logistic regression analyses were used to identify factors associated with recurrent falls and fear of falls. results: our study identified elderly who had recurrent falls and fear of falling ( . % and . % respectively). young elders (≤ years) had more falls and greater probability for fear of falling compared to older ages. sex had no significant differences. the factor associated with an increased risk of recurrent falls and fear of falling in the elderly were low physical performance, fragility and polypharmacy. chronic illness such as osteoarticular disease, mental disease, diabetes and chronic pulmonary disease were significantly associated with recurrent falls and fear of falling. finally, when adjusted for age, sex, sociodemographic factors and comorbidities in a logistic regression model, frailty was associated with fear of falling and recurrent falls, while cognitive frailty and low physical performance only were associated with fear of falling. conclusion: recurrent falls have a significantly association with frailty. there are cognitive, physical performance and clinical factors associated with fear of falling that could be preventable and treatable. rubbieri gaia , ceccofiglio alice , mazzeo nicla , pupo simone , cartei alessandro , rostagno carlo , mossello enrico (( ) department of perioperative medicine, careggi hospital and university of florence, italy; ( ) department of geriatric medicine, careggi hospital and university of florence, italy) background: the prevalence of frailty in patients with hip fracture is high, but little is known about the choice of the best frailty tool in terms of prediction of functional recovery. objectives: the aim of this preliminary study was to determine the most predictive validated frailty tool in older people with hip fracture and to determine whether frailty can predict functional recovery during the hospital acute phase. methods: this study was observational prospective cohort study. participants aged + admitted to hip fracture units in florence, were assessed pre surgery (t ), and post surgery. each participants underwent a comprensive geriatric assessment and frailty was defined using: clinical frailty scale (csf), frail scale (fs), reported edmonton frail scale (refs), postal frailty screening (pfs). the outcome was functional recovery, evaluated by a score of postoperative performance on the cumuleted ambulation score (cas). data recorded included pre-recovery barthel index (bi), charlson comorbidity index (caci), handgrip strenght test (hg), asa score, mini nutritional assessment short-form (mna-sf), delirium. results: sample included patients (mean age ± years, female . %). cfs was the most predictive frailty tool, with a % sensitivity and a % specificity (auc = . , cut off > ). dividing the sample according to premorbid bi, while bi itself had the highest predictive value when premorbid level was < %, cfs was the best predictor of functional outcome in the %+ subsample (auc= . ). conclusion: frailty defined by cfs can predict short-term functional recovery during acute phase following hip fracture. this appears particularly relevant for subjects with a higher pre-morbid functional independence. s % were women. individuals had data for all five frailty measures. nine percent of participants were non-frail by all instruments, % were frail by all measures and thus % had discordant frailty measurements. % were frail by at least one measure method. the prevalence of frailty ranged from % to % for the different measures. those classified as frail by cfs and non-frail by bp were more likely to be men, be co-living, have lower cognitive function and a higher dependency in iadl compared to those classified as frail by bp and non-frail by cfs. conclusion: frailty measures cannot be used interchangeably. specifically the cfs might not identify physical frail women, with high cognitive ability who lives alone. factors contributing to the heterogeneity of groups classified as frail by different measures need to be further explored. background: polypharmacy is increasingly common amongst older, multimorbid adults. in these individuals, studies have shown a high prevalence of frailty. identification of frailty can be performed using comprehensive assessments registering accumulation of deficits like in the frailty index, or using single-trait markers of frailty like gait speed and handgrip strength. polypharmacy is recognized as an independent risk factor for the development of frailty, and the subgroup of psychotropic drugs may be particularly important in the development of this syndrome. objectives: our objectives were to study the relationship between the total burden of polypharmacy on frailty status using three different measurements of frailty, and specifically the influence of psychotropic drug use on frailty status. our overall aim was to explore whether either of these could be used as independent predictors of frailty. methods: we used data from a -year follow-up study of older people living in the community and receiving home care nursing, i.e. the cascade-study. data collection was completed in june . all participants were aged > years (mean years). a item frailty index was calculated based on results from a comprehensive geriatric assessment performed in the patients' own home. a fourmeter gait speed test was performed, as well as measurement of handgrip strength. information on regular medications was collected from the patients if they administered own medications, or from the home care nursing service if they were responsible for administering the patients' medications. psychotropic drugs were selected based on beers criteria. results: we found a significant association between the use of psychotropic drugs and frailty index, and frailty index increased by . for each psychotropic drug added (p< . ). one additional psychotropic drug decreased gait speed by , m/s (p< , ). there was no statistically significant association between psychotropic drug use and handgrip strength. conclusion: our study showed that psychotropic drug use was a significant predictor of increased frailty index and reduced gait speed. this was not the case for handgrip strength in our material. laetitia beernaert , frédéric schuind , sandra de breucker (( )department of geriatrics, hôpital erasme -université libre de bruxelles, belgium; ( ) department of orthopedics, hôpital erasme -université libre de bruxelles, belgium) background: anemia is a condition whose prevalence might reach % in the geriatric population. anemia and frailty are two prognostic factors for patients admitted for a hip fracture. objectives: we analyzed retrospectively if preoperative frailty and anemia were independently predictive of postoperative complications and mortality in old patients admitted for hip fracture. methods: ninety-seven patients above years old have been admitted for urgent surgery for a hip fracture during and . we excluded patients with a pathological fracture or fractures due to high energy trauma. preoperative anemia was defined as an hemoglobin level under g/dl for women and g/dl for men. frailty was assessed with the isar (identification of seniors at risk) score. results: seventy-five percents of patients were considered as frail (isar score> ). the prevalence of preoperative anemia was %. we found no statistically significant correlation between anemia and frailty (r = - . -p = . ). in multiple regression logistic analysis, the only independent parameter associated with anemia was the presence of comorbidities (or . ( . - . )-p = . ), and the only parameter associated with frailty was the presence of malnutrition (or . ( . - . )-p = . ). neither anemia nor frailty was associated with postoperative complications and mortality. conclusion: preoperative anemia and frailty are not interrelated in patients admitted for hip fracture. anemia is associated with comorbidities, but not postoperative mortality. frailty is associated with preoperative malnutrition. the isar score may not be ideal to screen for frailty in old patients admitted for hip fracture, an item being attributed to the current loss of autonomy. settings. m martinez , maria montoya , , davide angioni , lizeth canchucaja , natalia ronquillo , maria luz gallego , claudia bejar , emmanuel gonzalez , olga vazquez , anna renom (( ) institute de viellisement toulouse, france; ( ) hospital del mar, barcelona, spain; ( ) hospital de terrasa, barcelona, spain; ( ) parc tauli, barcelona, spain) background: frailty is a common critical geriatric syndrome which has been associated with poor health outcomes.a wide variety of frailty indices (fis) have been developed. frail-vig («vig» is the spanish/catalan abbreviation for comprehensive geriatric assessment).it contains simple questions that assess different deficits. it has been inspired by the rapid geriatric assessment. objectives: the aim is to compare the prediction capacity of clinical rockwood index frailty (rif) and frail-vig index (vif) for poor health outcomes (pho) defined as: emergency department visits and/or hospital admission and/or mortalityamong elderly patients. methods: a retrospectiveobservational study was conducted with a followup up to months or pho occurred. patients were admitted in acute geriatric unit care and geriatric day hospital at hospital del mar; barcelona; spain during august and march . the inclusion criteria were the admission ones. frailty was measured at admission. survival analysis was conducted; cox proportional hazards regression was used to build a pho predictive model based on both indexes. best model according to contrast of hypothesis log-rank ,aic; bic and c harrel was selected.diagnoses of the chosen model was done. results: a total of patients were included, mean age was and . % female. the mean of follow-up was . , % patients presented a pho. . % died, % were admitted at emergency department, . % were hospitalized and % presented more than one event.survival curves for frail and non-frail according to pho showed statistically significance for vif (x = . p= . )but not for rif (x = . p= . ). cox proportional hazards regression showed vif hazard ratio . (p= . ) and rif hazard ratio . (p= . ). predictive capability resulted in a model for vif containing cognition and sex, with harrel c of . . as for rif the most parsimonious model rif would be absent and harrel c . . the diagnoses of the model showed time covariate variable test with p= . , p= . , p= . for each predictive variable; squared linear predictor with p= . of and outliners. conclusion: the vig frailty index performed better; compared to rockwood clinical index; in predicting a composite outcome composed by mortality, hospitalization and visits to emergency departments in patients admitted in acute and outpatient settings. after hospital discharge. methods: this study was conducted in the departments of internal medicine and neurology of the university hospital of araba (basque country, spain). participants were >= years, scoring >= on the mmse test and able to stand and walk independently for at least -meter. participants performed twice-weekly moderate intensity group sessions of multicomponent exercise at the hospital during -week, followed by a home-based intervention ( week) . both were focused on balance, aerobic capacity and strength. taking together both interventions, participants completed -week of physical exercise. at the beginning and the end of the program, frailty was measured though fried´s index and sarcopenia with different criteria : muscle strength ( -chair stand), muscle quality (dxa) and physical performance (sppb). we compared the results before and after the intervention by mcnemar test. results: patients ( females, %) were enrolled, were lost to follow-up at the -week time point and people finished the intervention. the intervention decreased significantly the percentage of frail individuals (p< . ) according to fried´s index, and the percentage of people who met sarcopenia criteria for sitto-stand (p= . ) and sppb (p= . ). however, there were no differences in the percentage of people with low appendicular muscle mass. conclusion: our study showed that a multicomponent exercise program is effective for posthospitalization patients because after -week intervention there were significant reductions in frailty and improving results in muscle strength and physical performance. we did not find changes related to muscle mass. references: . background: alcohol addiction can impact every part of the body, including bones. research shows that chronic heavy alcohol use, especially during adolescence and young adult years, can dramatically affect bone health and increase the risk of osteoporosis and bone fracture later in life. objectives: the purpose of this study is to compare data from international scientific literature with data from the study of patients admitted for alcohol dependence, to assess whether there are significant connections between alcohol dependence and unrecognized fractures. methods: we analyzed meta-analysis's studies from the pubmed search engine to evaluate the association between bone fractures with alcohol use disorders. only humans studies from the last years have been analyzed. subsequently, data related to patients admitted for an alcohol rehabilitation cycle were analyzed. results: scientific literature show that there is a close correlation between alcohol abuse and greater frequency of bone fractures. this is partly due to association between alcohol consumption and both osteoporotic fracture and bone density, and partly to the fact that there is an increased risk of falls in alcohol intoxicated patients compared to the general population. patients were considered: % male and . % female. the average age was years. of these , . %, patients, had unrecognized fractures. conclusion: intoxicated patients admitted in alcoholic rehabilitation with recurrent falls anamnesis often did not perform any diagnostic assessment. this is due to the lack of pain perception in the patients or due to family members or emergency physicians who placed the state of drunkenness before any consequences caused by repeated falls. there is an increased risk of unacknowledged fracture in the patients admitted in alcohol rehabilitation this is partly due to the fact that alcohol intoxicated patients often do not perceive the pain and therefore do not investigate any falls that occurred in a state of drunkenness, in part it is due to the damages that alcohol causes on the bone. our data show that alcohol dependence and unrecognized fractures can often be associated. studies in the literature confirms that there is an increased risk of non-cone fractures in patients with alcohol dependence. zamudio-rodríguez, hélène amieva, luc letenneur, karine pérès (centre de recherche inserm u université de bordeaux -isped, bordeaux, france) background: although conceptually distinct, frailty and disability are very common among older adults. both are multifactorial conditions and share some risk factors and pathophysiological mechanisms, such as inflammation or sympathetic-parasympathetic balance alteration. furthermore, each individual component of the frailty phenotype defined by the cardiovascular health study (chs) has been associated with disability in basic and instrumental activities of daily living. objectives: the present study aimed to determine whether pre-frail and frailty are part of the natural history of the disability process. methods: a sample of people aged of the three cities ( c) study in bordeaux were followed for four years. pre-frailty and frailty were defined according to the original phenotype proposed in the chs. disability was defined using the basic (adl) and instrumental (iadl) activity of daily living scales. seven mutually exclusive hierarchical groups were distinguished at inclusion: ) robustness (no frailty or disability); ) pre-frail (without disability); ) frailty (without disability); ) iadl (without pre or frailty or adl) ) pre-frail with iadl (no adl); ) frailty with iadl (no adl); ) frailty with iadl and adl. results: deaths ( . %) occurred during the four years follow-up. compared to the robust group, all other hierarchical subgroups had an increased risk of death, with an increasing gradient: pre-frailty (hr= . ; ic %= . - . ); frailty (hr= . ; ic %= , ) , iadl disability (hr = . ; ic %= . - , ); pre-frailty with iadl disability (no adl) (hr= , ; ic %= , - . ); frailty with iadl disability (no adl) (hr= , ; ic %= . - . ); frailty with iadl and adl disability (hr= , ; ic %= . - . ) were significant after adjustment by age and sex. conclusion: there is a gradual risk of mortality across the different groups ( i.e., ) robust; ) pre-frail; ) frail; ) iadl disability without pre or frailty; ) pre-frail with iadl disability; ) frail with iadl disability; ) frail with iadl and adl disability) thus suggesting a hierarchical relationship. this study could have important clinical implications since pre-frailty and frailty are assumed more effectively reversible conditions in order to interrupt the continuum at the early phase of the disability processes. background: joint replacement provides significant improvement in pain, physical function, and quality of life in patients with osteoarthritis. with a growing body of evidence indicating that frailty can be treated, it is important to determine whether targeting frailty in joint replacement patients is feasible and improves post-operative outcomes. objectives: to examine the feasibility of a preoperative multi-modal frailty intervention (mmfi) compared to usual care in pre-frail/ frail older adults undergoing elective unilateral hip or knee replacements. methods: in this pilot randomized controlled trial (rct), participants who are )>= years old; ) pre-frail (score of - ; (fried frailty phenotype (ffp)) or frail (score of - ; ffp); ) having elective unilateral hip or knee replacement with surgery wait times between - months were recruited from the regional orthopaedic clinic mcmaster university, ontario canada. the mmfi included tailored exercise, protein ( - gm/day), vitamin d ( iu/day) supplementation, and medication review with recommendations sent to family physicians. frailty and mobility were assessed at baseline and -weeks post-operative using ffp, short performance physical battery (sppb) and oxford hip/knee score (ohs/ oks) respectively. results: we recruited and randomized participants between september and may . of those, . % were referred for total hip replacement and . % for knee replacement. the included participants' mean age (standard deviation (sd)) was . ( . ) years; . % were women; . % lived alone, body mass index was . kg/ m ( . ) and . % were former smokers. at the baseline assessment, on the ffp, % were prefrail, % were frail and the sppb was . ( . ). for participants with hip osteoarthritis, ohs mean (sd) was . ( . ) and for participants with knee osteoarthritis, oks mean (sd) was . ( . ). the study recruitment rate was . %, and the retention rate was %. eighty three percent of participants of the intervention group completed the intervention. self-reported adherence to the intervention components was as follow: ) exercise sessions: . %, ) protein supplement: . %, ) vitamin d supplement: . % and ) medication review completion: %. conclusion: this is the first study to examine the feasibility of a multi-modal frailty intervention in pre-frail/frail older adults undergoing joint replacement. this study showed that frailty screening, assessment and management is feasible for older adults undergoing joint replacement in orthopaedic surgery clinics. results have informed the current multi-centre rct to determine effectiveness. christine tocchi , sathya amarasekara , michael cary (( ) school of nursing, duke university durham, nc usa; ( ) school of nursing, duke university durham, nc usa; ( ) school of nursing, duke university durham, nc usa) background: inpatient rehabilitation facilities (irfs) provide intensive rehabilitation therapy to patients to reduce functional impairment, enhance independence and return patients to the community. determination of eligibility for irf is currently based on preadmission screening. subpopulations of older adults may require special consideration in determination of irf admission due to greater risk for poor functional recovery such as those with pre-existing functional limitations and those who are frail. frailty, a pervasive characteristic in older adults with hip fractures has not been examined as a clinical factor influencing discharge destination outcomes in irfs. objectives: ) determine the prevalence of frailty among older adult with hip fracture receiving inpatient rehabilitation; and ) determine the association between frailty and discharge destination among hip fracture patients receiving inpatient rehabilitation. methods: a retrospective cohort study design using cms inpatient rehabilitation facility-patient assessment instrument file. multivariate regression models were performed to examine the association between frailty and discharge destination. frailty status was measured using a frailty index of items with the following cut-off points: - . robust/non-frail; . - . pre-frail; and . or greater as frail. the final sample included , hip fracture patients. results: frailty, pre-frailty, and nonfrail were present in . % (n= ), . % (n= ), and % (n= ) of hip fracture patients, respectively. the majority ( %) of the frail hip fracture patients were discharged home. there were significantly greater proportion of females than males discharged home and those of white race, to years of age, and with higher functional status. regression analysis showed significantly lower functional status at discharge (p < . ) for patients with these characteristics: males, non-white race, and older age. additional factors that influenced discharge destination included: marital status, living in the community prior hospitalization, and length of stay. conclusion: frailty was the most common frailty status on admission to irf. home is the most common discharge destination for all frailty status groups. frailty status could be used to identify hip fracture patients at high risk for adverse outcomes. future studies should be used to explore the potential of frailty to provide valueadded utility to clinical settings such as irfs. background: front-line care providers are seeking direction on how frailty measures may be integrated into existing or future care pathways to enhance the experience of individuals who live with it. multidimensional frailty measures such as the edmonton frail scale offer the potential for case-finding, estimation of severity, and definition of frailty components. objectives: test the feasibility of the implementation of a multidimensional frailty order set into acute care. methods: in , we conducted a literature search to identify existing frailty guidelines and systematic reviews related to frailty in acute care. an expert panel graded the quality the evidence, then generated recommendations, graded by strength to inform the generation of a clinical knowledge and content management (ckcm) topic for dissemination throughout alberta health services (ahs). ahs is the largest province-wide, fullyintegrated health system in canada. this ckcm would include graded statements and recommendations, clinical decision support, electronic alerts, and a frailty order set. results: four guidelines, systematic reviews, and one scoping review informed the development of the frailty ckcm. from this, we developed eight recommendations, covering topics such as prevention, case-finding, estimation of severity, definition of components, triggers for expert assessment, and linkage to care processes. the recommendations also addressed safeguards to avoid labelling and other unintended consequences. an order set employs the clinical frailty scale, electronic frailty index, and edmonton frail scale to support a clinician to develop a personalized care plan. the order set empowers front-line clinicians to administer these frailty measures, based on cut points that prompt personalized recommendations on diet, activity, fall prevention, bladder management, and infusions. depending on the frailty component of concern, clinicians are also prompted with specific options to address cognitive impairment, functional dependence, falls and immobility, social isolation, nutritional risk, polypharmacy, urinary incontinence, chronic pain, and constipation. in preparation for the conversion to a province-wide electronic medical record (emr) in november , the ckcm was released in may and the frailty order set was built into the emr by september . conclusion: development and implementation of a multidimensional frailty order set in the setting of acute care is feasible. masayo kojima , toshihisa kojima , yuko nagaya , yasumoto matsui (( ) national center for geriatrics and gerontology, obu, aichi, japan; ( ) nagoya university, nagoya, aichi, japan; ( ) nagoya city university, nagoya, aichi, japan) background: prevention programs for frailty at community usually target healthy older people. to further prolong healthy life expectancy, we need to approach those who already have got chronic diseases such as rheumatoid arthritis (ra). objectives: the aim of this study is to assess the prevalence and factors associated with frailty in japanese ra patients. methods: ra patients aged - -yearold who visited two university hospitals between march and july were consecutively invited to join the study. those who agreed to participate the study provided written consent forms. frailty was assessed by the total score of the kihon checklist >= . self-report questionnaires were used to evaluate patients' demographic characteristics, perceived degree of pain, depression (the beck depression inventory-ii) and physical function (the health assessment questionnaire, haq). rheumatologists' global assessment of disease severity, swelling and/or tender joint counts, years of ra duration, frequency of arthritis surgery and crp level were also measured. results: total of ra patients were included in the study ( women, average age: . ± . years, average disease duration: . ± . years), and the prevalence of frailty was . %. the higher the age and the longer the duration of the disease, the higher percentage of ra patients with frailty was observed. . % among ra patients of working age ( - years), were frail, whereas . % and . % were frail among those aged - years and >= years, respectively. stepwise logistic regression analysis revealed that age, haq, depression severity and trust in neighbors were independently associated with frailty in ra. no significant gender difference was observed. conclusion: frailty is common even among working age in ra patients. physical function, depression and social capital were suggested to be independently associated with frailty. on-going followup study will disclose the influence of frailty on fracture, dependency, and mortality among ra patients. background: frailty is an important modulator of ageing and might impact on clinical presentation and progression of parkinson's disease. objectives: to evaluate the prevalence of frailty and correlation with motor and non motor symptoms as well as mri atrophy and white matter hyperintensities in parkinson's disease. methods: consecutive parkinson's disease patients underwent a comprehensive motor and non motor evaluation and geriatric assessment using multidimensional prognostic index (mpi). a subset of patients underwent mri with assessment of atrophy and white matter hyoperintensities by visual rating. results: pd outpatients (mean age . y, mean disease duration . years) entered the study. pre-frailty assessed by mpi was presented by % of patients and correlated with age and disease duration. when adjusting for these ariables, mpi correlated with updrs-iii, non motor symptoms assessed by umsar, prevalence of prevalence of orthostatic hypotension, rbd and depression. the mri assessment showed a correlation between global atrophy and frailty indipendently from mmse and educational levels. no association between frailty and wm hyperintensities was found. conclusion: frailty is a possible important modulator of pathology and brain vulnerability in parkinson's disease and could explain different severity in motor and non motor symptoms. longitudinal studies are warrented to evaluate the impact of frailty in disease progression. background: accidental falls in older adults have been associated with worse health-related outcomes especially in the frailest individuals, such as nursing home (nh) residents. in this special population of older adults, falls have been related to greater morbidity and mortality, but their impact on nutritional status is still unclear. moreover, so far there are no data on the potential role of unmodifiable (e.g. cognitive impairment [ci] ) and modifiable factors (e.g. assistance from informal caregivers) in influencing the impact of falls on nutritional status in older residents. objectives: we aimed to evaluate the changes in body weight during the six months after the occurrence of a fall in nh residents, and the possible influence of severe cognitive impairment, depressive symptoms and of the assistance from informal caregivers on such variations over time. methods: the sample included older residents who experienced at least one fall since nh admission. for each participant, we collected data on sociodemographic information, mean frequency of visits from informal caregivers, medical history, and cognitive and functional status at nh admission. severe ci was defined as the presence of a physician-based diagnosis of ci or a mini-mental state examination < points. the frequency of the visits from informal caregivers was categorized as none or (low) vs > (high) per week. falls' date and characteristics were obtained from structured forms completed by physicians. monthly body weight in the six months before and after the fall were derived from the nh medical records based on nurses' assessments. linear mixed models were used to evaluate the body weight changes after a fall, as a function of the presence of severe ci and low visits' frequency from informal caregivers, alone or in combination. results: the mean age of our sample was . ± . years and % were women. more than half ( . %) of residents involved had severe ci and . % had low visits' frequency from informal caregivers. after adjusting for potential confounders, the presence of severe ci (b=- . , se= . , p< . ) and the report of low visits' frequency from informal caregivers (b=- . , se= . , p= . ) were associated with steeper decline in body weight during the six months after the fall. when combining these variables, we found an additive effect of severe ci and low visits' frequency from informal caregivers in influencing weight loss (b=- . , se= . for residents with severe ci and high visits' frequency, and b=- . , se= . for those with severe ci and low visits' frequency; p< . for all). conclusion: our results suggest that cognitive impairment may worsen the impact of falls on nutritional status in nh residents, and that this effect may be exacerbated by scarce assistance from informal caregivers. ( ) tokyo women medical university, tokyo, japan, japan; ( ) department of geriatic medicine, kyorin university medical hospital, tokyo, japan; ( ) tokyo metropolitan institute of gerontology, tokyo, japan) background: in consideration of the future rapid aging of the society, to achieve healthy and active aging is indispensable. because especially the major issue is to prevent "multi-faceted frailty", it is necessary to reconsider regarding nutrition, physical activity and sociality/sociability in the elderly. sarcopenia is associated with adverse health outcomes, such as frailty, limited physical function, falls, disability and loss of independence. objectives: our aim to notice evidencebased new information, leading to frailty prevention, and let the community-based activity by elderly citizen only promote as a voluntary motion in each community. methods: we have already established many new evidences from our on-going japanese large-scale longitudinal study 'kashiwa study'. these evidences include the impact of overlapping of slight oral dysfunction, namely "oral frailty", as well as unbalanced diet and inadequate physical activity in early-stage sarcopenia. furthermore, we found the negative impact of several social disengagements including eating alone, so-called "social frailty", leading to subsequent sarcopenia. we developed a simple screening tool, ''frailty check-up activity'', which elderly citizen supporters only can operate in each small gathering place (e.g. community salon) via support by its local government. results: based on the concept of all-including three pillars, ) nutrition (i.e. dietary food intake including diversity and adequate protein intake, and treatment/maintenance against oral frailty), ) physical activity (not only exercises but also social daily activity) and ) social participation, the newly citizen activity ''frailty check-up'' has developed. after elderly citizen supporters received training fully, they could implement this activity completely and repeatedly in each local municipality. elderly participants could learn how to improve/conquer by themselves with raising their self-awareness for the importance of early frailty/sarcopenia prevention and could change their behavior modification. in addition, using big data combined with preexisting database of new-onset regarding care needs and/or all-cause mortality, we found the new cut-off point in our frailty check-up activity. conclusion: we could confirm that our interdisciplinary "action-research" can raise the citizen's early awareness and affect their behavior modification via elderly citizen supporter system for frailty prevention, consequently leading to extend healthy life expectancy. saguez, carlos márquez, bárbara angel, mario moya, lydia lera (inta, universidad de chile, santiago, chile) background: physical phenotype of frailty has been associated with quality of life deterioration and some studies have calculated cost-effectiveness of interventions on frailty in quality-adjusted life years (qalys), however studies on the direct burden of frailty expressed in qualys lost in community dwelling older adults are scarce. objectives: to forecast qalys lost caused by frailty in older chileans and describe health profiles as determined by euroqol (eq- d) in community-dwelling older chileans with and without frailty. methods: cross sectional study in ( , % women, mean age y± . ) community dwelling people >= years participants in alexandros cohorts. the frailty phenotype was defined as having >= from the following criteria: weak handgrip dynamometry, unintentional weight loss, fatigue/ exhaustion, five chair-stands/slow walking speed and low physical activity. qol was evaluated trough euroqol (eq- d) five dimensions: mobility, self-care, usual activities, pain/ discomfort and anxiety/depression and self-rated health trough eq -visual analogue scale (eq- d-vas). qualys were calculated by the eq -d time trade-off (tto) method. to estimate life expectancies (le), multistate methods based on the follow-up of alexandros cohorts, were employed. results: frailty was identified in , % of the sample. selfrated health according to eq- d-vas was lower in frail than non-frail people ( . ± . vs . ± . , p< , ). after adjusted multinomial logistic regression, the eq- d dimensions of anxiety/depression (very depressed rrr= . ; %ci: . moderate rrr= . ; %ci: , ) and pain (much pain rrr= . ; moderate pain rrr= . ; had the highest association with frailty. the valorisation of years in qualys was lower in frail than in non-frail people ( . ± . vs. . ± . qalys per year, p< , ) and among those frail, much lower in people >= y than in the group - y ( . ± . vs. . ± . , p< , ). the qualys remaining years were lower in frail people than in non-frail:total le at - y was , y corresponding to , qalys in frail and , qalys in the non-frail; in the group >= y tle was , y corresponding to , qalys in frail people and , in the non-frail. conclusion: the high burden of frailty on qalys, mostly related to pain and anxiety/depression makes compulsory its early detection and treatment. its knowledge allows calculating cost-effectiveness of interventions. background: + agil barcelona is a real-life a multicomponent intervention against frailty implemented in a primary care center, which promotes a comprehensive and coordinated approach between primary care, geriatrics teams and community resources, to detect and reverse frailty in the older adults. objectives: we aimed to assess the -months impact on physical function of +agil barcelona in community-dwelling frail older adults with cognitive impairment. methods: the study population was driven from the +agil barcelona program population. we included participants with cognitive impairment or dementia past history and those who performed a minicog test < points. after frailty screening by the primary care team, a geriatric team performed the comprehensive geriatric assessment. according to cga results, a tailored and specific multidisciplinary intervention for each person was designed. the intervention could include a) multi-modal physical activity (pa) sessions, b) promotion of adherence to a mediterranean diet c) health education and d) medication review. the physical performance was assessed at baseline and at -omths follow-up by the short physical performance battery (sppb) and gait speed. the pre/post intervention analysis was done by a paired sample t-test for repeated samples for continuous variables and chi-square for categorical variables. results: we included participants (mean age= . ± . , . % woman and . % lived alone). despite being independent in daily life, . % had fallen the past year, . % were vulnerable or frail according to the csf. physical performance was impaired: sppb= . ± . and gait sped= . ± . m/sec and . % had balance impairments. after months, . % of participants completed >= . physical activity sessions. the mean improvements were + . ± . points (p< . ) for sppb, + . ± . m/ sec (p< . ) for gait speed, - . ± . sec (p< . ) for chair stand test, and . % (p . ) improved their balance. additionally, psychoactive treatment was withdrawn in . %. conclusion: according to our results, a multidisciplinary and comprehensive geriatric intervention for frail elderly people with cognitive impairment of the community improves physical function and could reverse fragility at months. clarence mwelwa patrick chikusu, amritha narayanan, joel james (ashford and st peter's nhs foundation trust, chertsey, uk) background: frailty and muscle strength are a critical component of walking ability and presence of these can result in high prevalence of falls. it also results in increased morbidity and mortality among the elderly. despite sarcopenia being very common and a reversible condition in its early stage it is a frequently overlooked and undertreated geriatric syndrome a greater understanding of sarcopenia and frailty among healthcare professionals could have a dramatic impact on outcome and quality of life of the elderly. objectives: this study aimed to assess the current knowledge about the concept of sarcopenia and frailty among the healthcare professionals working in an nhs district general hospital in surrey. methods: this longitudinal study included nhs healthcare professionals (n = ) who were asked to complete a questionnaire regarding awareness of concept, risk, diagnostic strategy and management of frailty and sarcopenia. results: . % of healthcare professionals stated to know the concept of sarcopenia, % indicated to know how to diagnose sarcopenia and % had seen patients with suspected sarcopenia in the last one month. only % knew the risk associated with sarcopenia. . % used sarc f questionnaire as diagnostic method for sarcopenia. percent of the cohort experienced bottle necks during the implementation of diagnostic strategy. lack of awareness and time ( . %) was the main reason for this . . percent heard the term frailty and . % knew that sarcopenia and frailty is not the same . . percent was aware of the scoring methods for the frailty and . % used clinical frailty score as the method. . % was aware of the frailty pathway but only . % knew whom to contact regarding managing frailty. . % heard the term comprehensive geriatric assessment. only . % was aware of key recommendations of managing frailty in the acute settings. conclusion: although concept of sarcopenia and frailty is familiar to most nhs healthcare professionals, the practical and clinical application is limited due to a lack of awareness regarding the diagnostic methodology, risks as well as time constrains. as such the benefits and potential treatment options may be overlooked and we aim to improve awareness so that these measures can improve outcomes for patients. mahtab alizadeh-khoei , fatemeh sadat mirzadeh , reyhaneh aminalroaya , fati nourhashemi (( ) gerontology & geriatric department, medical school, tehran university of medical sciences, ziaeian hospital, tehran, iran; ( ) department of internal medicine and clinical gerontology, toulouse, france) background: frailty is a potentially reversible geriatric syndrome associated with geriatric risk factors. detecting risk factors is a useful purpose to predict frailty levels incidence to plan for institutional or home care services. objectives: the aims were finding frail and prefrailty frequency in iranian geriatric outpatients' and determining demographics related factors and geriatric syndrome predictors on frailty levels, based on frailty fried index. methods: in this cross-sectional study elderly >= years old, selected by convenience sampling from geriatric day clinics in the area of tehran university of medical sciences. the effect of risk factors (adl and iadl dependency, obesity, and polypharmacy) and geriatric syndromes (falling, chronic pain, sleep problems, vertigo, vision and hearing impairments, incontinence, dementia, and depression) were evaluated on frailty fried index. predictor factors by logistic regression model were analyzed, according to demographic risk factors and geriatric syndromes. results: the mean age was / ± / years old, majority were male ( %). prefrailty was . % in men and . % in women based on fi. the significant risk factors in elderly prefrail women were depression ( . %), polypharmacy ( . %), visual impairment ( . %), and chronic pain ( . %); although, in prefrail men were vertigo ( . %), falling ( %), sleep disorder ( . %), and incontinence ( . %). in prefrail older adults>= years, only sleep disorder was significant. in logistic regression model, six significant predicted factors were included depression, iadl dependency, falling, chronic pain, vertigo, and age. depression increased the risk of prefrailty by . times, dependency in iadl increased . times; moreover, chronic pain and vertigo increased prefrailty risk about times. dependency on iadl increased the risk of frailty . times, and chronic pain and falling increased the risk of frailty about . times. by logistic regression model, % of prefrail outpatients elderly could be diagnosed. conclusion: geriatric syndromes in outpatients' elderly could predict prefrail more than frail elderly. in the iranian community dwellers prevalence of prefrailty was high, so the on-time screening and outpatients' interventions can help to prevent frailty. background: frailty is a key condition to be screened among elderly oncological patients. nevertheless, the use of the frailty index (fi) in onco-geriatrics is still limited. objectives: aim of our work is to measure the functional and prognostic value for -year mortality of the frailty index (fi) in a cohort of older women with gynecological cancer. methods: the prognostic value of fi was tested in older women with gynecological cancer (mean age = . years). fi was retrospectively calculated following the rockwood model[ ]. spearman's rho test was used for correlations with other oncological scales: eastern cooperative oncology group performance status (ecog); karnofsky performance status (kps); vulnerable elders scale- (ves- ). cox proportional hazard models and roc curve were performed to estimate prognostic role of -year mortality. sensitivity and specificity were also calculated. results: fi is normally distributed and descriptive statistics define our population as frail (mean = . ± . , range . - . ). . is confirmed as an upper limit compatible with life. fi doesn't significantly correlates with age, ecog and kps while it positively correlates with ves- (r= . , p < . ). fi is the strongest predictor for -year mortality confirmed after all adjustments for confounders (or . ; % ci . - . , p < . ) and by roc curve analyses ( . , % ci . - . , p=. ). conclusion: frailty index is a useful tool to detect vulnerability in onco-geriatrics and it predicts -year mortality. it predicts negative health-related outcomes (mortality) better than other traditional scales. its adoption may support a more efficient identification of patients in the need of adapted and personalized care. further studies are needed to confirm and extend these findings. background: frailty has been studied in the old population due to its association with negative outcomes but more information is needed about frailty in very old samples. the fried frailty phenotype (ffp) has been widely used and includes a set of objective indicators: weakness, slowness, unintentional weight loss, exhaustion and low physical activity. objectives: to determine which sociodemographic, functional and health-related variables predict ffp in a sample of community-dwelling individuals aged +yrs. methods: data from individuals living in the metropolitan area of porto were considered: sociodemographic information (age, sex, education level, living status), ffp ( - ), functionality (basic and instrumental activities of daily living), health information (nr. medicines, nr diseases, nr. falls, cognitive impairment, and self-perception of health). descriptive and correlational analysis were conducted and followed by a linear regression analysis (stepwise method) of variables significantly associated with ffp. results: participants' mean age was . years (sd= . ), they were mainly women ( . %), with - years of education ( . %) and living with a relative ( . %). high disability levels were found both for basic and instrumental activities of daily living. the mean of medicines intake was . (sd= . ) and of diseases . (sd= . ); . % of the participants rated their health as poor. the median number of falls in the last year was (iqr= ). participants scored on average . points (sd= . ) in mmse. gender or age were not associated with ffp. basic and instrumental activities of daily living, selfperception of health and cognitive performance significantly predicted ffp. in the adjusted model (r = . ), the stronger predictor was the higher dependency for basic activities of daily living, followed by worst self-perception of health and lower scores of cognitive performance. the dependency for instrumental activities of daily living lost its significance in the adjusted model. conclusion: our results identify three main predictors of ffp (basic activities of daily living, selfperception of health, and cognitive performance) in participants with advanced age. these results provide relevant information for further understanding of frailty and the ffp among the oldest old. background: unplanned hospital readmissions are associated with poorer prognosis and increased risk of functional decline and dependence in older people. identifying major risk factors and assessing clinical risk scores can help to distinguish patients at risk of worse outcomes and rehospitalization, allowing the proposal of preventive measures. the aim of this study was to compare the accuracy of different instruments and risk factors in predicting readmission, functional decline and death in hospitalized older patients in a brazilian geriatric unit. methods: in a cohort study performed at a geriatric unit, patients, years old or over were included. demographic data, functional status, prisma scale, geriatric depression scale, mini mental state examination, timed get up and go test, gait speed, mini nutritional assessment, palmar prehension strength, charlson comorbities index, frailty score of the cardiovascular health study and the senior index risk for rehospitalization were assessed at study admission. all patients received a follow-up telephone call at days after discharge to assess potential readmissions, deaths and functional status. results: mean age was . years (sd +- . ) and the mean barthel adl score was . (sd +- . ). altered barthel ( . ; ci % . - . ; p< . ), chs score ( . ; ci % . - . ; p< . ), isar-hp ( . ; ci % . - . ; p= . ), tgug ( . ; ci % . - . ; p< . ), palmar prehension ( . ; ci % . - . ; p= . ) and gait speed ( . ; ci % . - . ; p= . ) were associated with higher mortality days after discharge. the risk of functional decline at -month follow up evaluation was higher in patients with altered barthel ( . ; ci % . - . ; p< . ), lawton ( . ; ic % . - . ; p= . ), chs score ( . ; ci % . - . ; p< . ), isar-hp ( . ; ci % . - . ; p< . ), prisma ( . ; ci % . - . ; p= . ), tgug ( . ; ci % . - . ; p< . ), palmar prehension ( . ; ci % . - . ; p< . ) and gait speed ( . ; ci % . . ; p= . ). conclusion: altered iadl, frailty chs score, isar, tgug, palmar prehension strength and gait speed are predictive of functional decline and mortality days after hospital discharge. these tools can be useful to pinpoint frailty in older patients, allowing the implementation of preventive interventions to avoid functional decline. more research is needed to evaluate the role of these tools in predicting rehospitalization. to limit the strain on available resources and prevent an unnecessary increase in patient burden. objectives: this study aimed to improve patient selection for multi-disciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients. methods: two-centre prospective cohort study in patients aged >= years undergoing elective cardiac surgery. before surgery frailty characteristics were investigated. outcome was disability at three months defined as world health organisation disability assessment schedule . >= %. multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index were used to identify factors contributing patient selection. results: disability occurred in ( %) patients. ten out of frailty characteristics were associated with disability. a multivariable model including euroscore ii and preoperative haemoglobin yielded a c-statistic of . ( % ci . - . ). after adding prespecified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health related quality of life, and living alone) to this model the c-statistic improved to . ( % ci . - . ). net reclassification index was . (p< . ) showing improved discrimination for patients at risk for disability at three months. conclusion: using preoperative frailty characteristics improves discrimination between elderly patients with and without disability at three months after cardiac surgery and can be used to guide patient selection for preoperative multi-disciplinary team care. fabiola valero , , henry tapia , , enrique valencia , , tania tello , , (( ) facultad de medicina, universidad peruana cayetano heredia, lima, peru; ( ) instituto de gerontología, universidad peruana cayetano heredia, lima, peru; ( ) hospital cayetano heredia, lima, peru) background: frailty is increasingly recognized as a risk assessment to detect vulnerability and complexity. currently, there are limited tools to predict adverse perioperative outcomes for the geriatric population with hip fracture. objectives: to determine frailty and functional dependence as predictors of intrahospital adverse events in hospitalized older adults with hip fractures in the orthogeriatric unit of a general hospital in lima, peru. methods: we conducted a prospective cohort involving patients aged years or older who were admitted to the orthogeriatric unit with hip fracture from june to june . data were obtained at the time of admission to our unit: frailty was assessed with the frail scale, function ability with the barthel scale, cognition with the short portable mental state questionnaire (spmsq) scale of pfeiffer, comorbidities, socio-family assessment and geriatric syndromes. patients were followed up to discharge, and adverse events were evaluated during this period. univariate models were performed, and logistic regression was done subsequently. results: patients with hip fractures were evaluated, the mean age was . ( . ) years, . % ( ) were women and . % ( ) came from nursing homes. hypertension was the most frequent comorbidity in . % ( ). % ( ) had a history of functional dependence on basic activities of daily living (abvd), % ( ) had some degree of cognitive impairment, . % ( ) had social problems, polypharmacy in . % ( ) and . % ( ) history of falls in the last year. according to frail scale, . % (n = ) were robust, . % (n = ) were pre-frail and . % were frail (n = ). . % ( ) had an adverse event while hospitalized (pneumonia, uti, delirium, acute renal injury, pet), of whom % ( ) were robust, . % ( ) pre-frail and % ( ) frail (p = . ). . % of patients with functional dependence on abvd presented adverse events. in the multivariate analysis, the factors associated with in-hospital adverse events were functional dependence in abvd, or: . , (ci: . - . ); frailty with an or: . ic ( . - . ) and social problem, or: . ic ( . - . ). conclusion: older adult patients hospitalized for hip fracture who had frailty, functional dependence, and social problems had significant adverse events at a general hospital in lima, peru. aiko inoue , chi hsien huang , , chiharu uno , kosuke fujita , , tomoharu kitada , , joji onishi , hiroyuki umegaki , masafumi kuzuya , (( ) institutes of innovation for future society, nagoya university, japan; ( ) department of community health and geriatrics, nagoya university graduate school of medicine, nagoya, japan; ( ) department of business administration, seijoh university, aichi, japan) background: social frailty was associated with age, sex, income, education, marital status, and household status. however, the risk factors of social frailty relatively less investigated. objectives: the aim of this study is to clarify the risk factors of social frailty in community-dwelling japanese elderly. methods: a health promotion project (nagoya-teng project) is designed to distribute health promotion programs including enhancement of nutrition and physical activity via cable tv channel for community-dwelling elders. of all participants (n= ), participants with complete baseline information (mean age . ± . years, men ( . %)) were included in our cross-sectional analysis. at baseline, demographic data, socio-economic status, geriatric depression scale (gds- ), japanese version of european health literacy survey questionnaire (j-hls-eu-q ) were obtained. social frailty was defined by household status (living alone or not), financial difficulty, social activity, and fulfilment of social needs. total deficit scores of or more were defined as social frailty, as social pre-frailty, and as robustness. results: a total of ( . %), ( . %), and ( . %) of all participants were categorized as social non-frailty, pre-frailty and social frailty, respectively. in multivariable logistic regression model after adjusting for age, sex, bmi, and education level, living without a spouse is a significant risk factor (p< . ) for social pre-frailty (or . , % ci . - . ) and social frailty (or . , ). low gds- scores were associated with high risk of social prefrailty (or . , % ci . - . ) and social frailty (or . , % ci . - . ). in addition, health literacy was inversely associated with social frailty (or . , % ci . - . ). age, sex, and education level were not associated with social frailty. conclusion: regardless of age and sex, living with a spouse and depression which is associated with activity of daily living and quality of life are associated with social frailty. low health literacy is also a risk factor of social frailty. in literature, loneliness and social frailty were associated with functional decline and mortality in the elderly. future approaches incorporating health literacy interventions are warranted to prevent social frailty in the aged society with increasing number of physical frail older adults. background: frailty increases the risk for morbidity and mortality after cardiac surgery. the influence of frailty on postsurgical functional outcomes is largely unknown. objectives: the aim of this research was to study the association of preoperative frailty characteristics on adverse functional outcomes and to investigate the trajectory of functional recovery among frail and non-frail elderly patients up to one year after elective cardiac surgery. methods: a prospective two-centre observational cohort study in elective cardiac surgery patients aged >= years. preanaesthesia assessment was supplemented with frailty tests covering the physical, mental, and social domain. functional outcomes were assessed at one year and included change in health related quality of life (hrql) measured by the short form and disability measured by the world health organisation disability assessment schedule . . adverse functional outcome was considered when worse physical or mental hrql or disability was present after surgery. results: frailty characteristics were present in ( %) patients of whom ( %), ( %) and ( %) showed frailty in the physical, mental or social domain respectively. adverse functional outcome at one year after surgery occurred in ( %) patients. patients with an adverse functional outcome were more often frail ( ( %)) than patients without an adverse functional outcome ( ( %) p< . ). worse physical or mental hrql occurred in ( %) and ( %) patients respectively. the most important frailty characteristic associated with worse physical hrql was high preoperative physical hrql (β - . per point ( % ci - . to - . ). preoperative mental hrql showed the strongest associations for worse mental hrql (β - . per point ( % ci - . to - . )). disability was reported by ( %) patients and associated with preoperative polypharmacy, gait speed, health related quality of life, living alone or dependent living. gait speed had the strongest association (β . per second ( % ci . to . )). conclusion: preoperative frailty characteristics were common and predictive for adverse functional outcome one year after cardiac surgery. frailty screening can be used to improve risk stratification and decision making in older cardiac surgery patients. background: frailty frailty has many elements and these can be characterised as physical, nutritive (including body composition), cognitive and sensory (including hearing and seeing). the relative prevalence and importance of these elements are not known. objectives: to estimate the prevalence of frailty and relative contribution of physical/ balance, nutritive, cognitive and sensory frailty to important adverse health states (falls, physical activity levels, outdoor mobility, problems in self-care or usual activities, and lack of energy or accomplishment) in an english cohort. methods: analysis of community-dwelling older people. the sample was drawn from a random selection of all people aged or more registered with general practices across england. data were collected by postal questionnaire. frailty was measured with the strawbridge questionnaire. we used cross sectional, multivariate logistic regression to estimate the association between frailty domains and adverse health outcomes. some models were stratified by sex and age. results: mean age of participants was years (sd . ), range to and . % ( / ) were men. the prevalence of overall frailty was . % ( / ) and there was no difference in prevalence by sex (odds ratio . ; % confidence interval . to . ). sensory frailty was the most common and this was reported by more men ( / ) than women ( / ; odds ratio for sensory frailty . , % confidence interval . to . ). men were less likely than women to have physical or nutritive frailty. physical frailty had the strongest independent associations with adverse health states. however, sensory frailty was independently associated with falls, less frequent walking, problems in selfcare and usual activities, lack of energy and accomplishment. conclusion: physical frailty was more strongly associated with adverse health states, but sensory frailty was much more common. the health gain from intervention for sensory frailty in england is likely to be substantial, particularly for older men. sensory frailty should be explored further as an important target of intervention to improve health outcomes for older people both at clinical and population level. background: it live independently. our goal is to encourage independent living, wellbeing and to relieve health and care services budget pressure. longevity is one of the biggest achievements of modern societies. by , a quarter of europeans will be over years of age. combined with low birth rates, this will bring about significant changes to the structure of european society, which will impact on our economy, social security and health care systems. the most problematic expression of population ageing is the clinical condition of frailty. frailty develops because of age-related decline in multiple physiological systems. it is estimated that a quarter to a half of people over years are frail , and this is set to reach epidemic proportions over the next few decades. while frailty increases, the average amount of health spending increases as well with the frailty level in a range from , to , €/person year, depending upon the frailty status and the setting of care. frailty usually comes along associated with another risk facto; loneliness. then, ageing, frailty and loneliness constitute overlapping conditions submitted to multiple health and care interventions. ecare project aims to deliver disruptive digital solutions for the prevention and comprehensive management of frailty to encourage independent living, wellbeing and to relieve health and care services budget pressure, throughout the implementation of a pre-commercial procurement scheme. pre-commercial procurement is an ideal framework for the delivery of innovative solutions. the ecare network of procurers and the service providers are often on the frontline as new needs emerge. this pcp will allow the procurers to voice out their unmet needs, create a new demand to access sustainable products of higher quality, and develop new applications with lower life cycle costs. the demand and the supply side will work together to co-create and co-design the solutions and validate their functionalities against the specific challenges outlined in the pcp call for tender. this will clearly maximize the engagement of innovation in health and care services. solutions should improve outcomes for frailty in old adults entailing the physical and the psychosocial factors. the target group are the pre-frail/frail old adults with emphasis on those that feel lonely and/or isolated. the project will procure the development, testing and implementation of digital tools/services and communication concepts to facilitate the transition to integrated care models across health and social services and country-specific cross-institutional set-ups, including decentralised procurement environments and collaboration across institutions. objectives: the project objectives are: • newly development easy-to-use and reliable solutions that facilitate early detection of frailty based on the most efficient standards and methods. • improve the understanding of the factors affecting frailty and the feelings of loneliness and isolation, and how they do correlate (e.g.: gender dimension, social context, etc.). • deliver personalised intervention plans taking into account the end-user societal context. • innovative and meaningful means to tackle the feelings of loneliness and isolation. • new approaches to engage patients as active self-managers of their own health. • new technology developments designed and oriented to the target end-user. • and among all, investigate to deliver cost-efficient solutions, affordable to the payers involved. methods: ecare procurers will proactively organize the requirements of the demand for care solutions in a coherent way. the procurers (buyers' group) will assess the solution adequacy to the targets. the preferred partners will contribute with solid knowledge of innovative procurement paths to the innovation procurement tender. the project partners will do this by: • providing a solid and informed base for dialogue between stakeholders by determining a coherent picture of the market state of the art of the sector based on practical experience of customers and suppliers. • enabling a genuine and credible dialogue between the supply-chain and customers to determine the practical policy and procurement actions required to deliver the ecare solutions. • defining the common unmet needs, communicating these to stakeholders and initiating a mobilization plan for a pcp addressing ecare needs. the pcp may be summarized in a series of actions: • convey the relevance of innovation procurement to public procurers: encouraging suppliers to offer novel solutions to address ecare challenges rather than the lowest price solutions. • analyze the state of the art of the market with all potential suppliers, as well as the main problematic and barriers faced in the sector and that need to be overcome a set of actions involving both the supply and demand sides will be carried out: a coordinated first analysis of the state of the art conducted by all project members followed by a coordinated market sounding through all dissemination channels managed by the consortium will be undertaken to spread project results aiming to receive feedback from all key market players. for this, the role of procurers is vital to replicate and stretch the impact of the project. • providing public procurers with procurement know-how to improve public sector procurement efficiency and increase public sector market power by giving support to apply the methodologies of innovation procurement. market sounding will provide an opportunity for engagement and two-way dialogue with innovative companies that can offer solutions and guidance on how to overcome the procurement barriers. • launching an agreed, realistic and validated joint pcp tender. results: the ecare consortium is immerse in a deep process of unmet needs detection. our goal is to be extraordinarily concrete when defining what the end users and the healthcare professionals are willing for. those unmet needs will be critical for the definition of the requirements and uses cases that the it suppliers will have to follow to design the ict solutions. then… what a better way to know their needs that asking them personally? the vision of providing tailored fit solutions and tools to the end users led to the consensus in creating and facilitating focus group sessions across the procurers regions -campania (italy), barcelona (spain), santander (spain) and wroclaw (poland)-. these sessions will be involving end users, health and social care professionals, and it internal departments of the procurers' organisations. -the focus group script for the end users sessions integrates as main topics the specific condition and related symptoms; experiences of services and care provided; experiences of managing condition when progressing rapidly ; needs for symptom management and how these can be met ; integration of it supportive tools in the management of frailty and loneliness. -the professionals are invited to reflect and discuss the topics of common symptoms and actual care model; experiences of monitoring elderly when condition is progressing rapidly; views about the supportive care needs of elderly and caregivers; early integration of the new care in the management of frailty and loneliness; integration of it supportive tools in the management of frailty and loneliness. -the identified and proposed topics for the it staff would be the state of the art of the relation in between it and social/healthcare; state of the art of interventions on frailty and loneliness. all the four procurers were challenged to organize, at least, focus sessions, one with each specific target group. so far, all the procurers already organized and scheduled the sessions that will occur until the end of january. in terms of impact, participants are expected to be involved ( end users, healthcare professionals and it people). all the representative of the procurers reported so far that the participants have been considering the sessions so interesting and useful. in fact, new topics have been put in the table for discussion in all the different sessions, adding more important information for the definition of the unmet needs. the journey of the project so far has been providing very powerful insights and evidences that people and professionals appreciate to be involved and e(motionally) cared. conclusion: ecare will progress beyond the state of the art by approaching older people not just in terms of their diseases but also in terms of physical, cognitive and psychosocial care and support to prevent functional decline, frailty and disability. the project key components to address frailty are those that define also integrated care, with the addition of targeting high risk frail individuals, an enablement attitude and a focus on outcomes most relevant to frail individuals and their caregivers. for these, a multimodal comprehensive system able to provide the most effective care will need to be provided. background: maintaining autonomy as life progresses has become a challenge for the health systems. this objective can only be achieved by moving the axis of health policies and health care practice from the disease to the preservation of functional capacity. objectives: the aim of this study is to design and pilot a model for the assessment and support of functionality for community dwelling older people. methods: a space in which nurse and social worker jointly assess the functional capacity of older people and identify and provide responses to the detected deficits was proposed. this study was performed in osi donostialdea (gipuzkoa, spain). three main tasks were carried out: . definition of the joint assessment procedure of functionality. . identification of the existing resources and community assets to give answer to the identified needs. . piloting the model in a sample of older people. the identified needs and the availability of resources to respond to them were obtained from the pilot phase. results: in the initial version of this integral assessment were included, functional capacity, physical activity, cognitive capacity, sense organs, nutritional status, social assessment and housing and environmental conditions. a total of individuals ( % women; mean age years, sd= . ; barthel index, mean . , sd= . ; % living alone; % without cognitive impairment) were recruited during the pilot. the following needs were identified: personalized workout routines, fine motor skill exercises, visual and efficient diets adjusted to each patient, make sure resources reach the community, promote the use and design of gadgets to assist the needs of basic and instrumental activities of daily living, improve strategies to prevent cognitive function impairment, ease loneliness and avoid or minimize physical and environmental barriers to access home, to walk the streets and, particularly, to use public transport. there were no resources available for all the identified needs. conclusion: this study will allow the development of a model for the integral assessment of functionality for the aged population, based in a multidisciplinary team, a space and a new way of working in primary care. mónica machón - , maider mateo-abad , , mercedes clerencia-sierra , , , carolina güell , , beatriz poblador-pou , , kalliopi vrotsou - , antonio gimeno-miguel , , alexandra prados-torres , , itziar vergara - ( ( ) background: multimorbidity and frailty are often present in older people and are found to be associated to increased risk of adverse health events. it is necessary to improve the knowledge of the characteristics of such populations to design adequate clinical guidelines seeking to avoid or delay the onset of dependence. objectives: the aim of this study was to identify clusters of chronic diseases in robust and frail individuals and compare sociodemographic and health characteristics between these clusters. methods: this was a cross-sectional study based on data from two longitudinal studies. the sample was composed of functionally independent community-dwelling older people with multimorbidity living in gipuzkoa (basque country, spain). information from electronic health records (diagnose diseases and medication) and a baseline assessment (sociodemographic characteristics, functional status, self-perceived health, cognitive status, sight and hearing impairments, history of falls and nutritional status) was used in the analysis. the timed up and go test of physical performance was included as a measure of frailty. multiple correspondence and cluster analyses were performed to identify groups. results: the study population consisted of individuals ( . % women; mean age . years, sd= . ). frail individuals (n= ) were older, had a lower educational level and a poorer health status than robust individuals (n= ). three clusters were obtained in robust (rc , n= ; rc , n= and rc , n= ) and four among the frail individuals (fc , n= ; fc , n= ; fc , n= and fc , n= ). in rc and fc , none of the chronic diseases had a higher prevalence than in rc -rc and fc -fc -fc , respectively. individuals pertaining to rc and fc presented more frequently diseases related to mobility limitation or limb pain compare to the other clusters. higher rates of cardiovascular diseases and risk factors were seen in rc and fc . in frail individuals a new cluster emerged, fc , containing individuals with higher rates of cognitive and eye problems and a clearly poorer health status. conclusion: the findings obtained in this exploratory study may provide insight for the designing of more specific health interventions for older patients with multimorbidity, even though the chronic diseases cluster identified were similar in robust and frail individuals. background: older african americans (oaa) are at high risk for becoming frail in later life. interventions can reverse or delay frailty, yet oaa have largely been excluded from frailty intervention research. many interventions are also time and resource intensive, making them inaccessible to socially disadvantaged oaa. objectives: we present results of a feasibility trial of a low dose frailty prevention intervention among community-dwelling, pre-frail oaa aged + recruited from a primary care clinic between june st and october st . methods: using a -arm rct, participants were assigned to the intervention, which was delivered by an occupational therapist (ot) and comprised of four sessions over four months (an ot evaluation, and sessions on healthy dietary practices, increasing physical activity, and maintaining a healthy lifestyle), or enhanced usual care (publicly available information about healthy lifestyle, home safety, and local elder services). feasibility criteria were set a priori at % for participant retention (including attrition due to death/ hospitalization), % for session engagement, participants/ week for mean participant accrual, and % for program satisfaction. results: participants were % female with an average age of . years, . % of which lived alone and . % lived off of less than k per year. feasibility metrics were met. the study recruited . participants per week and retained % of participants who attended % of scheduled sessions. mean satisfaction scores were %. the treatment also resulted in positive trends in the expected direction in the treatment group for the following outcomes (d = effect size): global health (d = . ), mental health (d = . ), qol (d = . ), social functioning (d = . ), depression (d = . ), and pain reduction (d = . ). descriptively, treatment group participants were also less likely to experience a progression (deterioration) in three frailty status indicators at -months compared to controls: weight lost, walking speed slowness, and grip strength weakness. conclusion: the intervention was feasible to deliver. qualitative findings from exit interviews suggested changes to the program dose, structure, and content that could improve it for future use. background: it is well known that frail patients are potentially most at risk of functional decline following a hospital admission. objectives: to measure the effects of an augmented prescribed exercise programme versus usual care, on physical performance, quality of life and healthcare utilisation for frail older medical patients in the acute setting. methods: this was a parallel single-blinded randomised controlled trial. within two days of admission, older medical inpatients with an anticipated length of stay >= days, needing assistance/aid to walk, were blindly randomly allocated to the intervention or control group. until discharge, both groups received twice daily, monday-to-friday half-hour assisted exercises, assisted by a staff physiotherapist. the intervention group completed tailored strengthening and balance exercises; the control group performed stretching and relaxation exercises. length of stay was the primary outcome measure. blindly assessed secondary measures included readmissions within three months, and physical performance (short physical performance battery) and quality of life (euroqol- d- l) at discharge and at three months. time-to-event analysis was used to measure differences in length of stay, and regression models were used to measure differences in physical performance, quality of life, adverse events (falls, deaths) and negative events (prolonged hospitalisation, institutionalisation). results: of the patients allocated, patients' (aged ± . years) data were analysed. groups were comparable at baseline. in intention-to-treat analysis, length of stay did not differ between groups (hr . ( % ci, . - . ) p= . ). physical performance was better in the intervention group at discharge (difference . ( % ci, . - . ) p= . ), but lost at follow-up (difference . ( % ci, - . - . ) p= . ). an improvement in quality of life was detected at follow-up in the intervention group (difference . ( % ci, . - . ) p= . ). overall, fewer negative events occurred in the intervention group (or . ( % ci . - . ) p= . ). conclusion: improvements in physical performance, quality of life and fewer negative events suggest that this intervention is of value to frail medical inpatients. its effect on length of stay remains unclear. background: to propose a simple frailty screening tool able to highlight frailty profiles, already since the initial screening phase. methods: a -item questionnaire (lorraine frailty profiling screening scale, lofpross), constructed by an experts' working group, was administered by health professionals to participants > years old (n= ) and living at home, in different clinical settings: a primary care outpatient clinic (rural population, n= ), a geriatric day clinic (day-clinic population, n= ) and healthy volunteers (urban population, n= ). a multiple correspondence analysis (mca) followed by a hierarchical clustering of the results of the mca performed in each population was conducted to identify participant profiles based on their answers to lofpross. a response pattern algorithm was resultantly identified in the rural (main) population and subsequently applied to the urban and day-clinic populations and, in these populations, the two classification methods were compared. finally, clinically-relevant profiles were generated and compared for their ability to similarly classify subjects. results: the response pattern differed between the subpopulations for all items, revealing significant intergroup differences ( . ± . positive responses for urban vs. . ± . for rural vs. . ± . for day-clinic, all p< . ). five clusters were highlighted in the main rural population: "non-frail", "hospitalizations", "physical problems", "social isolation" and "behavioral", with similar clusters highlighted in the remaining two populations. identification of the response pattern algorithm in the rural population yielded a second classification approach, with % of tested participants classified in the same cluster using the different approaches. three clinically-relevant profiles ("non-frail" profile, "physical frailty and diseases" profile and "cognitive-psychological frailty" profile) were subsequently generated from the clusters. a similar double classification approach as above was applied to these profiles revealing a very high percentage ( . %) of similar profile classifications using both methods. conclusion: the present results demonstrate the ability of lofpross to highlight frailty-related profiles, in a consistent manner, among different older populations living at home. such scale could represent an added value as a simple frailty screening tool for accelerated and better-targeted investigations and interventions. ( ) homburg/saar/germany, saarland university medical center, neurology, homburg/germany) background: frailty is the most important short and long term predictor of disability in the elderly. no study to date evaluate the impact of frailty on short and long term independently from neurological outcome measures. objectives: the aim of the study was to evaluate whether diagnosis frailty predicts short and long-term mortality and neurological recovery in old patients who underwent reperfusion acute treatment in stroke unit. methods: consecutive patients were older than years who underwent thrombectomy or thrombolysis in a single stroke unit from to . predictors of stroke outcomes were assessed including demographics, baseline nihss, time to needle, treatment and medical complications. premorbid frailty was assessed with a comprehensive geriatric assessment (cga) including functional, nutritional, cognitive, social and comorbidities status. at and months, all-cause of death and clinical recovery (using mrs) were evaluated. results: patients, of whom underwent mechanical thrombectomy and venous thrombolysis (mean age . , - years) entered the study. frailty was diagnosed in out of patients and associated with older age (p= . ) but no differences in baseline nihss score or treatment strategies. at follow-up, frail patients showed higher incidence of death at ( % vs %, p= . ) and ( % vs %, p= . ) months. frailty was associated with worse neurological recovery at month (mrs . + . vs . + . , p= . ) and one year followup (mrs . + . vs . + . ) for free survival patients. conclusion: frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. larger prospective studies are warranted in order to confirm our findings. background: frailty becomes increasingly common as adults age and has known associations with activity limitations and injurious falls among older adults. while it is believed that frailer older adults are less socially connected than their more functional counterparts, less is known about the relationship between frailty and social isolation among community-dwelling older adults. objectives: the purpose of this study was to examine associations of frailty indicators on self-reported social isolation risk among community-dwelling adults age years and older. methods: the upstream social isolation risk screener (u-sirs) was developed to assess social isolation risk among older adults within clinical and community settings. comprised of items (cronbach's alpha= . ), the u-sirs assesses physical, emotional, and social support aspects of social isolation. using an internet-delivered survey, data were collected from a national sample of , adults age years and older. participants completed the u-sirs and additional items on sociodemographics and other health risks. theta scores for the u-sirs serve as the dependent variable, which were generated using item response theory. an ordinary least squares regression model was fitted to identify frailty indicators associated with social isolation risk. results: participants' average age was . (± . ) years. the majority of participants was female ( . %) and lived with a partner/spouse ( . %). twenty eight percent of participants reported difficulty walking or climbing stairs, . % reported difficulty dressing or bathing, and . % reported a fall in the past year. higher u-sirs theta scores were reported among males (b= . , p< . ) and those with more chronic conditions (b= . , p< . ). participants who reported difficulty walking or climbing stairs (b= . , p< . ), difficulty dressing or bathing (b= . , p= . ), or a fall in the past year (b= . , p< . ) also reported higher u-sirs theta scores. further, higher u-sirs theta scores were reported among participants who had not left their home in the past three days (b= . , p< . ). conclusion: findings suggest frailer older adults and those with functional limitations may have greater risk for social isolation. this highlights the critical demand for easy-to-administer and practical assessments for frail older adults that identify their social isolation risk and link them to needed resources and services. background: peak expiratory flow (pef) has been linked to several negative health-related outcomes in older people, but its association with frailty is still unclear. objectives: this study investigates the association between pef and prevalent and incident frailty in older adults. methods: data come from community-dwelling participants of the swedish national study on aging and care in kundgsholmen (snac-k), aged >= years. baseline pef was expressed as standardized residual (sr) percentiles. frailty was assessed at baseline and over six years, according to the fried criteria. associations between pef and frailty were estimated crosssectionally through logistic regressions, and longitudinally by multinomial logistic regression, considering death as alternative outcome. obstructive respiratory diseases and smoking habits were treated as potential effect modifiers. results: our crosssectional results showed that the th- th and < th pef sr-percentile categories were associated with three-and fivefold higher likelihood of being frail, than the th- th one. similar estimates were confirmed longitudinally, i.e. adjusted or= . ( %ci: . - . ) for pef sr-percentiles< th, compared with th- th. associations were enounced in participants without physical deficits, and tended to be stronger among those with baseline obstructive respiratory diseases, and, longitudinally, also among former/current smokers. conclusion: these findings suggest that pef is a marker of general robustness in older adults and its reduction, exceeding that expected by age, is associated with frailty development. background: as consistently reported in the literature, muscle strength (ms) decreases at a higher rate than muscle mass (mm) during aging resulting in a decreased muscle quality (mq). loss of mq has been associated with loss of mobility, falls, frailty and an increased risk of mortality. however, the degree of muscle declines is varying throughout the population leading to states: successful, normal or pathological. it has been proposed that healthy life habits such as be physically active, having a healthy diet etc. could reduce the muscle aging decline. thus, identifying if life habits could counteract or maintain muscle quality during successful aging is important to better characterize aging and to intervene more specifically. objectives: the aim of the present study was to identify whether a physically active lifestyle could attenuate the effects of aging on mq. methods: active young were compared to active older men. to be considered active, young and older men need to practice voluntary physical activity at least min/week since yrs. body composition (dxa; mri) and maximum knee extension strength were measured. mq was calculated as the ratio of ms to mm. aerobic capacity (vo max; moxus©) and muscle contractility (emg) were also measured. muscle biopsies were performed to determine fiber typing, size, intermuscular adipose tissue (imat) and intramyocellular lipid content (imcl). results: absolute mm (p< . ) and ms (p= . ) was greater in young participants compared to their older counterparts while mq was similar between them. even if total (p= . ) and type iia (p= . ) fiber size were greater in ya than in oa, muscle fiber proportion, muscle contractility and lower limb fat mass (imat, imcl) were similar between both groups (p> . ). conclusion: mq was similar between younger and older physically active men suggesting that being physical activity may have mitigated the loss of mq with aging and delayed some physiological age-related changes (muscle composition, contractility). i r a t x e e g a ñ a , itxaso mugica , , nagore arizaga , maider ugartemendia , nagore zinkunegi , janire virgala , maider kortajarena ( ( ) and sppb test (p< , ). similar results have been found in other researches. the parameters that have higher influence in cognition are handgrip test (p< , ) and frailty (p< , ). in other investigations, they got the same results; better cognition is related to better physical capacity and less fragility. in regards with functionality, the values of tug test (p< , ) and gait speed (p< , ) are the ones that show stronger relation. in other investigations, they observed that physical state and functionality were related. conclusion: the quality of life, the functionality and moca test are interconnected and the parameters that have the strongest statistical relationship are fragility and physical state. the greater the physical capacity of the older person is, the greater the functional capacity is too and the fragility decreases. in conclusion, the quality of life is better. kazuki kaji , jun kitagawa , takahiro tachiki , naonobu takahira , masayuki iki , junko tamaki , etsuko kajita , yuho sato , jpos study group (( ) national center for geriatrics and gerontology, obu, aichi, japan; ( ) nagoya university, nagoya, aichi, japan; ( ) nagoya city university, nagoya, aichi, japan) background: the skeletal muscle mass index (smi), which is the appendicular skeletal muscle mass (asm) adjusted for height squared (kg/m ), is used to assess skeletal muscle mass. we reported at this conference last year that smi was overestimated by height loss due to aging in elderly women. furthermore, age-related changes in smi were inconsistent with changes in physical function such as grip strength and walking speed. objectives: the purpose of this cross-sectional study was to investigate the effects of height loss on agerelated changes in smi and physical function in japanese women aged or older. methods: this study was part of the / -year follow up survey of the japanese population-based osteoporosis (jpos) cohort study conducted in / . the jpos study was started in . the subjects of the / year follow-up were women (mean . ± . years). we divided the subjects into quartiles based on years of height loss (q : the lowest, q , q and q : the highest). asm was measured by dual x-ray absorptiometry (qdr a, hologic, usa). grip strength, maximum walking speed, and timed up and go (tug) were also measured. results: the mean change in height during the / -year follow-up was - . ± . cm. mean changes in height in q (n= ), q (n= ), q (n= ) and q (n= ) were - . ± . cm, - . ± . cm, - . ± . cm and - . ± . cm, respectively. the trend test demonstrated significant increases in the mean age and smi from q to q . on the other hand, there was a significant decrease in asm from q to q . the mean grip strength and maximum walking speed significantly decreased from q to q . tug results were similar, suggesting that greater height loss led to longer times. conclusion: in japanese elderly women with height loss, asm and physical function decreased with age, but the smi adjusted for height increased. it may be necessary to establish a muscle mass parameter other than smi to investigate the relationship between muscle mass and physical function. kota tsutsumimoto , takehiko doi , sho nakakubo , satoshi kurita , hideaki ishii , hiroyuki shimada (( ) section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan; ( ) center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: sarcopenia was defined as decline in skeletal muscle mass and muscle function, leading to serious health problems including disability. the modifiable risk factors of sarcopenia should be elucidated to contribute to develop intervention from sarcopenia. objectives: to examine the association between anorexia of aging and sarcopenia among community-dwelling elderly japanese individuals. methods: population-based, cross-sectional cohort study in japanese older adults was conducted and participants were identified from the database of the national center for geriatrics and gerontology-study of geriatric syndromes. anorexia of aging was assessed via a simplified nutritional appetite questionnaire. handgrip strength and walking speed were tested, and skeletal muscle mass was assessed using a bio-impedance analysis device. subjects with sarcopenia were defined as those who met the criteria of the asian working group for sarcopenia. the association between anorexia of aging and sarcopenia was then analyzed via multiple regression analysis. results: in total, , elderly japanese individuals were evaluated. the prevalence of sarcopenia and anorexia of aging was . % and . %, respectively. in multivariable logistic regression model adjusted for the covariates except for nutritional status such as albumin, anorexia of aging was independently associated with sarcopenia (or: . , % ci: . to . ; p = . ). this significant association remained even after adjusting for all covariates including nutritional status (or: . , % ci: . to . , p = . ). conclusion: anorexia of aging is associated with sarcopenia among japanese older adults. further studies are needed to determine whether a causal association exists between anorexia and sarcopenia. background: low grip strength is consistently associated with higher rates of mortality, disability and other age-related health outcomes, and is a key characteristic of sarcopenia. grip strength has thus been proposed as a general biomarker of ageing. life expectancy in russia is substantially lower than in norway but whether this is reflected in differences in grip strength across adulthood, as observed in previous comparisons of older adults from russia, denmark and england, needs to be established and explained. objectives: we aimed to compare grip strength in norwegian and russian populations by age and gender, and investigate whether any observed differences were explained by contrasts in height, weight, smoking or education. methods: we used harmonised cross-sectional data on grip strength for , men and women aged - years. this comprised participants from the russian know your heart study (n= , ) conducted in the cities arkhangelsk and novosibirsk in - , and from wave of the norwegian tromsø study (n= , ) conducted in - . grip strength was assessed using the jamar+ digital dynamometer in both studies, and the maximum of six measurements (three in each hand) was used. the association between grip strength and covariates was assessed using linear regression. results: norwegian males had stronger grip than russian males at all ages, for example they were an average of . kg ( % confidence interval (ci) . , . ) stronger at age years and . kg ( % ci . , . ) stronger at age years. among women, corresponding numbers were . kg ( % ci . , . ) at age and . kg ( % ci . , . ) at age . adjustment for weight, education and smoking did not affect the results, but height attenuated the between country differences, especially at older ages. among women aged +, differences in height between countries fully explained the differences observed in grip strength. conclusion: norwegian -year-olds had the grip strength of -year-old russians suggesting that russians are ageing more rapidly in terms of muscular strength than their norwegian counterparts. the important role of height in explaining these differences, especially at older ages, suggest contrasts in early life circumstances may be of key importance. eleanor lunt , , paul greenhaff , , adam l gordon , , , john rf gladman , ( ( ) background: frailty is a state of vulnerability to stressors resulting in adverse clinical outcomes including falls and fragility fractures. identifying biomarkers associated with these outcomes may help target interventions. objectives: to compare parameters of body composition, muscle thickness and muscle strength between patients and healthy older and young volunteers. methods: six young ( - years) and older (>= years) healthy female volunteers were recruited by advert from community groups. female patients (>= years) with an acute fragility fracture were recruited from hospital wards and measured during first week of admission (median th day (iqr - )). frailty was determined by the -item frail scale. height, weight, handgrip (jamar dynamometer) and knee extension (lafayette manual muscle tester) were assessed. body composition was estimated using whole body bioelectrical impedance (bodystat quadscan ®). midpoint vastus lateralis (vl) muscle thickness and mid-thigh subcutaneous fat thickness were assessed using ultrasound (mylab gold, esaote biomedica, italy) with a hz linear-array probe. oneway anova and post hoc tukey's test were used to compare end-point measures between groups. results: frailty was significantly more prevalent in the patient group ( % frail, % pre-frail, % robust) than the healthy older group ( % robust, p< . ). the patient group was older ( ± years vs ± years, p< . ) and had more co-morbidities (p< . ). there were no significant differences between the patient and healthy older group in weight, height, bmi, percentage body fat or subcutaneous fat thickness of lateral thigh. vl muscle thickness was lower in the patient group compared to healthy older and young volunteers ( . ± . cm, . ± . cm and . ± . cm respectively, p< . ). the patient group also had lower handgrip strength ( . ± . kg, . ± . kg, . ± . kg respectively, p< . ) and lower knee extension strength ( . ± . kg, . ± . kg, . ± . kg respectively, p< . ). vl muscle thickness associated with muscle strength (knee extension r= . , p< . and handgrip r= . , p< . ) and was significantly lower in the frail compared to pre-frail or robust participants ( . ± . cm, . ± . cm, . ± . cm respectively p< . ). conclusion: female patients presenting to hospital with a fall and fragility fracture have lower muscle thickness in the thigh compared to non-frail older women, despite no difference in other body composition variables. register, health technology assessment, nhs economic evaluation database) were searched from inception to april , . cross-sectional and cohort studies that reported adjusted risk ratios with % confidence intervals (ci) for frailty with serum level of total testosterone, free testosterone, sex hormone-binding globulin (shbg) were selected. a metaanalysis was carried out by using fixed effects and random effects models to calculate the or of relationship between low level of testosterone and risk of frailty. results: the crosssectional study concluded articles, there was statistically significant association between lower level of total testosterone and risk of frailty (or= . ; %ci, . - . , i = %), as well as free testosterone (or= . ; %ci, . - . ,i = % ), the highest level of shbg was no significant associated with the risk of frailty(or= . ; %ci, . , . ; i = %). the prospective cohort studies obtain articles, no significant were found between frailty and low total testosterone and frailty (pool or= . ; %ci, . - . , i = %). conclusion: the meta-analysis indicates that low level of serum testosterone is significantly associated with the risk of frailty in the crosssection studies. however, we found no significant relationship between low total testosterone and frailty in the cohort studies. more research is needed to address the underlying mechanisms to explain this relationship and to determine whether testosterone supplementation is effective for preventing frailty syndrome. background: although frailty and abdominal obesity are known risk factors for disability in older persons, few studies have investigated the interaction between both factors on the association with disability. objectives: to investigate the association of frailty and abdominal obesity with disability in older persons. methods: we used data from , participants ( % men) in the prospective, population-based singapore chinese health study cohort, who were interviewed and examined for frailty, abdominal obesity and disability at mean age of (range to ) years from - . we defined frailty as having three or more features of weak handgrip strength, slow timed-up-and-go test, low energy level, multiple comorbidities, and difficulty carrying out usual activities. we defined abdominal obesity by waist circumference using sexspecific cut-offs, and assessed disability using the lawton instrumental activities of daily living (iadl) scale. we used multivariable logistic regression models to compute the odds ratio (or) and % confidence interval (ci) for the association between frailty/abdominal obesity and disability. results: about . % of participants were frail and . % had abdominal obesity. frailty was associated with increased or ( % ci) of . ( . - . ) for disability. conversely, the or ( % ci) for the association between abdominal obesity and frailty was only . ( . - . ). compared to participants who were neither frail nor abdominally obese, the or ( % ci) for disability was . ( . - . ) in those who only had frailty, and . ( . - . ) in those who only had abdominal obesity. however, participants who were both frail and abdominally obese had markedly increased or ( % ci) of . ( . - . ) for disability; p-value for interaction between frailty and abdominal obesity was . . furthermore, while men who were both frail and abdominally obese had increased or ( % ci) of . ( . - . ) for disability compared to their counterparts who were neither frail nor obese, the corresponding or ( % ci) was much higher at . ( . - . ) in women; p value for heterogeneity by sex < . . conclusion: frailty and abdominal obesity interacted synergistically to increase the risk of disability in older persons, and the combined effect of both factors on disability was much stronger in women than in men. background: as the world's population ages, the prevalence of cognitive impairment associated with age increases exponentially. objectives: objective of this study was to investigate the longitudinal association of physical activity and cognitive function in two deferentl populations; older adults from mexico representing latin america and south korea representing asia. based on two large population-based longitudinal studies. methods: this is a secondary analysis of two surveys, mhas and klosa, designed to study the aging process of adults living in mexico and south korea. participants> were selected from rural and urban areas. here we investigate the longitudinal association of exercise and cognition using the two waves of each study. cross cultural cognitive examination and mini-mental state examinarion were used to analyze the association between physical activity and cognition in mexican and korean older adults. multivariate logistic regression models were used to evaluate the said association. results: in mexico, the prevalence of physical activity was . %, physical active older adults obtained a higher score in ccce ( . ± . ) p-value < . . they also had more years of education ( . ± . vs. . ± . ) p-value < . , had depression ( . % vs. . %) . and consumed less alcohol ( . vs. . ) p-value < . . in korea, the prevalence of physical activity was . %. the physical active group performed better in mmse (- . ± . vs. . ± . ) p-value < . . the no physical active group had a higher proportion of women, less alcohol consumption ( . vs. . %) p-value < . , fewer years of education p-value < . and a higher prevalence of depression ( . % vs . %) p-value . . in the multivariate analysis an independent association was found in the korean population between physical activity and mmse score even after adjusting for confounders ( . ( . ; . ) p value . ). conclusion: physical activity could have a protective effect on the cognitive decline associated with ageing. background: aging is related to the increase of several chronic diseases, such as, osteoarthritis, osteoporosis, diabetes, hypertension and sarcopenia. sarcopenia (progressive loss of muscle mass and physical performance) is related to difficulties in treating other comorbidities, whether pharmacologically or non-pharmacologically. it's important to understand the relations between muscular strength (w), muscular mass and the phase angle (pa) of bioimpedance, in sarcopenic subjects to prescribe more accurate treatments. objectives: to study the relations of skeletal muscle index (smi) with w, pa and the presents of comorbidities (nc) in elderly subjects. methods: a prospective, observational secondary analysis of data from the "the sarcopenia screening and health related issues in the region of algarve", was performed. community independent living elderly subjects were recruited. body composition was measured by bioimpedance (seca analytics ), knee flexion and extension isokinetic strength ( º/sec) (humac norm). a screening questionnaire was used to determine the presence of comorbidities. smi levels were assessed using european working group on sarcopenia in older people cut-off points. results: a total of female and males, were included, mean age , (± , sd). subject were divided into groups according to smi: normal (n= ), moderated impairment (n= ) and severe impairment (n= ). pearson correlation were calculated within each group for w; pa and comorbidities. normal smi level, were correlated to knee extensors w in both legs (right: r= , , p< , and left r= , , p< , ) . no significant correlations were found with pa. moderate smi level: were correlated to knee extensors w in both legs (right: r= , , p< , and left r= , , p≤ , ), and also with knee flexors w (right: r= , , p< , ; left: r= , , p< , ). a moderate correlation was also found in this group with pa (r= , , p< , ). severe smi level: no correlations were found, in this group, with w. a moderate correlation was found with pa (r= , , p< , ). comorbidities did not have any correlations with smi levels. conclusion: our results seem to indicate that isokinetic strength (work) may have in the future a role in understanding sarcopenia, once it is related to smi. also, pa may indicate moderate and severe smi impairment. background: body characteristics as low muscle mass and high fat mass (fm) affect the physical function of older people. physical function is a fundamental component for the performance of daily activities and for the maintenance of the independence of older adults. however, the relationship between body composition and physical performance varies in different studies and still demands further research. objectives: this study aimed to investigate the association of fat mass index (fmi) determined by dual-energy x-ray absorptiometry (dxa) with physical performance in brazilian communitydwelling older adults. methods: a cross-sectional study with a sample of participants aged years and older, living in ribeirão preto, brazil, including both men and women, was conducted. fm was measured by dxa and fmi was calculated as fat mass/height (kg/m²). the physical performance was assessed by the -minute walk test, and walking distance was recorded as the main parameter, considering the distance predicted by sex. the kolmogorov-smirnov test was used to verify the normality of data distribution. the association of physical performance and fmi was analyzed using the pearson's correlation test and statistical significance was set at p ≤ . (two-sided). results: the participants were aged . ± . years, fmi was . ± . kg/m and distance walked was . ± . m. there was a significant negative association (r = - , p = . ) between fmi and distance walked, showing that higher fat mass index is associated with worse performance in the -minute walk test. conclusion: high fat mass index is associated with worse physical performance in brazilian older adults. background: sarcopenia and physical frailty have been shown to be risk factors for mortality and major morbidity in older adults suffering from various forms of cardiovascular disease. ultrasound measurement of quadriceps muscle thickness (qmt) is an emerging biomarker for sarcopenia, which we hypothesized could be conveniently acquired during the routine echocardiographic exam. objectives: to demonstrate the feasibility of measuring qmt at the time of echocardiography, and determine the association between qmt and clinical indictors of frailty. methods: adult inpatients and outpatients undergoing a clinically-indicated echocardiogram for known or suspected cardiovascular disease were recruited for this cross-sectional study at the jewish general hospital. prior to the echocardiogram, trained research assistants measured height, weight, and three clinical indicators of frailty: rockwood's clinical frailty scale, handgrip strength (jamar dynamometer), and bioimpedance phase angle (inbody ). at the conclusion of the echocardiogram, cardiac sonographers blinded to the preceding assessments acquired a biplane image of the anterior thigh midway between the anterior superior iliac spine and knee, and measured qmt as the combined thickness of the rectus femoris and vastus intermedius muscles. a cardiac ultrasound machine and probe were used (ge vivid e /e , . - . mhz probe). results: the cohort consisted of patients, of which had an available measure of qmt. the acquisition and measurement of qmt added - minutes to the echocardiographic exam. the mean age was +/- years with % females. the mean qmt was +/- mm, similar in men and women, with the lowest quintile being < . mm. higher age and lower body mass index were associated with lower qmt. after adjustment for age, sex, and body mass index, qmt was found to be associated with the multivariate composite of frailty indicators (p< . ), particularly with the clinical frailty scale (beta - . per mm; ci - . , - . ) and bioimpedance phase angle (beta . per mm; ci . , . ). additional adjustment for heart failure and inpatient status did not alter results. conclusion: qmt can be efficiently measured during a routine echocardiographic exam and can add incremental insights about frailty in a diverse group of patients with cardiovascular disease. background: frailty is a clinical syndrome whose signs and symptoms are predictors of health complications, making this a major public health problem. objectives: this study aims to evaluate the prevalence of frailty, in communitydwelling older adults enrolled in a physical exercise program in the north region of portugal, based on fried's phenotype, its association with other variables. methods: in this crosssectional analysis, we used data from individuals who were enrolled in physical exercise programs. gender and age standardized prevalence and the association between frailty and sociodemographic (age, gender, marital status, education, shortage of money) physical (self-perceived health, polypharmacy, physical fitness, vision, hearing), cognitive (memory), social (emptiness, loneliness and abandonment) and psychological (depression and anxiety) variables were evaluated. results: of the participants, the mean age was . ± . years old, and . % were female. prevalence of pre-frailty and frailty were of . % and . %, respectively. from the fried's phenotype criteria, exhaustion is the most common reported by . % of the pre-frail and . % of the frail participants. age, marital status, self-perception of health, physical fitness, memory and depression were found to be independently associated with pre-frailty, while age, education, self-perception of health, physical fitness and anxiety were independently associated with frailty. conclusion: we reported lower prevalence of pre-frailty and frailty compared with other studies, showing that physical exercise may delay the progression of frailty. interventions aimed to prevent frailty must address the diversity of the associated variables. background: frailty is related with ethnicity and impaired physical capacity which is also affected by diabetes. however, little is known about how physical health indicators of frailty are associated with each other in older hispanics with diabetes. objectives: the goal of this study was to investigate the relationship between physical health indicators of frailty in older hispanics with diabetes. methods: thirty-eight older hispanics with diabetes ( women, men, age = ± years) participated in the study. the variables included age, weight, body mass index, body composition (% of muscle mass and body fat -bio-impedance), fear of falls (falls efficacy scale international -fes-i), chair stands in sec, grip strength (jamar® dynamometer), balance with eyes open and closed (force plate), preferred walking speed, gait velocity during regular and reduce time street crossing simulations (gaitrite®). results: characteristics: body mass = ± kg, % of muscle mass = ± %, % of body fat = ± %, fes-i score = ± points, chair stands = ± repetitions, grip strength = ± kg, center of pressure area with eyes open = ± cm and with eyes closed = ± cm , preferred walking speed = ± cm/s, gait velocity during regular = ± cm/s and during reduced time street crossing = ± cm/s. there were significant correlations (*p< . , **p< . ) between age and gait velocity during regular street crossing (r = - . *); grip strength and % of body fat (r = - . **) and % of muscle mass (r = . **); chair stands and preferred walking speed (r = . **), gait speed during regular (r = . **) and during reduced time street crossing (r = . **) and center of pressure area with eyes closed (r = - . *), and between fear of falls and center of pressure area with eyes closed (r = . **). conclusion: gait speed during street crossing simulations decreased with age. greater grip strength was associated with lower % of body fat and higher % of muscle mass. people who completed less chair stands in s also walked slower and had worse balance, and those with poor balance had increased fear of falls. britta c arends, lisa verwijmeren, peter g noordzij, douwe h biesma, leon timmerman, eric pa van dongen, heleen j blussévan oud-alblas (st. antonius hospital -nieuwegein, netherlands) background: chronic pain after cardiac surgery is common and has a negative impact on quality of life. frailty is an important risk factor for adverse surgical outcomes. the influence of frailty on chronic pain after cardiac surgery is unknown. objectives: this study aimed to address whether frailty characteristics were associated with chronic pain after cardiac surgery in an older population. methods: this study was based on the anesthesia geriatric evaluation (age) and quality of life after cardiac surgery study, which included patients >= years undergoing elective cardiac surgery. preoperatively, frailty was tested in physical, mental and social domains. pain was evaluated with the short form questionnaire (sf- ) preoperatively and one year after surgery. multivariate logistic regression was used to investigate the association between frailty and chronic pain. change in health related quality of life (hrql) was analyzed to evaluate the impact of chronic pain. results: ( %) patients were included in the analysis. / patients ( %) reported new or increased pain one year after surgery. in patients ( %) at least one frailty characteristic was present and patients ( %) were frail in two or more domains. after adjustment for possible confounders in multivariate analysis, patients with single status and polypharmacy were at increased risk for new or increased chronic pain (aors . ( % ci . - . ) and . ( % ci . - . ). new or increased chronic pain was associated with a worse hrql (aor . ; % ci of . - . ). conclusion: frail patients are at risk for chronic pain and worse hrql after cardiac surgery. future research should focus on perioperative interventions to reduce chronic pain in elderly patients. background: frailty is a vulnerability state that is associated with negative outcomes such us falls, in-hospital admissions and mortality. many factors can contribute to the pathogenesis of frailty and nutritional status is playing and important role. that´s why undernutrition and frailty must be overview in older adults before surgical procedures in order to treat them earlier. objectives: identify the relationship between physical frailty and undernutrition in older adults undergoing elective abdominopelvic surgery in a general hospital in lima-perú. methods: this is a secondary database study from the original "physical frailty and adverse events in older adults undergoing elective pelvic abdominal surgery in a general hospital, lima-perú", it was realized between august and march , using validated face to face questionnaires. physical frailty was determined with fried criteria, undernutrition by mini nutritional assesment (mna). in adition, they also evaluated functional status and cognition. univariate models were performed, and logistic regression was done subsequently. results: older adult met inclusion´s criteria, the mean age was . (+ . ) years old, , % ( ) were female, , % ( ) had hypertension, , % ( ) were diabetic, the mean number of comorbidities were . (+ . ), , % ( ) had functional impairment, , %( ) had cognitive impairment. the mean bmi was . ± . . , % ( ) were underweight, . %( ) normal , . %( ) overweigth and . % ( ) obese. by mna % ( ) had risk or undernutrition, . % ( ) of them had functional impairment in contrast with , %( ) who weren´t at risk or undernutrition; p= . . also, . %( ) who had risk or undernutrition had cognitive impairment in contrast with . %( ) who weren´t at risk or undernutrition; p= . . by fried criteria, % ( ) were frailty, % ( ) prefrailty and , % ( ) robust. the frailty patients % ( ) had risk or undernutrition vs , %( ) in prefrailty and . %( ) in robusts; p= . . conclusion: there is an increased risk of undernutrition in frail older adults undergoing abdominopelvic surgery at a general hospital in lima, peru. background: cognitive frailty increases the risk of dementia, dependency and mortality in older people. moderatevigorous physical activity (mvpa) improves frailty syndrome and cognitive functions in older people, but being physically inactive is still prevalent. walking is the most common and inexpensive form of physical activity in older people and brisk walking is a form of mvpa. m-health has been successful in changing health behaviours in many populations. however, its effect in treating cognitive frailty through promoting mvpa in older people is not known. objectives: the aims of this study were to examine the effects and feasibility of an m-health intervention. methods: a pilot randomized controlled trial was employed. eligibility criteria include ) age > years, ) living in community, ) having cognitive frailty, and ) mobility at "outdoor walker" level. the study was conducted in community settings. subjects were recruited in the elderly community centres. subjects were randomized into either intervention or control at a : ratio. in the intervention groups, the subject received a smartphone pre-installed with physical activity tracking and social media applications. they received a course of brisk-walking in daily living training, health education, and a -week behavioural change intervention on the smartphone platform. in the control group, participants received a course of brisk-walking in daily living training, health education, and telephone follow-up. the outcomes were frailty (ffi), cognitive function (moca) and mvpa (actigraph). we targeted at recruiting totally subjects. nonparametric tests were used to compare the effects within and between groups. missing values were replaced by last observed values. results: this study recruited subjects (intervention: n= , control: n= ). significant improvements in frailty (p< . ), cognitive function (p< . ), and mvpa (p< . ) were observed in the intervention group after the completion of the intervention. only cognitive function was also observed to be improved in the control group (p< . ). the compliance of wearing devices (i.e., smartphones and actigraphs) and the usage of the smartphone applications were highly satisfactory. three subjects withdrew from the study (intervention: n= , control: n= ). conclusion: m-health intervention is feasible to treat cognitive frailty in older people. it is more effective to ameliorate frailty and increase mvpa in older people with cognitive frailty when compared to conventional training. background: the prevalence of dementia and associated healthcare cost increases with aging population. population health management and proactive screening with increased emphasis on primary risk reduction may reduce the overall prevalence of dementia. motoric cognitive risk syndrome (mcr) has been increasingly studied as a pre-dementia stage to identify older adults at risk of transiting to dementia while few studies explored the association between mcr and functional capabilities. objectives: the aims are to investigate the prevalence of mcr and its associated factors among community-dwelling older adult and also to examine possible impact of mcr on functional capabilities. methods: data for older adults aged above years old staying in northwest region of singapore was used. mcr was defined as slow gait speed over m ( sd below population mean) with subjective memory complaints in the absence of dementia. functional capability was determined by administering the lawton instrumental activities of daily living (iadls). differences in demographics, socioeconomic and lifestyle factors between mcr positive and mcr negative groups were found using independent t-test and chi-square test. risk factors of mcr and impact of mcr on functional capability were examined using logistic regression. results: the prevalence of mcr in the studied population was . %. after adjusting for demographics and socio-economic factors, indians (adjusted or = . , % ci = . - . , p = . ), increasing age (adjusted or = . , % ci = . - . , p < . ), higher bmi (adjusted or = . , % ci = . - . , p < . ) increased likelihood of mcr while increased years of education decreased likelihood (adjusted or = . , % ci = . - . , p = . ). the odds of having at least one impairment in iadl after adjusting for demographics, socio-economic and health factors amongst those with mcr were . (adjusted or = . , % ci = . - . , p = . ). conclusion: our study found in to have mcr, the pre-dementia stage. indian ethnicity, those with increased age and higher bmi are at greater risk of having mcr. as mcr is also associated with functional impairment, it can serve as a useful screening tool to identify those at risk of progressing to dementia. background: sleep disturbance has been found in older persons with dementia, which impact on the quality of life of older persons and on the caregiving burden of the family. little is known about the sleep patterns and sleep problems of older persons with dementia. exploring these data would provide basic information to develop interventions for this population. objectives: to explore sleep patterns and sleep problems in community-dwelling older persons with dementia. methods: the sample recruited by purposive sampling consisted of community-dwelling older persons with any stage of dementia who used healthcare services at outpatient departments of a university hospital, thailand. data were collected using a demographic data questionnaire, a sleep diary recorded by caregivers, and an electronic wrist activity tracker to assess sleep data for consecutive nights. the data had been collected for three months and were analyzed using descriptive statistics. results: the sample had an age range from to years (m= . , sd = . ). the total sleep data of the older persons with dementia consisted of episodes. almost all of the sleep data showed the polyphasic sleep pattern (sleeps for several periods of time a day), but a few had monophasic and biphasic sleep patterns. the total sleep time per night ranged from to hours with a mean of hours. the mean sleep latency was minutes, by which two-thirds of them had sleep latency less than minutes. three-quarters of the data woke up at night. the mean duration of waking up at night was minutes. two-thirds of the data had sleep problems, including insomnia, waking after sleep onset, and excessive daytime sleeping. also, most of them had snoring ( %), followed by sleep talking ( %). conclusion: the polyphasic sleep pattern was found mostly in older persons with dementia. also, they had sleep problems of insomnia at night and excessive sleeping during the daytime. healthcare providers may use the results from this study to understand the sleep patterns and then find strategies to promote the sleep quality of older persons with dementia. yumi umeda-kameyama , masashi kameyama , taro kojima , masaki ishii , shinya ishii , mitsutaka yakabe , kiwami kidana , tomohiko urano , , sumito ogawa , masahiro akishita (( ) department of geriatric medicine, the university of tokyo school of medicine, tokyo, japan; ( ) department of diagnostic radiology, tokyo metropolitan geriatric hospital and institute of gerontology, tokyo, japan; ( ) department of geriatric medicine, international university of health and welfare, narita, chiba, japan) background: «perceived age» of facial appearance in elderlies was shown to be a robust biomarker of aging that predicts survival, telomere length, and dna methylation. it is also reported to correlate with carotid atherosclerosis and bone status. objectives: this study aims to determine whether perceived age is a better biomarker than chronological age for a variety of aspects in dementia assessment, which includes general cognition, vitality, depressive state, and selfsupportability. methods: one hundred twenty-six patients admitted to the department of geriatric medicine, the university of tokyo hospital with suspect of cognitive decline were enrolled. mmse, vitality index, gds , iadl, and barthel index were performed. ten geriatricians and clinical psychologists determined the perceived age of subjects based on their photographs. results: the average values of rates showed excellent reliability (icc( , )= . ). perceived age showed significantly better correlation with mmse (female), vitality index (total, female), and iadl (total) than chronological age by steiger's test, but not with gds and barthel index. conclusion: perceived age was demonstrated to be a better biomarker for cognitive assessment than chronological age. l a u r a t a y , h u d a m u k h l i s , jolene ho , aisyah latib , eeling tay , shimin mah , candy chan , yeesien ng (( ) department of general medicine, sengkang general hospital, singapore; ( ) office of regional health system, singhealth, singapore; ( ) department of physiotherapy, sengkang general hospital, singapore; ( ) dietetics, sengkang general hospital, singapore) background: cognitive frailty is characterized by co-existence of physical frailty and cognitive impairment. earlier studies reported aggravated health outcomes attributable to cognitive frailty over physical frailty alone. objectives: we examine risk factors for cognitive frailty, and its impact on physical performance and health outcomes, compared with isolated occurrence of cognitive impairment or physical frailty. methods: cross-sectional analysis of communitydwelling older adults who completed multi-domain geriatric screen assessing for social vulnerability, mood, cognition, functional performance, nutrition, physical frailty (frail) and sarcopenia (sarc-f). cognitive impairment was defined using locally validated education-adjusted cut-offs on modified-chinese mini-mental state examination. participants underwent physical fitness tests comprising grip strength, gait speed, lower limb strength and power, flexibility, balance, and endurance. health outcomes included hospitalization, emergency department visits, falls and self-rating of health. each participant was categorized as robust-cognitive intact (pf--/ ci-), pre-frail/ frail only (pf+/ ci-), cognitive impaired only (pf-/ ci+), and cognitive frailty (pf+/ ci+). results: mean age of study cohort was . ( . )years. ( . %) were pf-/ci-, ( . %) pf+/ci-, ( . %) pf-/ci+, and ( . %) pf+/ ci+. in multi-nomial logistic regression referenced to pf-/ci-, older age significantly increased risk for pf-/ci+ and pf+/ci+. cognitive frailty contributes to worse physical performance and poorer health outcomes compared to physical frailty and cognitive impairment in isolation. while social vulnerability and depression were differentially associated with isolated frailty status, malnutrition and sarcopenia should be targets for preventing frailty and cognitive impairment. osamu katayama, sangyoon lee, seongryu bae, keitaro makino, ippei chiba, kenji harada, yohei shinkai, hiroyuki shimada (department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, japan) background: cognitive frailty is a condition recently defined by operationalized criteria describing coexisting physical frailty and mild cognitive impairment (mci). however, there is no consensus on the definition of cognitive frailty for use in clinical and community settings. objectives: this study aimed to use latent class analysis (lca) to discover potential subtypes of cognitive frail older people. in addition, we explored the relationship between the identified cognitive frailty subtypes, and their demographical, neuropsychological, body composition, and lifestyle activity characteristics. methods: a total of community-dwelling older adults aged >= years participated in the study. we characterized physical frailty as >= of the following criteria: slow walking speed, muscle weakness, exhaustion, low physical activity, and weight loss. we used tests of word list memory, attention, and executive function, and processing speed to screen for cognitive impairment. the presence of >= cognitive impairments were defined as mci. we defined the condition where physical frailty and mci coexist as cognitive frailty. lca was applied to characterize classes or subgroups with different cognitive frailty phenotypes. subsequently, we performed multinomial logistic regression analysis with cluster membership as dependent variable and dichotomized demographics and lifestyle activity characteristics as independent variables. results: lca identified eight distinct subgroups included three different cognitive frailty phenotypes: cognitive frailty composed of physical frailty and amnestic mci (acf), cognitive frailty composed of physical frailty and non-amnestic mci (nacf) and, cognitive frailty in which physical frailty and global cognitive impairment (gcf). cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. in particular, the acf cluster was associated with younger age and also related to the inactivity of productive and cognitive activities (p< . ). the nacf cluster was related to the inactivity of social and cognitive activities (p< . ). finally, the gcf cluster was associated with older age (p< . ). conclusion: using lca, we identified eight distinct subgroups included three different cognitive frailty phenotypes in a large sample of community-dwelling older adults. cognitive frailty subtypes were associated with distinct demographical, neuropsychological, and lifestyle activity characteristics. sara g aguilar navarro, alberto j mimenza alvarado, itzel aparicio gonzález, clarita cabrera juárez, alejandra samudio cruz, monsal alexa, ja avila funes, teresa juarez-cedillo (instituto nacional de ciencias médicas y nutrición salvador zubiran, ciudad de méxico, mexico) background: the prevalence of mild cognitive impairment (mci) ranges between - % and is times more frequent than dementia. the dcl has been associated with cardiovascular risk factors, mainly changes at the executive level. the apoe genotype, on the other hand, is a gene that confers susceptibility to alzheimer's disease in addition to participating in lipid metabolism, giving greater risk of atherosclerosis and cardiovascular risk. however, given the genetic heterogeneity of the mexican population, this association is not clear. objectives: to establish the strength of association between the different types of dcl (amnesic and non-amnesic) in mexican mestizo older adults according to their carrier status of the apoe allele and cardiovascular risk factors. methods: patients in a memory clinic were evaluated from to , older than years, without sensory deficit, psychiatric diseases or uncontrolled metabolic pathology, separating them into mutually exclusive groups: healthy controls, group with amnesic mci, group with nonamnesic mci, performing geriatric and neuropsychological evaluation. parametric and nonparametric statistics (x , anova, multivariate linear regression analyzes) were used to find statistical differences between groups. results: multivariate linear regression analyzes were performed to examine the relationship between vascular risk factors, the presence of the apoe ε allele, and cognitive change. apoe genotype significantly modified the associations between both hypertension and cardiovascular disease and a decline in language abilities as well as diabetes and decline in verbal memory, attention, and visuospatial abilities in non-amnestic mci. associations between increased vascular risk burden and greater cognitive decline were observed among apoe ε carriers but not non-carriers with mci. conclusion: the present study revealed an increase in the association between non-amnestic mci (apoe ε carriers with vascular risk factors) and suggests that the treatment of vascular risk factors could contribute to reducing the risk of progression of cognitive impairment, particularly among patients with apoe ε mexicans. background: a number of cross-sectional and longitudinal studies have demonstrated an association between physical frailty and cognitive impairment ( ). many mechanisms have been suggested to explain the presence of cognitive impairment in frail subjects, such as cardiovascular risk, hormonal disturbances, chronic inflammation or nutrition ( , ). another hypothesis is that cognitive impairment in frail patient may be due to alzheimer's disease (ad) ( , , ). however, the link between frailty and amyloid deposition has to date never been studied in vivo. objectives: ( ) to examine the prevalence of cerebral amyloid pathology as measured with amyloid positron emission tomography (pet) or amyloid-β- - level in cerebrospinal fluid, among frail and pre-frail individuals presenting an objective cognitive impairment ( ) to characterize the cognitive and clinical progression of frail cognitively impaired patients according to the amyloid status. methods: cogfrail is a monocentric observational prospective study of cognitive frail and prefrail older participants (according to fried criteria), aged >= years, with an objective cognitive decline (defined by a clinical dementia rating (cdr) scale scoreat . or ). the participants will be followed up every months, during years. in addition to cerebral amyloid pathology (measured by amyloid positron emission tomography (pet) or amyloid-β- - level in cerebrospinal fluid), measurements include cognitive performance, physical function, nutritional status, depressive symptoms biology, nutrition, magnetic resonance imaging (mri), and body composition to better understand the mechanisms and progression of cognitive frailty. results: the study is currently being recruited. to date, patients were included. mri pet scan and lumbar puncture have been performed. subjects completed the study. conclusion: this study will allow us to determine, for the first time, the prevalence of amyloid pathology, a marker of ad, among frail and pre-frail patients presenting objective memory impairment. the results will help characterize the cognitive decline in frail and pre-frail patients, with important implications for the detection, management and ultimately prevention of neurocognitive disorders among frail old individuals references: ) kojima g, taniguchi background: cognitive impairment is a well-known risk factor for falls in older adults. the risk of falls is increased in those with diminished executive function and reduced processing speed. while participants with cognitive deficits are more prone to falling, it is unknown whether risk of falling on cognitively intact individuals placing them at higher risk for future cognitive decline. objectives: to ascertain the incident development of cognitive decline in those at higher risk for falls using the center for disease control's fall risk assessment tool, steadi (stop elderly accidents, deaths, and injuries) in community dwelling individuals > years of age. methods: we identified individuals >= years old using the longitudinal national health and aging trends study (nhats) that consists of eight years of follow-up. these individuals did not have cognitive impairment at baseline. fall risk was defined using the algorithm from the center for disease control's steadi initiative. participants were classified at baseline in three categories of fall risk (low, moderate, severe). impaired global cognition was defined as nhats-defined impairment in either the alzheimer's disease- score, immediate/delayed recall, orientation, clock-drawing test, or date/person recall. the primary outcome was the risk of incident cognitive impairment over time. cox-proportional hazard models and linear mixed-effects modeling ascertained the incidence of cognitive impairment, adjusting for age, sex, smoking status, education, co-morbidities and an ability to walk. our referent variable was individuals at low steadi fall risk. results: of the , participants ( . % female), median age category was - years. prevalence of baseline fall risk using the steadi measure in participants was low ( . %), medium ( . %) and high ( . %). the rate of cognitive impairment in our sample was . %. in our fully adjusted model, the risk of developing cognitive impairment was hr . [ %ci: . - . ] in the intermediate risk group, and hr . [ %ci: . - . ] in the high risk group. using linear mixed-effects modeling yielded similar results. conclusion: steadi fall risk at baseline was predictive of higher rates of cognitive decline in those with normal cognition. elevated fall risk by steadi may suggest need for more thorough cognitive assessment. background: the concept of cognitive reserve (cr) has been developed as a potential factor able to describe individual differences in vulnerability to cognitive, functional, or clinical decline along aging. the progressive reduction of cognitive and functional performances represents an outcome commonly associated with aging. objectives: the aim of this crosssectional study is to investigate the association of cr with cognitive and functional outcomes in a sample of elderly outpatients. methods: subjects aged >= were consecutively recruited. patients who were unable to undergo the execution of required tasks due to severe cognitive, functional or sensory impairment were excluded. mini mental examination (mmse), brief intelligence test (tib) and cognitive reserve index questionnaire (criq) were administered. handgrip strenght, gait speed and daily life autonomy were measured; a frailty index (fi) was eventually calculated. results: data from patients were analyzed. criq was significantly correlated with mmse (r = . , p < . ), handgrip (r = . , p < . ) and gait speed (r = . , p= , ). furthermore, criq was correlated with badl (r = , , p= , ), iadl (r= , , p= , ) and inversely with fi (r= - . , p < . ). significant correlations were found between tib and mmse (r = . , p < . ), between tib and criq (r = . , p < . ), and between tib and iadl (r = , , p= , ). conclusion: this preliminary report highlighted that patients with higher cr showed not only better overall cognitive functioning, but also better functional status and a lower degree of frailty. in the light of a multidimensional geriatric assessment, the integrative evaluation of cr in elderly might offer the opportunity to track possible trajectories of aging, since it appeared related either to cognitive status, either to functional oucomes and to frailty. background: the clinical syndrome of "physical" frailty has been conceived without regard for cognitive decline. nevertheless, it has been suggested that frail elders exhibit frailty-specific cognitive impairments, and that the cognitive correlates of frailty may be dementing in their own right. meanwhile, we have used confirmatory factor analysis (cfa) in a structural equation model (sem) framework to construct a latent dementia phenotype, "δ". our approach is modular and can be redirected to other clinical targets. objectives: in this analysis, we create a δ ortholog representing the "cognitive correlates of frailty" (df). methods: first, we constructed a frailty index (if) from wave- data collected as part of the hispanic established population for epidemiological studies in the elderly (h-epese). a δ ortholog targeting if was then constructed from a cognitive battery that included the mini-mental status exam (mmse) and clox: an executive clockdrawing task (clox). results: the model fit the data well and df exhibited factor determinance. dfrailty was strongly indicated (r = . , p< . ) by if and explained % of the index's variance. it was also significantly indicated by mmse and clox scores. df was strongly correlated (r = . , p< . ) with instrumental activities of daily living (iadl), independently of age, gender and education. the remaining % of if's variance had no significant association with iadl. the orthogonal latent variable "g'", df's residual in spearman's general intelligence factor "g", was strongly indicated by all three cognitive performance measures. nevertheless, it was weakly associated with iadl. measure specific cognitive performance, residual to both df and g', had no independent: association with iadl. conclusion: these results suggest that the frailty syndrome does indeed have specific cognitive correlates. these are strongly associated with iadl and therefore potentially "dementing". like δ, the cognitive correlates of frailty are extractable from spearman's g, which may constrain the biology and psychometric properties of frailty-specific cognitive changes. independently of df, cognition has little association with iadl. this suggests that frailty may be a major determinant of iadl performance in elderly ma, and possibly a major etiology of "all cause" dementia in that population. background: cognitive-frailty has been proposed as a distinctive entity which preludes dementia. objectives: we aimed to examine the relationship between physical frailty, cognitive status, and gait performance as predictors of cognitive decline and incident dementia. methods: cohort study of community older adults free of dementia at baseline with a year follow-up. inclusion criteria: > years, english speaking, able to ambulate one city block. exclusion criteria: hip/knee joint arthroplasty in past months, parkinsonism, major depression, and diagnosis of dementia (dsm-iv criteria). cognition was assessed using the moca, the mmse, and the clinical dementia rating (cdr) scale was performed. physical frailty was defined using the phenotypic criteria described by fried and walston. cognitive-frailty was defined as the simultaneous presence of physical frailty with objective cognitive impairment, and absence of concurrent dementia. the main outcome measure was all-cause dementia (dsm-iv criteria). cox proportional hazards models were used to estimate the risk of cognitive decline and incident dementia. results: over a -year follow-up, participants experienced cognitive decline and participants progressed to dementia (global incidence rate (ir): per -person/y). participants with frailty had a higher prevalence of cognitive impairment ( %) compared to those without ( %, p= . ) but the risk of progression to dementia was not significant. adding cognitive impairment to the frailty phenotype (cognitive-frailty) predicted further cognitive impairment and progression to dementia. dementia ir for frailty was per person/y and for cognitive-frailty, per person/y. however, when slow gait was combined with baseline cognitive impairment, it showed the highest risk of progression to dementia (hr: . , %ci: . - . ; p = . ) with an ir of per person/y. conclusion: frailty and cognitive impairment are common and often coexist in the same individuals. however, slowing gait seems to be the frailty component driving the association with future dementia. background: assisted bathing requires the most hours of home care. for the frail elderly and their caretakers, the bathroom presents the most risk factors for falls and injury. bathroom adaptation is the primary reason for consultation in community occupational therapy and available resources cannot meet the increasing demand. the hygiene . (h . ) website (https://algo.grismoir.com/) addresses this need by offering a structured questioning to identify bathing assistive technology for the frail elderly living at home. objectives: our actionresearch protocol aims to establish a partnership between actors in the home care social economy enterprises (eÉsad), the home care programs offered through the healthcare system and the private sector (e.g., assistive technology providers). this implies: ) adapting h . to the home care service workers' needs; ) designing an implementation model for h . in order to formalize a partnership in the community; ) conducting pilot testing in two eÉsad. methods: ) user-centered design and a multiple case study where a case represents a home care worker (n= ) from a eÉsad (québec, canada) offering bathing assistance for the elderly. during testing, the home care worker will explore the h . prototype with an elderly in his or her home, sharing their thoughts out loud. the unit of analysis is the usability of h . , allowing improving to the prototype after every three participants. ) all collaborators will participate in the iterative modification of a preliminary logic model for the implementation of h . . modifications suggested will be integrated to the model throughout three meetings, or until a consensus is reached. ) the adapted version of h . (obj. ) will be tested according to the implementation model developed (obj. ). a pilot project using mixed methods in collaboration with two eÉsad will be conducted with older adults having difficulty bathing. results: anticipated results: responsive h . website adapted to the users' needs, an implementation model and pilot data allowing scaling-up technology meeting needs of frail elderly and their caretakers issues during bathing. li-ning peng , , , fei-yuan hsiao , , , wei-ju lee , , , shih-tsung huang , liang-kung chen , , ( ( ) background: the theory of cumulative deficits using big data to develop the multimorbidity frailty index (mfi) has become a widely accepted approach in public health and healthcare services. however, constructing the mfi using the most critical determinants and stratifying different risk groups with dose-response relationships remain major challenges in clinical practice. objectives: this study aimed to develop the mfi by using machine-learning methods that select variables based on the optimal fitness of the model and to further establish four entities of risk using a machine-learning approach as well as to ensure the dose-response relationship and the best distinction between groups. methods: in this study, we used taiwan's national health insurance research database to develop a machine-learning multimorbidity frailty index (ml-mfi) using the theory of cumulative diseases/deficits of an individual older person. compared to the conventional mfi, in which the selection of diseases/deficits is based on expert opinion, we adopted the random forest method to select the most influential diseases/deficits that predict adverse outcomes for older people. to ensure that the survival curves showed a dose-response relationship with overlap during the follow-up, we developed the distance index and coverage index at any time point to classify the ml-mfi of all subjects into the categories of fit, mild frailty, moderate frailty and severe frailty. survival analysis was conducted to evaluate the ability of the ml-mfi to predict adverse outcomes, such as unplanned hospitalizations, intensive care unit (icu) admissions and mortality. results: the final ml-mfi model contained diseases/deficits in this study. compared with conventional mfi, both indices had similar distribution patterns by age and sex; however, among people aged - , the mean mfi and ml-mfi were . (standard deviation (sd) . ) and . (sd . ), respectively. the difference may result from discrepancies in the diseases/deficits selected in the mfi and the ml-mfi. a total of , subjects aged to years were included in this study and were categorized into groups according to the level of the ml-mfi. both the kaplan-meier survival curves and cox models showed that the ml-mfi significantly predicted all outcomes of interest, including all-cause mortality, unplanned hospitalizations and all-cause icu admissions, at , and years of follow-up (p< . ). in particular, a doseresponse relationship was revealed between the four ml-mfi groups and adverse outcomes. conclusion: the ml-mfi consists of diseases/deficits that can successfully stratify risk groups associated with all-cause mortality, unplanned hospitalizations and all-cause icu admissions in older people, which indicates that precise, patient-centered medical care can be a reality in an aging society. to return home. understanding the home environment prior to discharge is crucial. occupational therapists (ots) often depend on client's verbal descriptions, pictures and sketches when planning rehabilitation exercises and suggesting adaptations. the information obtained is therefore partial. mapit is a new mobile application which scans a room producing a d representation with virtual measurements of environmental elements. this could provide a more complete representation of the home needed by inpatient rehabilitation ots. objectives: to target mapit's clinical applications for inpatient rehabilitation of the frail elderly. methods: multiple case study where mapit was introduced in three inpatient geriatric rehabilitation units over days. five ots maintained a logbook and participated in four individual semi-structured interviews. a deductive thematic analysis of the logbooks and interview transcripts was corroborated by two additional ots. results: mapit is useful for ots in rehabilitation settings by allowing them to ) see it: see the home environment, ) measure it: take measurements of desired environmental elements, ) document it: have a copy of the environment on hand, ) communicate it : facilitate exchanges with the client and with colleagues. with mapit, ots gain a better understanding of the environment, which informs the rehabilitation intervention. better communication could also improve the client's implementation of the therapeutic strategies. conclusion: mapit is a useful resource to optimise intensive rehabilitation for the frail elderly. sonia jiménez-mola , javier idoate-gil , david idoate , maría plaza carmona (( ) geriatric department, complejo asistencial universitario, león, spain; ( ) university of salamanca, salamanca, spain; ( ) urgency department, complejo asistencial universitario, león, spain) background: as the age of the population increases, the incidence of osteoporosis and its direct consequence, fragility fractures, are also increasing. hip fractures are associated with the greatest number of complications, functional deterioration, and mortality of up to % one year after the fracture. objectives: the aim of this study is to determine the prevalence of previous diagnosis of osteoporosis in elderly patients who suffer hip fracture and its relationship with age distribution ( - , - and > years old), gender, type of fracture and funtionality. methods: we enrolled patients with hip fracture, aged years or older in an orthogeriatric unit between december and november . underwent comprehensive geriatric assessment that evaluates comorbidities, medication use, ability to perform basic activities of daily living, place of residence, anesthesia risk as measured by the asa score, type of fracture, type of surgery and anesthesia and in-hospital mortality. spss®, v. . . results: the mean age was . ± . years ( - years). . % female. % pertrochanteric fractures. ( %) underwent surgery. only . % received general anesthesia. % walked independently, % had barthel > , ( %) had a previous diagnosis of dementia, and % live in nursing home prior to fracture. we found a previous diagnosis of osteoporosis in patients ( . %). in these patients, statistically significant differences were shown for sex p< . ( . % female vs . % male), age distribution p< . ( . %( - ) vs . % ( - ) vs . % (> ) and the presence of anti-osteoporotic treatments p< . . all other measurements (barthel index, cognitive degree, type of fracture, asa score and type of surgery, did not show statistically significant differences (p>. ). conclusion: patients in very advanced age showed neither significantly higher percentage of diagnosed osteoporosis, not significantly higher amount of preexisting osteoporosis-related medication. although the prevalence of osteoporosis increases with age, the diagnosis and treatment prevalence decreased in higher age groups. background: aging is associated with a decrease in bone density, muscle mass and a gain in fat mass which increase physical disabilities and falls. nevertheless, the impact of obesity on bone density and architecture is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle and physical function, but also with bone density and architecture. however, the role of initial protein intake in osteopenic-obese older adults is still unclear. objectives: to examine the influence of initial protein intake on muscle and bone function in osteopenic-obese older adults. methods: cross-sectional a-posteriori matched study design. fourteen obese (total fat (%): men > ; women: > ) osteopenic (bmd t-score <- . ) older adults (age > years old) were divided in groups according to their initial protein intake (prot-(n= ): < g/kgbw/d or prot+ (n= ): > . g/ kgbw/d) and were matched for age (± years) and gender. body composition (fat, fat-free and bone masses, dxa), muscle composition and bone architecture (qpct), muscle function (grip strength, knee extension strength, muscle power), physical performance (walking speed ( m), tug ( m), unipodal balance, stair and chair tests), cardiorespiratory function ( min walking test) and lifestyle habits (physical activity level: -axial accelerometer and nutritional status: food record) were assessed. results: our groups (prot-vs. prot+) were similar (p> . ) in terms of age ( . ± . vs. . ± . years), bmi ( . ± . vs. . ± . kg/m ), body fat (total(%): . ± . vs. . ± . ), muscle quantity (fat-free mass or limb muscle area) and quality (intra & submuscular adipose tissues), bone density (total hip or spine) and architecture (marrow, cortical or total area, and compressive or torsion strength), physical performance (walking speed(m/s): . ± . vs. . ± . ), cardiorespiratory function, lifestyle habits (steps: ± vs. ± ), except (by design) for the initial amount of protein intake ( . ± . vs. . ± . g/kgbw/d) respectively. conclusion: the initial protein intake does not seem to influence bone architecture, muscle function, or physical performance in elderly osteopenicobese. obesity but also the level of protein intake above the official recommendation (> . g/kgbw/d) could explain these conclusions. thus, future studies are needed to confirm our preliminary results. background: the glim definition of malnutrition is the first intended to be used globally. glim uses five criteria (two phenotypic and three etiologic) for the diagnosis of malnutrition, which is made when at least one etiologic and one phenotypic criterion are present. mna-sf is a validated widespread screening tool used in geriatric settings. glim and mna have not been compared in acute geriatric care. objectives: to measure the prevalence of malnutrition in older patients admitted to an acute geriatric unit using glim criteria and to assess the accuracy of the mna-sf in predicting glim defined malnutrition. methods: a prospective study was conducted among all patients older than years old admitted to an acute geriatric unit. end-of-life situations and wearers of pacemakers were excluded. glim criteria and mna-sf were assessed on admission. muscle mass (one of the glim criteria) was estimated by bioimpedance (thresholds for low muscle mass: < . kg in men; < . kg in women). results: patients were included (mean age . ± . years, % women). on admission, . % were malnourished according to the glim criteria ( . % met at least one etiologic criterion, . % met at least one phenotypic criterion). . % were malnourished using mna-sf. however, there was no correlation between glim and mna-sf (correlation coefficient r=- . , p= . ). mna-sf had low sensitivity ( . %) and low specificity ( . %) to detect malnutrition diagnosed with the glim criteria (roc curve auc= . ). conclusion: more than half of the very old patients admitted to an acute geriatric unit were malnourished according to the glim diagnostic criteria. a very similar proportion of patients had a mna-sf suggesting malnutrition. however, mna-sf had a low reliability to detect patients with glim defined malnutrition. corina naughton , rachel simon , tj white , darren daly ( ( ) background: hospitalised older adults are at risk of hospital associated decline (had). optimising nutrition intake is an important modifiable factor in protecting against had and promoting recovery, but food intake and the quality of mealtimes are frequently overlooked nursing activities. objectives: the study aim was to undertake an in-depth analysis of mealtime practices and to identify patient and mealtime factors associated with low food intake (<eating % of meal provided). methods: we carried out structured observation of mealtimes using a validated tool examining patient positioning, mealtime set up and assistance. the primary outcome was food consumption categorised as , %, % % or % based on visual inspection of food trays. data were also collected on patient characteristics. data analysis used descriptive statistics and univariate logistic regression to examine the association between low food intake and mealtime and patient factors. results: we included mealtime observations on patients aged years and older. at % (n= ) of meals, patients ate half or less of the food provided. meal time factors with a weak association with low intake were: allocated red tray (an indicator of nutrition risk), modified diet, and needing assistance. breakfast time was the most important meal for food intake. nearly half of the patients ( / ) ate % or less of the food provided on two or more occasions over a -hour period. patient frailty and a moderate to high nutrition risk score were independently associated with low food intake. conclusion: patient factors are the strongest predictors of low food intake. increasing the quality of the mealtime experience and more tailored nutrition plans could improve nutrition intake in frail older adults. were hospitalized at least once, ( . %) fell at least once, and ( . %) had at least one fracture during the -year follow-up. no association was found between malnutrition and -year risk of institutionalization, hospitalization, falls, or fractures (p> . ). conclusion: malnutrition according to glim criteria was associated with a . -fold higher mortality risk; double that of the espen criteria, during a -year followup. no association was found between malnutrition according to these two criteria and incidence of other adverse health consequences. glim criteria anticipate outcome and might guide interventions, with important implications for clinical practice and research. background: older adults are at high risk of developing cardiovascular disease. pre-clinical studies indicate that resveratrol (rsv), a polyphenol present mostly in grapes and red wine, may prevent development of cardiovascular disease. objectives: our hypothesis was that rsv will reduce biomarkers of cardiovascular disease risk in obese, rather healthy older adults in a dose-dependent manner. methods: older participants ( years and older) were randomized to a day rsv treatment with mg (n= ), mg (n= ) or placebo (n= ). we measured levels of atherosclerosis development risk biomarkers i.e. oxidized low-density lipoprotein (oxldl), soluble e-selectin- (se-selectin), soluble intercellular adhesion molecule- (sicam- ), soluble vascular cell adhesion molecule- (svcam- ), total plasminogen activator inhibitor (tpai- ). statistical significance was set at p< . . results: changes in svcam- mg vs. mg vs. placebo: (- . ± . ng/ml vs. . ± . ng/ ml vs. . ± . ng/ml) and tpai- mg vs. mg vs. placebo (- . ± . ng/ml vs. . ± . ng/ml vs. . ± . ng/ ml) indicate significantly higher levels in a mg group compared to a mg and a placebo groups. other biomarkers ( mg vs. mg vs. placebo: oxldl, seselectin- and sicam- ) followed the same trend toward higher levels in the mg group compared to the mg and placebo groups, without reaching statistical significance. conclusion: this pilot project suggests that a higher dose of rsv may increase the levels of cardiovascular disease risk biomarkers in overweight older adults. given no change in the cardiovascular disease risk biomarkers in response to a lower dose, future studies should test the effects of different doses of rsv on reduction of cardiovascular disease biomarkers in overweight, rather healthy older adults. background: actual nutrition is a factor that continually effects physiological capacity and workability, the functional aging rate of an elderly persons. objectives: the purpose of this study was to determine the relationship between nutrition and physiological abilities, the work performance, functional aging rate, residual working capacity and frailty of the elderly. methods: it has been studied anthropometric and functional parameters of respiration, physical performance, mental capability, sensory skills, as well as the rate of functional aging in different aging groups: - years - persons, - years - persons, - years - persons. we have also analyzed the professional history, social status, and factual nutrition (according to the questionnaire proposed by the who and adapted for ukraine) of the elderly. results: the nutrition or diet factors influence on the problems dealing with working capability, reduction of the hand grip strength and endurance, independence and frailty (for elderly) in overall . % for all mentioned factors. right and left hand grip strength associate with protein consumption (r = . ; r = . ; p < . accordance) with variety of cereals (r =- . ; r =- . p < . accordance) also with variety of vegetables (r = . ; r = . ; p < . accordance)variety of fruits (r = . ; p < . ; r = . ; p < . accordance). it was studied features of an actual food at centenarians of ukraine which not only have lived to this old age, but also have the relatives who have lived to age of centenarians. it was established, that meals of ukrainian centenarians include high percentage of vegetables, fruits and dairy products. meanwhile menu has been deprived practically all basic alimentary pathology risk factors which accelerates biological age, creates certain preconditions to preservation of health and longevity. conclusion: as a result of a comprehensive study and mathematical modeling was developed a quantitative method for assessing the residual working capacity for elderly persons. background: age-related decline in olfactory function has implications for health and nutrition due to reduced appetite and decreased sensory perception of food. several studies have investigated olfactory performance in the elderly, but studied mostly single odour components often less related to food and meals. food odours are composed of multiple odorants and compensation for specific perceptual losses among elderly may occur. therefore, it is relevant to study olfactory perception of complex food odours to improve understanding of odour perception in the context of foods and meals. objectives: to develop a test method to screen young and elderly ( +) subjects on their olfactory capacity for everyday food odours. the method included a series of sniffing sticks with relevant and familiar complex food odours from primarily essential oils. methods: the olfactory sniffing sticks test kit was developed in four steps: ) selection and validation of relevant, familiar and diverse food odours, evaluated on perceived familiarity. ) standardization of an iso intensity reference level for the food odours in relation to n-butanol. ) assessment of shelf-life stability for the sniffing sticks within an weeks period. ) evaluation of test-retest reliability for intensity and identification of the odours within a weeks period. results: food odours were selected due to their diverse sensory characteristics. they were provided from a french manufacturer which may have compromised the familiarity in a danish context as only out obtained satisfactory familiarity score. however out showed reliable results in a test-retest procedure. n-butanol, in two concentrations provided a satisfactory reference frame for the iso intensity scaling. furthermore the food odours were overall shelf-life stable within an weeks period. conclusion: a new odour test kit for everyday food odours was developed and validated for screening olfactory capacity (intensity perception, familiarity and identification) in elderly subjects. based on the evaluations, odours were included in the final test kit. this olfactory test reflects the complex stimulation of the olfactory system, when stimulated by eating a food, compared to odour test kits with single or few components which makes it relevant when customizing of meals for elderly to improve nutrition and wellbeing. background: nordic nutrition recommendations (nnr) ( ) suggest protein intake >= . g/kg body weight (bw) to preserve physical function in nordic older adults. however, no published study has used this cut-off to evaluate the association between protein intake and frailty. objectives: this study examined associations between protein intake, and sources of protein intake, with frailty status at the -year follow-up. methods: participants were women aged - years enrolled in the kuopio osteoporosis risk factor and prevention -fracture prevention study. protein intake g/kg bw and g/d was calculated using a -day food record at baseline . at the -year follow-up ( ), frailty phenotype was defined as the presence of three or more, and prefrailty as the presence of one or two, of the fried criteria: low grip strength adjusted for body mass index, low walking speed, low physical activity, exhaustion was defined using a low life satisfaction score, and weight loss > % of bw. the association between protein intake, animal protein and plant protein, and frailty status was examined by multinomial regression analysis adjusting for demographics, chronic conditions, and total energy intake. results: at the -year follow-up women were frail and women were prefrail. higher protein intake >= . g/kg bw was associated with a lower likelihood of prefrailty (or= . and % confidence interval (ci) = . - . ) and frailty (or= . and ci= . - . ) when compared to protein intake < . g/kg bw at the -year follow-up. women in the higher. conclusion: protein intake >= . g/kg bw and higher intake of animal protein may be beneficial to prevent the onset of frailty in older women. background: sarcopenia is a geriatric syndrome with increasing importance due to the aging of the population. progressive resistance training and protein supplementation are currently recommended for the prevention and treatment of sarcopenia. however, elderly are less responsive to these anabolic stimuli compared to healthy adults. inflammation is considered an important contributor to this age-related anabolic insensitivity. therefore, anti-inflammatory strategies, such as omega- , are a promising strategy to combat sarcopenia. furthermore, omega- were also shown to improve muscle anabolism though activation of the mtor signalling pathway and reduction of insulin resistance. objectives: firstly, we performed a narrative review of literature that gives an overview of the current knowledge about omega- intake and sarcopenia defining parameters (grip strength, gait speed, muscle strength or physical performance). secondly, we provided an overview of data on omega- supplementation and sarcopenia defining parameters. methods: a literature search was conducted in november , using electronic bibliographic databases (pubmed and embase). the reference lists of all full texts retrieved during the search process or as identified in already published (systematic) reviews were scanned. results were published in a narrative review (dupont j. et al. aging clin exp res.) results: seven observational studies described the associations between omega- intake and sarcopenia defining parameters. four interventional studies looked at the effect of omega- supplementation alone and suggested an improved muscle protein synthesis, improved gait speed and increased muscle strength and physical performance. three studies combining exercise with omega- supplementation suggested an enhancing effect of the supplement on the exercise-induced gains in muscle mass and strength. we found one study combining omega- and protein supplementation with exercise, but omega- dosage was too low for conclusive results. conclusion: observational data on omega- intake and sarcopenia remain conflicting. from current interventional data we conclude that there is growing evidence for a beneficial effect of omega- supplementation in sarcopenic elderly, which may add to the effect of exercise and/or protein supplementation. however, the exact dosage, frequency and use (alone or combined with exercise and/or protein supplementation) in the treatment and prevention of sarcopenia still need further exploration. background: with the growing incidence of cancer in older persons, malnutrition rates have increased. tumor-related malnutrition is a risk factor of treatment side effects. it reduces the quality of life and increases morbidity and mortality. therefore, malnutrition screening and diagnosis are mandatory to implement proper nutritional support. objectives: this study aimed to evaluate and compare the short form of mini nutritional assessment (mna-sf) nutritional screening tool with the new global leadership initiative on malnutrition (glim) diagnostic criteria for malnutrition among elderly patients with cancer. methods: patients >= years old, with a g screening tool ≤ , were referred to an oncogeriatrics consultation between february and september . the data recorded comprehended, demographic variables (age, sex), type of tumor, functional (barthel, lawton index, fac) and mental (mmse, yesavage) status, nutritional (mna-sf, glim criteria) and social assessment and number of drugs. if-vig, cirs-g, rockwood-ms, cci-sf, sppb and handgrip strength were used to estimate frailty. the roc curve was used to evaluate the ability to accurately distinguish malnourished patients. to determine diagnostic concordance between the assessment and the new glim diagnostic criteria of malnutrition, retrospectively analyzed, cohen's К statistic was calculated. results: patients were included, mean age . ± . , . % were women. gastrointestinal ( . %) and gynecological ( . %) neoplasms were most prevalent. . % were independent or had mild dependence on badl, . % on iadl. . % had no cognitive impairment and . % had no depressive symptoms. frailty scales showed a pre-frail patient profile, with good social support and a . ± drugs on admission. according to the new glim diagnostic criteria for malnutrition, % of the patients were malnourished. with the use of mna-sf, . % of the patients were found to be at risk of malnutrition. the roc curve of mna-sf had an area under the curve (auc) of . . no concordance was found between the mna-sf and the malnutrition diagnostic results (К= , p< . ). conclusion: in this small sample, most cancer patients were male, > years old, with low frailty index, good functional and mental status and at risk of malnutrition. the mna-sf scale detected more risk cases so preconditioning and nutritional recommendations before specific oncological therapies could be made. concentration is associated with muscle mass and strength in healthy elderly. however, there are several confounders, including body composition, nutrient intake, physical activity level and blood parameters which may also influence muscle mass. previous studies have not thoroughly examined the relationship between serum (oh)d concentration and muscle indices by comprehensively considering the potential confounders in healthy elderly. objectives: the purpose of this study was to investigate the relationship of serum (oh) d concentration with muscle mass and strength in healthy japanese elderly. methods: this cross-sectional study included healthy elderly in shiga prefecture in japan (age: . ± . years, m = , w = ). total fat-free mass (tffm) and appendicular (affm) were measured using dual-energy x-ray absorptiometry. in addition, handgrip strength and leg extension power were measured. a blood sample was collected in an overnight fasted state, and serum (oh)d concentration was assessed. habitual dietary intake and physical activity were assessed. protein intake, carbohydrate, and vitamin d intakes were adjusted for energy by the residual method. association of serum (oh)d concentration with tffm, affm, handgrip strength, and leg extension power was assessed by hierarchical multiple regression analysis with adjustment for age, gender, weight, energy, energy-adjusted protein, carbohydrate, vitamin d intakes, serum albumin concentration, and physical activity. results: the mean serum (oh)d concentration of participants was . ± . nmol/l. low serum (oh)d status (< nmol/l) was observed in . % ( / ) of participants. the mean affm was . ± . kg, and handgrip strength was . ± . kg. serum (oh)d concentration was significantly associated with affm (β = . , p = . ), but not with tffm (β = . , p = . ), handgrip strength (β = . , p = . ) and leg extension power (β = - . , p = . ). conclusion: serum (oh)d concentration is related to affm japanese healthy elderly people, even if confounders are comprehensively considered. background: muscle quality, often defined as force produced per area or mass of muscle, declines as people age. objectives: we hypothesized that dietary protein quality will better predict muscle quality than energy, carbohydrate, protein, fat, or leucine intakes when controlling for age, bmi, composition, and moderate to vigorous physical activity (mvpa). methods: strength was measured using isokinetic dynamometry at degrees per second, leg composition (lc) was examined via dual-x-ray-absorptiometry, and mvpa was measured with accelerometry. dietary intake was estimated using three-day food logs and esha software. muscle quality was defined as right knee extensor peak torque relative to right leg lean mass. protein quality was the ratio of total leucine over total protein intake. multiple linear regression and stepwise linear regression models were used. results: ninety-four women (mean ± sd; age . ± . years; bmi . ± . kg/m ; lc . ± . % fat; mvpa . ± . min/day; energy , ± kcal/day; carbohydrate . ± . g/ day; protein . ± . g/day; fat . ± . g/day; leucine . ± . g/day) completed the assessments. only protein quality (mean ± sem; beta = . ± . ; t = . ; p = . ) was significant to the full regression model containing all covariates (r = . ; adjusted r = . ; f ( , ) = . ; p = . ). to verify the importance of protein quality, a stepwise regression analysis using the same variables was performed and resulted in a model (r = . ; adjusted r = . ; f ( , ) = . ; p < . ) that included protein quality (mean ± sem; beta = . ± . ; t = . ; p = . ) and energy intake (mean ± sem; beta = . ± . ; t = . ; p = . ). conclusion: dietary protein quality is positively associated with muscle quality when controlling for bmi, lc, mvpa, and energy, protein, fat, carbohydrate, and leucine intakes. the most parsimonious model included protein quality and energy intake, suggesting that they are most related to muscle quality. background: it has been suggested that disruption of the apoptotic process may have an effect on the incidence of sarcopenia. on the other hand, one of the dietary recommendations for seniors is to increase their daily protein intake. however, the effect of protein intake on apoptosis is not well understood. objectives: the purpose of this study was to investigate the effect of eight weeks of protein whey supplementation on the expression of genes involved in the internal and external pathways of apoptosis of long extensor muscle of thumb of aged wistar rats. methods: this is an experimental studies. statistical sample of this study consisted of male wistar rats (age: months, weight: ± gr). they were randomly divided into supplement (n= ) and control (n= ) group. supplement group received . gr per body weigh protein whey daily for eight weeks. the left thumb extensor muscle of all subjects was carefully separated and after freezing in liquid nitrogen transferred to - ° c. quantitative real time-pcr was performed to measure bax, bcl- , caspase , and gene expression levels. independent t-test and mann-whitney u test were used to compare the means and rankings. the hypotheses were tested at the significant level p< . . results: results showed that bax, caspase , caspase , and caspase genes expression increased in all samples in training group compared to the control group but this increase was only significant for bax, caspase and gens (p < . ) and also bcl- gene expression significantly deceresed (p < . ) in comparison with control group. conclusion: it seems that protein supplementation lead to activation of the internal pathway of apoptosis by increasing mitochondria permeability. background: the presence of obesity alongside with impaired aging in general, and with impaired muscular performance in particular, may result in a unique and growing phenotype of obese frail/sarcopenic, which may be hardly diagnosed by simple observation. characterizing the nutritional intake of this phenotype is of a substantial relevance. objectives: to characterize the nutritional intake among frail prone (fp) and obese subjects in a sample of community dwelling older adults in israel. methods: in this cross sectional study we evaluate the nutritional intake of frail, frail prone and robust subjects (with and without the presence of obesity), as well as their adherence to the dietary reference intakes (dri). data were retrieved a series of national studies on the status of health and nutrition in different age groups in israel (mabat zahav) for [ ] [ ] . the frailty likelihood presented here is based on a previous study from our group suggesting a non-direct validated model estimating frailty based on components. results: compared to the robust, fp subjects were more likely to have lower intake of several nutrients. among them are: iron (mg) (mean . vs. . , p < . ), vitamin c (mg) (mean . vs. . , p < . ), folate (μg) (mean . vs. . , p < . ), vitamin a (iu) (mean . vs. . , p = . ). the average overall adherence score according to the dri (based on a sum of nutritional components) was . among fp subjects, compared to . among robust subjects (p = . ). obesity either defined by bmi or by wc had a lower «effect» on the nutritional intake differences as compared to frailty status. this observation was seen when obese subject were compared to non-obese subjects and as fp subjects were more likely to show a poor nutritional status regardless of the presence of obesity. conclusion: our results show a clear association between frailty and poor nutritional intake, regardless of the presence of obesity. moreover, the functional status may better reflect nutritional gaps than obesity -challenging the concept of the frail -obese phenotype regarding to nutritional status. background: the loss of bone density during aging induces risks of falls, fractures and mobility decline. moreover, bone structure seems to be a better predictor of fractures than bone density. these phenomena are exacerbated in the presence of sarcopenia. however, dynapenia alone or in combination with obesity is more involved in falls and loss of mobility than sarcopenia. nevertheless, the impact of obesity on bone density and bone structure is still controversial. furthermore, protein intake appears to be associated with maintenance of muscle, bone density and bone structure. to our knowledges, the impact of protein intake on bone density and bone structure among dynapenic-obese older adults is not known even if this condition reached around % of elderly. objectives: to assess the influence of protein intake on bone density and bone structure among dynapenic-obese older adults. methods: twenty-six older adults (>= years), obese (%fat: men > ; women: > ) and dynapenic (relative to body weight grip strength: men < . ; women < . ) were divided into groups according to their initial protein intake : prot-: < g/kg/d (n= ; . % of women; . ± . years) and prot+: > . g/ kg/d (n= ; . % of women; . ± , years). the following measurements were performed: relative to body weight grip strength using lafayette dynamometer, body composition using dxa, femoral bone structure using ct-scan, nutritional intake using the -day food record method. results: excepted, by design, for initial protein intake, both groups were comparable at baseline. the prot-group had a higher (p< . ) marrow area ( ± ) than the prot + group ( ± ). in addition, the compressive loading strength was greater (p< . ) in the prot-group ( ± ) than in the prot + group ( ± ). finally, the total bone area was larger (p< . ) in the prot-group ( ± ) compared to the prot + group ( ± ). conclusion: surprisingly, a lower protein intake but higher than rda seems to protect bone structure but not bone density among dynapenic-obese older people. these results should be confirmed in larger studies designed to address this question. background: unintentional weight loss occurs in % to % of older adults and has been associated with morbidity, functional incapacity, risk of hip fracture, and overall mortality. while the impact of this condition is well established in frailty, studies involving sarcopenia are still insipient. objectives: to investigate the association between unintentional weight loss and sarcopenia in community-dwelling older adults. methods: a cross-sectional study was conducted among older adults (>= years) assisted in primary care. the unintentional weight loss was assessed by questions contained in three frailty assessment tools and one nutrition screening and assessment tool, described below: ( ) "have you recently lost weight such that your clothing has become more loose?" [edmonton frail scale (efs)]; ( ) "have you lost a lot of weight recently without wishing to do so? ('a lot' is: kg or more during the last six months, or kg or more during the last month)" [tilburg frailty indicator (tfi)]; ( ) "in the last year, have you lost weight unintentionally (i.e., not due to dieting or exercise)? (unintentional weight loss is: more than . kg or of at least % of previous year's body weight)" [phenotype for frailty (pf)]; ( ) «weight loss greater than kg during the last months" [mini nutritional assessment (mna®)]. sarcopenia was identified by european working group on sarcopenia in older people (ewgsop ) criteria. the data were analyzed with use of pearson chi-square test (p< . ). results: a total of older adults were evaluated ( . % female). the mean age was . ± . years ( - y). sarcopenia was identified in . % of the sample (n= ). the frequency of unintentional weight loss in sarcopenics was % in tfi (n= ; p= . ), % in efs (n= ; p= . ), . % in pf (n= ; p= . ) and . % in mna® (n= ; p= . ). conclusion: we observed that the unintentional weight loss evaluated by tfi and efs (frailty assessment tools) was associated with sarcopenia. so, different ways to evaluate weight loss (amount and time) seems to influence this association. funding: this study was financed by fapergs (process number - / - ) and capes (finance code ). background: half of older adults admitted to hospital are malnourished. malnutrition often leads to weight-loss and may lead to a loss of muscle mass, muscle strength and physical performance. nutritional interventions should individualise nutritional requirements, particularly energy and protein. objectives: to assess if energy requirements, determined by indirect calorimetry compared to usual care (predictive equations), can lead to a reduction in weight loss (primary outcome) and improvements in muscle mass, muscle strength and physical performance (secondary outcomes) in geriatric rehabilitation patients at risk of malnutrition. methods: geriatric rehabilitation inpatients were derived from the resort cohort (royal melbourne hospital, australia) and allocated by wards to either the indirect calorimetry or usual care group for the need study. energy requirements were measured using indirect calorimetry; the results were utilised by dietitians in the indirect calorimetry group and concealed for the usual care group. weights were obtained weekly. food intake assessment, muscle mass (bioelectrical impedance analyser), handgrip strength (hgs) and physical performance (short physical performance battery (sppb)) were measured at admission and discharge. within-group and betweengroup differences were calculated for the changes in outcome measures during hospitalisation. results: twenty-one patients (indirect calorimetry n= ; usual care n= ) were included (mean age . ± years; males, females). preliminary results showed that in the indirect calorimetry group, five patients gained weight, four patients maintained weight and one patient lost weight during hospitalisation; the usual care group had four patients with weight gain and five patients maintaining weight. there were no significant within-group differences or between-group differences for changes in weight ( background: many older people have difficulties in performing daily living activities such as preparing meals and food shopping, which could be partly due to cognitive and physical decline [ ]. these factors may influence food choice and represent a potential barrier to achieving good nutrition [ ] . nevertheless, the association between mealrelated difficulties and nutritional risk, as well as dietary intake, has been understudied. objectives: ( ) to examine the prevalence of autonomy in food-related activities, as measured with instrumental activities of daily living scale (iadl), among frail and pre-frail older subjects with an objective cognitive impairment ( ) to characterize the association of food autonomy with an insufficient dietary intake and nutritional risk of cognitive frail older people. methods: this is a secondary cross-sectional analysis using baseline data from the cogfrail study, which is a monocentric observational study of cognitive frail and prefrail older participants, aged >= years, with an objective cognitive decline. dietary intake is evaluated with a dietitian, using a diet history method. autonomy in food-related activities is assessed using iadl scale. nutritional status was categorized according to the mini nutritional assessment (mna). results: ongoing analyses. preliminary results show a mean energy intake of less than kcal and g of protein per day, we considered all nutritional needs cannot be covered under this threshold. conclusion: frail older people, with cognitive impairment, are particularly at nutritional risk and insufficient dietary intake. food autonomy has to be evaluated systematically to prevent nutritional risk in this population. elderly aged years or over, and this number will continue to increase. in order to extend the healthy life expectancy, disease prevention and health management of the elderly are important. preventive intervention of sarcopenia is considered to be an important issue in promoting care prevention for the elderly. objectives: the purpose of this study was to clarify the relationship of muscle weakness and physical characteristics with nutritional intakes. methods: subjects were men and women ( to years old) in the nagoya longitudinal study for healthy elderly (nls-he) in , excluding those who had missing values of the examinations. nutritional intakes were assessed by the food frequency questionnaire (ffq). low grip strength (gs) was diagnosed by asian working group for sarcopenia (awgs) criteria. the cut-off value of gs was kg for men and kg for women. results: the number of the subjects diagnosed with low gs was , ( men and women). comparison was made between the low gs group and the normal group. there were no significant differences between the two groups in age, sex, number of teeth, chewing ability and occlusal force, whereas mini nutritional assessment (mna) score, walking speed at the normal and maximum speed, exercise habits, and percent of body fat were significantly lower in the low gs group than the normal group. also, the rate of polypharmacy was significantly higher. in nutritional intakes, vitamin d and b were significantly lower in the low gs group. in the intakes by food groups, fish and meat intakes were significantly lower, but the intakes of snack were significantly higher. furthermore, the protein ratio and the amount of animal protein intakes were significantly lower in the low grip strength group. conclusion: in this study, muscle weakness was related to lower intake of specific nutrients such as vitamin d, b , and animal protein, independent of number of teeth, chewing ability, and occlusal force. background: the status of calcium intake, the main mineral of the bone has no suitable biomarker to assess it. its evaluation is relevant in clinical practice as in research. postmenopausal women should be evaluated for risk factors for osteoporosis, including poor calcium intake. objectives: to develop and validate a food frequency questionnaire (ffq) to assess the calcium intake of mexican postmenopausal women. methods: after obtaining approval from the institutional ethics committee, a pilot study was performed including mexican women whose calcium intake was assessed trough a day food diary ( dfd). the ffq was designed including the foods reported by the participants of the pilot study that provided more than . % of the calcium requirement and that were reported by at least participants. the ffq was tested through a validation study that included postmenopausal whom also completed the dfd. the validity of the ffq was assessed with the interclass correlation coefficient (icc) alongside a bland-altman analysis. results: postmenopausal women were assessed from june , to january , . participant's characteristics are shown in the table . the ffq underestimated mean calcium intake compared to day food diary (- mg ± . , p< . ). the two methods were strongly correlated by the icc (icc= . , ci . - . ). the ffq could identify individuals who consumed >= mg/ day with a high sensitivity, and a reasonable specificity (table ). figure shows the agreement between the dfd and the ffq were plotted against the average of the two measurements (figure ), the mean (solid line) and the % ci (broken lines) of the difference are shown. conclusion: conclusions: the ffq´s good sensitivity in identifying low calcium intake in postmenopausal women makes it useful also as an educational tool in diet counselling and for identifying subjects in need of supplementation. the difference between methods limits its utility as an epidemiological tool. helen yl chan , winnie kw so , regina cheung , kc choi , brenda ho , francis li , ty lee , janet wh sit , martin mh wong , sy chair ( ( ) background: nutritional status has been recognized as a predictor of the level of frailty. however, little is known about how the eating habits and dietary preferences associated with frailty, especially in the chinese elderly population. objectives: this study aims to identify dietary factors in predicting frailty among community-dwelling older adults. methods: a multicentre cross-sectional correlational study was conducted in hong kong in . frailty was defined by using fried's phenotype model. the frail scale was used to classify level of frailty and the mini-nutritional assessment (mna) was used to evaluate the nutritional status, in addition to anthropometric parameters. association between nutritional status (at risk or malnourished vs normal) and frailty status was examined using ordinal regression in a hierarchical fashion for adjusting participant socio-demographics, health status, lifestyle characteristics, eating behaviours and dietary habits. all the statistical analyses were performed using ibm spss . . all statistical tests were two-sided with level of significance set at . . results: a total of chinese older adults participated in the study. the prevalence of robust, pre-frail and frail were . %, . % and . % respectively. one third of the participants were malnourished or at risk of malnutrition. malnutrition and at-risk of malnutrition significantly increased the likelihood of frailty (or . , % ci . - . ). however, the level of frailty was not associated with age, gender, anthropometric measurements, eating behaviours, and use of dietary supplements. other nutritional factors significantly increased the likelihood of frailty were chewing difficulties (or . , % ci . - . ) and inadequate consumption of vegetables (or . , % ci . - . ). however, good appetite significantly reduced the likelihood of frailty (or . , % ci . - . ). conclusion: the findings showed that chewing difficulties and inadequate consumption of vegetables were associated with frailty, whereas good appetite was a protective factor. hence, interventions for addressing chewing problem and promoting appetite and consumption of vegetables are imperative to counter frailty in the older population. lack of energy was associated with nutritional status in nursing-home (nh) residents. methods: we performed a cross-sectional analysis of the incur study cohort. lack of energy was measured at baseline as part of the -items geriatric depression scale. nutritional status was evaluated according to mini nutritional assessment short-form (mna-sf). a -items frailty index (fi) was computed. logistic regression models were performed to test the association of lack of energy with nutritional status. results: a total of nh residents were available for analysis. the median age (iqr) was ( - ) years, with ( . %) females. at baseline, median mna-sf (iqr) was ( - ) with ( . %) patients that were malnourished. among the patients included . % ( patients) reported lack of energy. at univariate logistic regression analysis mna was inversely associated with lack of energy. at multivariate logistic regression analysis, adjusted for age, sex nursing home years and fi, we found that mna was independently inversely associated with lack of energy (or . , % ci . - . ). being malnourished is independently associated with lack of energy (or . , % ci . - . ). among mna components we found that item a (decrease in food intake), item c (reduced motricity) and item d (psychophysical stress) were inversely associated with lack of energy (or . , % ci . - . ; or . , % ci . - . ; or . % ci . - . ; for each point respectively), independently each one and from the other confounders. conclusion: in a cohort of very old nh residents, we found that an impaired nutritional status is associated with lack of energy. in particular, being malnourished bring a -fold risk of reporting lack of energy. more precisely, decrease in food intake, reduced motricity and psychophysical stress, each one were independently associated with lack of energy. a g e . m a r g u e r i t a s a a d e h , , f e d e r i c a p r i n e l l i , , anna-karin welmer , , weili xu , davide l vetrano , , serhiy dekhtyar , laura fratiglioni , , amaia calderón-larrañaga ( ( ) background: while declines in physical function are a common feature of ageing, the rate of the loss varies substantially between individuals, and has been attributed to intrinsic but also extrinsic (modifiable) factors such as diet, physical activity, and psychosocial well-being. objectives: ( ) to assess the role of food and nutrient intake in the speed of functional decline over years of follow-up. ( ) to explore whether such an association differs between levels of physical activity and psychosocial well-being. methods: we analysed data from individuals aged + from the population-based swedish national study on aging and care in kungsholmen (snac-k). the mediterranean diet score, mds (trichopoulou et al.) and the healthy diet indicator, hdi (who recommendations for saturated fatty acids, monodisaccharides, cholesterol, pufas, protein and fibre) were calculated for each participant, based on baseline data from a validated food frequency questionnaire and the corresponding transformation into nutrient intake. physical activity levels were assessed with questions about type, frequency, and intensity, and categorised as inadequate vs health/fitness-enhancing. we created a psychosocial well-being index by integrating variables linked to life satisfaction, positive/negative affect, social network and social participation. a global score of physical function was obtained by combining data on walking speed, balance, and chair stand tests. linear mixed models were used and adjusted for age, sex, education, smoking, baseline number of chronic diseases and impaired activities of daily living, total energy intake and time to death/drop-out. results: one standard deviation (sd) increase in the mds was associated with a lower functional decline both crosssectionally (β= . ; p= . ) and over the -year follow-up (β*time= . ; p= . ). higher scores of the hdi were also significantly associated with a lower functional decline, but only cross-sectionally (β= . ; p= . for one sd increase). when stratifying the analyses by levels of physical activity and psychosocial well-being, the protective effect of high mds was limited to subjects with health/fitness-enhancing physical activity (β*time= . , p= . ) and high levels of psychosocial well-being (β*time= . , p= . ), respectively. conclusion: a high adherence to a mediterranean dietary pattern, especially in combination with higher physical activity and psychosocial well-being, may slow down the age-relate decline in physical function. background: this cross-sectional study describes the application and follow-up of the self-care actions applied in a white male, years old, . m tall, a former athlete, currently sedentary, who in january presented % of glycated hemoglobin in medical consultation -between . and . %: pre-diabetes; fasting glycemia (mg / dl); (mg /dl) and the postprandial dose between and mg / dl. blood pressure between - mmhg; characterizing hypertension in stage. objectives: the objective was applying and follow-up a food re-education program associated with a resistance training program to reduce non-communicable diseases. methods: during , a program of dietary reeducation was carried out, with a few complex carbohydrates, an increase in proteins of high biological value, associated with a program of resistance exercises, which was adapted and individualized, obeying the individual's particularities. a short physical performance battery (sppb) was also applied to assess walking speed, strength and muscle balance. this program was performed three times a week, under the supervision of a physical education professional. capillary blood glucose was collected and analyzed times and blood pressure times, respectively. it was carried out a basic training for weeks aiming to rescue the muscular memory of the elderly, after beginning the adaptive phase of the physical valence training (cardiovascular endurance, localized muscular resistance); for weeks and the specified. the loads corresponded to % of rm for - repetitions with three series and to minutes intervals at each stage of the training. we used the ibm spss statistics program to perform descriptive statistics. results: the mean glycemia was (mg / dl), the glycated hemoglobin analyzes showed . ; low risk of diabetes. systolic blood pressure and diastolic blood pressure presented a mean of . ± . mmhg, and . ± . mmhg, respectively. we observed a gradual gain every months of resistance training. the sppb score changed from to points; performance between intermediate to high. conclusion: dietary re-education associated with a well-designed strength training program can result in the reduction of diabetes and hypertension, as well as strengthening the muscular system of the elderly. background: diet can be an important non-pharmacological aspect in order to prevent and/or attenuate brain and frailty outcomes in older adfults. objectives: to investigate, by a systematic review, studies associating the dietary inflammatory index (dii) with brain and frailty outcomes in older adults. methods: we searched the publications in pubmed and lilacs databases up to june . inclusion and exclusion criteria were formulated based on pi(e)cos strategy (population= older adults, >= years; intervention/ exposition= dietary inflammatory index; comparison= not applied; outcomes= brain and muscle outcomes; study type= randomized clinical trials, cohorts, cross-sectional, casecontrol studies). results: searches resulted in publications, and after exclusion due to duplicity (n= ) and not compliance with exclusion and inclusion criteria (n= ), eight studies were selected. these studies were published from to , all of them were cross-sectional, with participants above years old, and the outcomes investigated were frailty and frailty risk, survival free of disabilities (by fried's frailty criteria, sppb test, lawton and broady scales); memory, cognitive decline and risk of dementia (by meem, cerad, gds, prime-md, dsst and animal fluency test). conclusion: the data extracted from the articles showed significant association between dii and the outcomes investigated, namely, the more inflammatory diet was associated with higher odds to be frail and pre-frail, and to have any type of cognitive impairment. therefore, the dii showed to be associated to brain and frailty outcomes in older adults, however, to understand causality, longitudinal studies are still necessary. background: it is well established that reactive oxygen species (ros) are increased in skeletal muscle with age. we have recently shown that increased ros with age is associated with increased expression of the senescence-associated microrna mir- a- p (mir- a) in skeletal muscle as well as in muscle-derived extracellular vesicles. these vesicles enriched in mir- a are elevated in aged mouse serum, and can induce senescence in bone stem cells. the histone deacetylase sirt is a validated target of mir- a, and sirt plays important roles in cell survival as well as in muscle hypertrophy with functional overload. importantly, we previously found that mir- a expression was much higher in muscle from aged female mice compared to male mice, a phenomenon others have observed in mouse cardiac muscle. objectives: here we tested the hypothesis that pharmacological ablation of senescent cells could modulate mir- a and sirt bioavailability in skeletal muscle of aged mice. we utilized the senescent drug abt- (navitoclax) since previous studies have shown that oral administration of abt- removed senescent satellite (stem) cells in mouse skeletal muscle. methods: ten male and ten female c bl mice, months of age, received either abt- ( mg/kg bw, ul) or vehicle by oral gavage for ten days. tibialis anterior muscles were removed at the end of the study for examination of mir- and sirt levels using rt-pcr and elisa, respectively. results: abt- reduced mir- a expression in both male and female mice, although the effect was more pronounced in male mice compared to females. abt- significantly increased sirt levels in male skeletal muscle but not in females. the changes in sirt and mir- a levels were not associated with significant differences in muscle fiber size over the treatment period. conclusion: these findings suggest that certain senolytic compounds can modulate levels of senescence-associated mirnas and their targets in aging skeletal muscle. these data also underscore the importance of considering sex differences in the molecular mechanisms underlying age-related muscle atrophy. background: the growth of the elderly population is a worldwide phenomenon and is associated with profound changes in body composition. the purpose of this study was to describe the magnitude of the problem, to evaluate the associated factors and the relation with functional capacity in the study population. objectives: to estimate the association between demographic factors, comorbidities and muscle mass index over time until functional disability or death appears in non-obese elderly individuals. methods: longitudinal study of elderly individuals aged years or over, non-obese and absence of functional disability at the beginning of the cohort on the epidoso project database. the variables gender, age, ethnicity, medical history, functional capacity and death were investigated. the low or normal muscle mass index (mmi) was obtained through anthropometric data and a predictive equation. the functional capacity was measured using a structured and validated multidimensional questionnaire. the deaths occurred in the period were investigated with relatives through household surveys, in registries and registries of the state system of data analysis foundation. estimates of eventfree survival (functional disability or death) were calculated using kaplan-meier curves using the log-rank test in the gross comparisons. a multiple cox proportional hazards model was used to identify the independent effect of time predictors until onset of functional disability or death. results: the mean time found for the onset of functional disability or death was . years ( %ci=[ . ; . ]). in the crude analysis, there were statistically significant differences in the time to occurrence of functional disability or death, by age group (p< . ), arterial hypertension (p= . ), diabetes mellitus (p= . ) and marginal statistical difference muscle mass level (p= . background: a consequence of the ageing population is the increasing number of older adults with physical limitations. these limitations are mainly caused by decreased muscle mass and strength (sarcopenia). treatment or rather prevention of sarcopenia is necessary, as it may lead to lowered quality of life, hospitalization, loss of independence and even mortality. since older ethnic minorities are more likely to have an unfavourable health status compared to the majority population, variations in the prevalence of sarcopenia for ethnic minority groups are expected. further investigation seems imperative to be able to target preventive interventions to those at high risk of sarcopenia within the population. objectives: to examine the sarcopenia prevalence and its association with protein intake in an older multi-ethnic population in the netherlands. methods: we used cross-sectional data from the helius (healthy life in an urban setting) study, comprising the largest ethnic populations living in amsterdam, the netherlands. in total individuals from dutch, south-asian surinamese, african surinamese, turkish and moroccan origin aged years and over were included. sarcopenia was defined according to the ewgsop . in a subsample (n= ), protein intake was measured using ethnic-specific food frequency questionnaires. descriptive analyses were performed to study sarcopenia prevalence across ethnic groups in men and women, and logistic regression analysis were used to study associations between protein intake and sarcopenia. results: sarcopenia prevalence was found to be sex-and ethnic specific, varying from . % in turkish to . % in south-asian surinamese men and ranging from . % in turkish up to . % in south-asian surinamese women. higher protein intake was associated with a % lower odds of sarcopenia in the total population (or= . , % ci . - . ) and across ethnic groups. conclusion: ethnic differences in the prevalence of sarcopenia and its association with protein intake suggest the need to target specific ethnic groups for prevention or treatment of sarcopenia. background: few studies have evaluated the relationship between frailty and acute respiratory illness (ari), despite of increasing heavy burden of ari in older people. objectives: we conducted a prospective cohort study in communitydwelling older people in hong kong, to evaluate the impact of frailty on the risk of acute respiratory infections in the community setting and the potential modifying role of outdoor activities. methods: we recruited and followed up participants who were chinese and aged from to years, from december to may . frailty was measured by fried frailty index (ffi) twice during the study period. daily hours of outdoor activities were collected by a monthly activity journal (n= ) during the whole period, and by wearable gps device from some participants for one week in summer (n= ) and winter (n= ), respectively. the ari incidence was collected by monthly phone calls to the participants. we used a logistic regression model to estimate the odds ratio (or) of ari associated with frailty status (robust as reference group). results: the participants were classified into three groups according to the ffi criteria: ( . %) as robust, ( . %) as pre-frail and ( . %) as frail groups. of them, reported ari during the study period. according to the activity journals, daily hours of staying outdoors in the ari participants were slightly less than those in without ari ( . vs . in whole study period, . vs . in summer, . vs . in winter). while, the gps data showed that the participants with ari had longer daily hours of outdoors activities in summer ( . vs . ) but shorter in winter ( . vs . ), although none were statistically significant (p > . ). after adjustment for age, age, living alone or with family and daily hours of outdoor activities, we found that the frailty and pre-frailty groups had a higher risk of ari incidence compared with the robust group, with or . (p = . ) and . (p = . ), respectively. conclusion: frailty might be associated with a higher risk of ari among older people, but the role of outdoor activities remains inconclusive. background: previous studies have investigated the association between impaired muscle health and mortality. however, muscle health is a dynamic entity which change with time. objectives: to assess the effect of a short-term decline of muscle health (i.e., over year) and its association with long-term mortality (i.e., over years). methods: the sarcophage cohort follows up older belgian adults to assess consequences of sarcopenia. an assessment of muscle mass (dxa), muscle strength (handheld dynamometer) and physical performance (by means of sppb, including gait speed) are performed annually. all-causes deaths are collected annually. the association between short term (i.e. after one year) decline in muscle parameters and -year occurrence of deaths was tested using cox model. roc analyses were performed to assess performance of prediction of the different muscle components and to find optimal cut-points. missing data were handled using multiple imputations. results: from the subjects recruited ( . ± . years, . % women), were discarded from our sample because they died during the first year. therefore, the muscle decline was available on a sample of subjects. deaths occurred within the first years of follow-up. a -point decrease in performance at sppb test resulted in % higher risk of dealth (hradjusted = . [ %ci . - . ]). for each decrease of . m/s of gait speed, we observed an % higher risk of death (hradjusted = . [ . - . ]). a -kg decrease of muscle strength resulted in % higher risk of death in men and % higher risk of death in women (hradjusted = . [ . - . ] and hradjusted = . [ . - . ], respectively). we did not found any association between short-term loss of muscle mass and the occurrence of death (p= . ). then, we tried to find cutoffs optimizing the sensitivity-specificity ratio and we found following results : over year, a decline of sppb superior or equal to , of gait speed superior or equal to . m/s and of muscle strength superior or equal to . kg in men and . kg in women. conclusion: a short-term decline in muscle function is predictive of premature deaths. background: sarcopenia, the age-related progressive loss of muscle mass and function, is associated with an increased likelihood of adverse outcomes like falls, fractures, physical disability, and mortality. international consensus groups continue providing new definitions and clinical cut-off points despite over a decade of work in this area. objectives: we examined the prevalence of sarcopenia using two of the most current operational definitions (foundation of nih sarcopenia project (fnih) and the european working group on sarcopenia in older persons (ewgsop )) in a cohort of older adults (n= , >= yrs) hospitalized for an acute disease at utmb hospital in galveston (jan -may ). methods: testing included measures of: demographics (age, gender, race, education), body composition (dexa), physical function tests (sppb, tug, grip), psychological wellbeing and independence questionnaires, and chart review (comorbidity, length of stay). results: we found % had low physical performance, % had low muscle strength, and % low lean mass. we compared multiple tests and cutoffs for each of the three groupings under the fnih and ewgsop and found there to be differences depending on the test usedespecially for low performance which varied from %- %. in our cohort, the prevalence of sarcopenia was . % by ewgsop and . % by fnih. the subgroupings were found to be near identical across almost all measures despite the definitions' discrepancies in cutoff points between fnih and ewgsop . conclusion: in conclusion, recent updates to the new ewgsop make it almost indistinguishable to the older fnih standard, but the new ewgsop algorithm does provide a grading system to identify different levels of severity of sarcopenia. background: the population is experiencing a fast growth in the number of older adults, therefore determine the prevalence of frailty could help to inform future strategies to reduce its social and health burden. objectives: determine the prevalence of frailty in chilean older adults. methods: participants, aged > years, from the chilean national health survey - were included in this study. frailty was assessed by fried criteria modified, therefore people classified as frail should meet at least out of the criteria (low strength, low physical activity, low body mass index, slow walking pace and tiredness). results: the prevalence of frailty was . % ( . % for men and . % for women). the prevalence of prefrailty was . % whereas . % was classified as normal. the prevalence of frailty increased with markedly with age, . % and . % of men and women, respectively, were frail at the age of . this prevalence increased to . % and . % for men and women at the age of . the prevalence of pre-frailty increased from . % to . % for men and from . % and . % for women from the age of to years, respectively. conclusion: the prevalence of frailty increased markedly with age. with the chilean population expected to increase their life expectancy and number of older adults, it is important to implement prevention strategies that allow for early identification of high-risk individuals. a year follow-up. jair licio ferreira santos , yeda aparecida de oliveira duarte , tiago da silva alexandre background: sarcopenia has been increasingly recognized as leading to poor prognosis in health outcomes. likewise, falls -although important at older ages -have not been studied frequently and may lead to an increased risk of death. we evaluated survival of elderly people living in são paulo -brasil in a -year follow-up, considering the presence of sarcopenia at baseline and the occurrence of falls before the interview. objectives: to investigate whether sarcopenia and/or falls increase mortality among brazilian older adults. methods: data came from the second ( ) and fourth ( ) rounds of the health, welfare and aging study (sabe), which begun in , with a sample of the population over years old in the city of são paulo, brazil. after the first round, follow-up was performed every five years. sarcopenia was defined according to the consensus of the european working group on sarcopenia in the elderly (ewgsop), and the occurrence of falls was assessed by direct questions answered by the elder or his caregiver. a multivariate analysis with robust estimation and control for exposure time was done using the poisson regression model. results: mortality rates (per thousand person years) were: . (non sarcopenic, no falls) ; . (non sarcopenic with falls); . (sarcopenic no falls) ); and . (sarcopenic with falls. the poisson regression resulted in incidence rate ratios (when compared to sarcopenic, no falls) of . for non sarcopenic with falls; . for sarcopenic elders with no falls and . for sarcopenic with falls. conclusion: sarcopenia and the occurrence of falls are important risk factors for mortality. this finding highlights the importance of considering sarcopenia in health risk assessment and developing educational programs to prevent falls. ecosse l. lamoureux, , , alfred t.l. gan , ryan e.k. man , , eva k. fenwick , , bao lin pauline soh , angelique chan , david ng , chong foong-fong mary , preeti gupta (( ) singapore eye research institute and singapore national eye centre, singapore; ( ) duke-nus medical school, singapore; ( ) singapore institute of technology, health and social sciences, singapore; ( ) saw swee hock school of public health, national university of singapore, singapore) background: individually, sarcopenia and frailty are known risk factors for cognitive impairment (ci) in older adults, but information on their conjoint presence on the increased risk of ci is unavailable in this same population. objectives: we examined the association of the combined presence of sarcopenia and frailty with ci in elderly singaporeans. health profile in elderly singaporeans study (pioneer), a nationally-representative, population-based study of singaporean chinese, malays, and indians aged >= years. participants underwent body composition (dual energy x-ray absorptiometry -dxa); grip strength (hand dynamometer) and habitual m-walking speed assessments. sarcopenia was defined using the asian consensus as low appendicular lean mass (lalm; men < kg/m , women < . kg/m ) and low muscle strength (lms; men < kg, women < kg) or slow walking speed (sws; < . m/s); and frailty was defined as meeting three or more of the following components: ) unintentional weight-loss >= . kg in the past - months and/or bmi < . kg/m , ) lms, ) self-reported exhaustion in the past one month, ) sws, and ) low physical activity level. ci was determined using the montreal cognitive assessment (moca) basic scale. logistic regressionb models were used to determine the cross-sectional sarcopenia-frailty and ci relationship. results: of the included participants (mean age [sd]: . [ . ] years; . % females), ( %); ( %); and ( %) had neither sarcopenia nor frailty, either sarcopenia or frailty, and both sarcopenia and frailty, respectively. ci was present in ( . %) individuals without sarcopenia and frailty; ( . %) with either sarcopenia or frailty; and ( . %) individuals with both sarcopenia and frailty. in multivariable-adjusted analyses, presence of either sarcopenia or frailty was not significantly associated with higher odds of ci (odds ratio (or) [ % confidence interval]: . [ . - . ]), while having both sarcopenia and frailty significantly increased the odds of ci by nearly . times ( . [ . - . ]). conclusion: the co-presence of sarcopenia and frailty is independently associated with a higher risk of ci, compared to one condition alone, although longitudinal studies are needed to confirm this finding. strategies to prevent the concomitant onset of sarcopenia and frailty may be warranted to potentially reduce the risk of ci in older adults. background: car accidents related to older adults increased with aging, particularly in japan. safety driving required robust of physical function. however, the association between frailty and car accidents was still unclear. objectives: the aim of this study was to examine the association between frail status and car accidents. methods: participants were , older adults ( . % women, mean age: . years) enrolled current drivers in the national center for geriatrics and gerontology -study of geriatric syndromes. the criterion of frailty used in this study was j-chs index modified according to fried's criteria (chs index). the components of frailty in j-chs index were based on the original chs index: shrinking (weight loss), weakness, poor endurance (exhaustion), low activity level, and slowness. based on the presence numbers of these five components, our study defined "frailty" as and over, i.e., including pre frail and frail. the data of car accidents were collected from self-reported history of car accidents during years. results: among , participants, , participants ( . %) had a history of car accident. higher proportion of car accidents group was observed in shrinking ( . % vs . %, p = . ), exhaustion ( . % vs . %, p = . ), physical inactivity ( . % vs . %, p = . ) and slowness ( . % vs . %, p = . ), but not weakness ( . vs . , p = . ). in a logistic regression analysis, frailty was independently associated with car accidents in an adjusted model (or . [ %ci . - . ], p < . ). conclusion: this population study reveals frailty associated with car accidents. the findings have contribution of enhancing utility of risk assessments among older drivers. further studies were required to clarify risk of car accidents.model. background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty is associated with higher morbidity, mortality and healthcare utilization. the national prevalence of frailty among us older veterans was found to be as high a %. however, little is known about the incidence of frailty in older, community-dwelling veterans. objectives: determine the incidence over years of frailty among robust or prefrail community-dwelling older veterans. methods: this is a retrospective cohort study of community-dwelling veterans years and older who had determinations of frailty from july -june and were followed until their last clinician visit before september , . a -item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables (morbidity, function, sensory loss, cognition and mood and other) with data from electronic health records. the va-fi categorized veterans into robust (fi<. ), prefrail (fi=>. , <. ) and frail (fi>=. ). using baseline and median duration of follow-up data based on event rates, incidence rates of frailty per person/years were calculated for robust, prefrail, combined (robust and prefrail) and gender groups. results: patients were . % white, . % non-hispanic, . % male, mean age . (sd= . ) years. the proportion of robust, pre-frail and frail patients at baseline was . % (n= ), . % (n= ) and . % (n= ) respectively. among robust veterans surviving a median follow-up of . (iqr . ) years, . % ( / ) became frail with an incidence rate of . cases/per person-years. among prefrail veterans . % ( / ) became frail and the incidence rate was . cases/per person-years. among the combined group, % became frail, with an incidence rate of . per person-years. the proportion of veterans becoming frail and the incidence rates were higher in women than men ( . % vs. . % and . vs . cases per person-years respectively). conclusion: this study shows a high incidence of frailty in community-dwelling older us veterans. identification of older veterans at high risk for frailty may assist in the development of interventions aimed at preventing frailty and its associated complications. background: anticholinergic drugs are prescribed to treat a variety of medical conditions through pharmacological actions opposing the actions of acetylcholine. anticholinergics and may contribute to frailty by causing cognitive, functional and physical impairment. frailty represents a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. frailty may potentially make patients more susceptible to the deleterious effects of anticholinergic medications on cognition. objectives: determine the crosssectional association of anticholinergics with cognitive impairment according to frailty status among communitydwelling older veterans. methods: this is a cross-sectional study of , community-dwelling veterans years and older whose frailty status was assessed october -october . the use of medications (active/inactive) with high anticholinergic burden scale (acb ) and cognitive impairment diagnoses (icd codes for mild cognitive impairment/dementia) were obtained from electronic health records. a -item va frailty index (va-fi) was generated as a proportion of all potential variables at the time of the assessment. we compared robust (fi≤. ), prefrail (fi=>. , <. ) and frail (fi>=. ) patients. after adjusting for age, gender, race, marital status, median household income, and bmi, odds ratios (ors) and % confidence intervals (cis) were calculated using binomial logistic regression with cognitive impairment as the outcome variable and anticholinergics (acb ) as independent variables. we repeated the analysis according to frailty status. results: patients were % white, . % male, mean age . (sd= . ) years, . % ( ) had cognitive impairment, . % (n= ) were taking acb medications, . % ( ) took them in the past and . % ( ) never used them. the proportion of robust, pre-frail and frail patients was . % (n= ), . % (n= ) and . % (n= ) respectively. in binomial logistic regression, active and inactive acb medications were associated with higher risk for cognitive impairment, adjusted or= . background: frailty, a state of vulnerability to stressors resulting from a loss of physiological reserve across multiple systems. the national prevalence of frailty among us older veterans was found to be as high a %. multiple studies have shown a higher prevalence of frailty and mortality in african americans. however, little is known about racial-differences in all-cause mortality in older veterans who had just transitioned to frailty. objectives: determine racial differences in allcause mortality over years among community-dwelling older us veterans who transitioned to frailty. methods: this is a retrospective cohort study of , community-dwelling veterans years and older who transitioned to frailty from july -september and were followed until death or september . a -item va frailty index (va-fi) was generated at baseline and during each subsequent primary care encounter as a proportion of all potential variables with data from electronic health records. the va-fi categorized veterans into robust (fi≤. ), prefrail (fi=>. ,<. ) and frail (fi>=. ). at the end of follow-up, we aggregated data on mortality only on those veterans who transitioned to frailty (robust/prefrail at baseline) and compared whites and african americans. after adjusting for age, gender, ethnicity, marital status and median household income, the association of race with mortality was determined using a multivariate cox regression model. results: patients were . % white, . % african-american, . % non-hispanic, . % male, mean age at frailty transition was . (sd= . ) years. over a median follow-up period of days (iqr= ) from the time they transitioned to frailty, deaths occurred (n= , in whites vs. n= in african americans). african american veterans had a lower risk for all-cause mortality than white veterans, unadjusted hazard ratio (hr) =. ( %ci: . -. ), p<. . however, these mortality differences disappeared after adjustment for covariates, adjusted hr =. ( %ci: . - . ), p=. . conclusion: our study suggests that in community dwelling older us veterans who had transitioned to frailty, race is not significantly related to overall survival when adjusting for other covariates. background: previous studies show that sarcopenic obesity (so) is associated with higher risk of mortality. however, a consensus definition of so is lacking, and more information is needed on the validity of simple measures applicable at a regular health care visit, such as anthropometric measurements and hand-grip strength or chair stand test. objectives: to examine the association between so and mortality, defining so based on body mass index, waist circumference, hand-grip strength and chair stand test, in a representative sample of finnish population. methods: this study was based on , participants aged years or over with data on anthropometrics, hand-grip strength and chair stand test from the nationally representative health survey. baseline sarcopenic obesity was defined as having bmi >= kg/m or waist circumference >= cm (men)/ cm (women), and hand-grip strength < kg in men, < kg in women, or chair stand > s for five rises. register-based follow-up data of the statistic finland containing , deaths during the years of follow-up were individually linked with the baseline data. survival analyses were based on cox proportional hazards models using age as the time scale. results: mean age was . years (sd . ) and . % were females. overall prevalence of sarcopenic obesity was . % at baseline. sarcopenic obesity was associated with higher risk of mortality (hr . , %ci . - . ) in an age and sex adjusted model. further adjustments for education, smoking, alcohol use, and physical activity did not notably change the results (hr . , %ci . - . ). conclusion: sarcopenic obesity, as defined based on anthropometric measurements as well as hand-grip strength or chair stand test, predicted higher mortality over years of follow-up. background: malnutrition and sarcopenia have a negative impact on mobility, risk of falls, fractures, physical disability and mortality. currently, limited information is available on nutritional status and nutritional interventions in geriatric rehabilitation (gr) patients. objectives: to characterize nutritional status and evidence of nutritional interventions with and without physical exercise in gr patients. methods: eight electronic databases were screened for nutritional status and interventions in patients >= years, admitted to gr, one search string was used for both topics. pooled estimates were calculated for mean bmi and prevalence of (risk of) malnutrition (mna). meta-analyses were performed to quantify intervention effects on albumin, muscle mass, barthel index (bi), and hand grip strength (hgs). results: observational and intervention studies were included out of references. pooled estimates ( % confidence interval (ci)) for prevalence of malnutrition and risk of malnutrition were ( - )% and ( - )%. pooled estimate ( %ci) for bmi was . ( . - . ) kg/m². low protein and energy intake and vitamin d deficiency were prevalent. intervention studies were heterogeneous in interventions and outcomes. meta-analyses showed no significant effects on albumin (standardized mean difference (smd) . , % ci - . : . ), muscle mass (mean difference (md) . kg, % ci - . : . ), bi (md . points, % ci - . : . ) and hgs (smd - . , % ci - . - . ), based on - studies. eight interventions tested oral nutritional supplements (ons) with protein, with or without exercise, reported protein intake and showed an increase, / studies showed increased albumin levels and / reported improved functional outcomes. conclusion: a high percentage of gr patients was affected by reduced nutritional status. intervention studies were limited and heterogeneous, but studies with ons improved nutritional outcomes, and functional outcomes in the majority of reporting studies. the results emphasize the need for malnutrition and sarcopenia screening and show benefits of protein supplementation in this population. future well-designed, well-powered trials are needed to clarify existing controversial aspects. therefore, feasibility of an intervention with a high-whey protein, leucine and vitamin d enriched ons (fortifit®), combined with resistance-type exercise in gr hip fracture patients will be investigated in a new intervention study (empower-gr). background: sarcopenia is a progressive and generalized skeletal muscle disorder associated with an increased likelihood of adverse outcomes such as falls, fractures, physical disability and mortality. the geographical region of residence (urban and rural area) may affect the prevalence of sarcopenia due to physical and environmental conditions. in , the european working group on sarcopenia in older people (ewgsop) updated the definition of sarcopenia (ewgsop ). objectives: to describe the prevalence of sarcopenia related to ewgsop and ewgsop criteria and to analyze the association between sarcopenia and geographical regions of residence. methods: this is a cross-sectional study involving elderly women ( years old or more) that were undergoing dxa in a radiology facility located in palmeira das missões (southern brazil). sociodemographic data were collected through a questionnaire. for the diagnosis of sarcopenia, we used the criteria recommended by the ewgsop (low muscle mass plus low grip strength and/or low gait speed), and ewgsop (low grip strength plus low muscle mass and/or low gait speed). the study was approved by the university ethics committee. results: out of the participants, . % was married, . % had education between and years of schooling, . % was caucasian, and . % was retired. the mean age was . ± . years old ( - ). the frequency of sarcopenia in the total sample assessed by the ewgsop and ewgsop was . % and . %, respectively. the prevalence of sarcopenia by the ewgsop was % in the urban area and . % in the rural area (p= . ) and by the ewgsop was . % in the urban area and . % in the rural area (p= . ). conclusion: in a sample of elderly women from the southern brazil, the prevalence of sarcopenia was low through both consensus (ewgsop and ewgsop ), and was higher among urban area. funding: this study was financed in part by the coordenação de aperfeiçoamento de pessoal de nível superior -brazil (capes) -finance code . background: patients with disuse syndrome have gradually increased with aging of inpatients in saitama medical university hospital. because these patients have been inactive in the acute phase, sarcopenia is likely to occur. sarcopenia was graded by three criteria in ewgsop ; muscle strength, muscle quantity and physical performance. muscle volume can be measured only in limited medical centers. many of patients with disuse syndrome can not walk even after the acute phase. for these reasons, muscle strength is the only quantitative factor reflecting sarcopenia, especially in old patients with disuse syndrome after the acute phase. objectives: to show ) muscle strength in old patients with disuse syndrome after the acute phase, ) effect of muscle strength on activities of daily living (adl). methods: subjects were old patients with disuse syndrome admitted in the department of rehabilitation medicine (rm) in saitama medical university hospital from january to december . inclusion criterion were as follows; ) patient age was or older ) patients could not walk independently at admission in the department of rm exclusion criterion were as follows; ) patients with motor paresis, contracture of fingers ) patients in inactivity before the onset of the disease causing disuse syndrome. grip strength (gs) was measured by handheld dynamometer. cut-off point of gs set by awgs in was adopted; kg for men and kg for women, adl was evaluated using functional independence measure motor scale (mfim) one week after admission in the department of rehabilitation medicine . percentage of gs below cut-off point was shown in men and women respectively. effect of gs on mfim was investigated using regression analysis. results: ninety nine out of patients were subjects in this study. median age was . years in men (n= ), . years in women (n= ). only two in men and one in women were below gs cut-off point. correlation coefficient between gs and mfim was . (p= . ) in men, . (p= . ) in women respectively. conclusion: gs was below cut-off point in most of the subjects. gp may affect adl after the acute phase in old patients with disuse syndrome. death, whereas measures of functional ability, physical strength and morbidity were stronger associated with time to death than with chronological age. from the age of and forwards participants have a high life-satisfaction in general, however, a decline is seen as persons get older and with proximity to death. measures of functional ability (e.g. going shopping) and morbidity (e.g. self-related health) had a significantly increasing effect on life-satisfaction with increasing age. whereas social function (e.g. living alone, meeting friends) did not significantly modify the decrease in life satisfaction with increasing age. conclusion: physical strength, functional ability and morbidity were measures mostly linked to biological aging, while social functioning was strongly correlated with chronological age. functional ability and self-related health are important factors to prevent age-related decrease in life satisfaction. background: previous studies mostly conducted in western countries support that physical frailty predicts future cognitive decline in general older populations. however, longitudinal evidence on this association is limited, especially among older japanese women. objectives: this study has investigated the prospective associations of frailty status with cognitive decline over two years among community-dwelling older japanese women, including which individual frailty components (i.e., slowness, weakness, exhaustion, low activity, and unintentional weight loss) could predict cognitive decline. methods: this study was a two-year population-based cohort study conducted in a metropolitan area of tokyo, japan. data were collected in october (baseline) and september (follow-up) and analyzed between december and january . participants were community-dwelling older japanese women, aged to years at the baseline, without any neurological diseases or cognitive impairment as measured by a mini-mental state examination (mmse) score of >= points. cognitive decline was defined as a drop of two points or more in the mmse score over two years. the physical frailty phenotype was classified by the japanese version of cardiovascular health study criteria. multiple poisson regression analyses with a robust error variance were applied to assess risk ratios (rrs) of two-year cognitive decline across the baseline frailty statuses (robust [reference category], prefrail, or frail). results: of the women analyzed, ( . %) were prefrail ( or components), and ( . %) were frail (≥ components) at the baseline. at the follow-up, ( . %) robust, ( . %) prefrail, and ( . %) frail women experienced cognitive decline. after being adjusted for various confounding factors including age, educational attainment, and baseline mmse score, the rrs of cognitive decline were . ( % confidence interval [ci]: . , . ) in the prefrail and . ( %ci: . , . ) in the frail women. among the five frailty components, slowness (rr: . , %ci: . , . ), weakness (rr: . , %ci: . , . ), and unintentional weight loss (rr: . , %ci: . , . ) were significantly associated with cognitive decline. conclusion: over the two-year period, approximately % of women experienced cognitive decline. baseline physical frailty status, particularly slowness, weakness, and unintentional weight loss, predicted this decline. intervention strategies targeting physical frailty may help delay cognitive decline in older japanese women. background: menopause leads to estradiol (e ) deficiency that is associated with decreases in muscle mass and strength. yet the mechanistic role of e in the loss of muscle mass has not been established. programmed cell death termed apoptosis has been proposed a key signaling route in skeletal muscle homeostasis, including muscle aging and sarcopenia. to date several micrornas (mirs) have been found to regulate key steps in apoptotic pathways. objectives: here we studied the effect of e deficiency on mir-signaling in skeletal muscle apoptosis. our aim was to reveal whether e -responsive mirs have mechanistic role in inducing skeletal muscle apoptosis. methods: we utilized c bl mice with three study groups; sham (normal estrous cycle, n= ), ovx (e deficiency, n= ) and ovx+e (high e supplemented by pellet, n= ). in our setup, ovx and ovx+e groups represent the extremes of e level. six weeks following the sham or ovx surgery, mice were sacrificed, gastrocnemius muscles were harvested and rna isolated. mir-profile was studied with ngs and candidate mirs verified using qpcr. the target proteins of the mirs were found using in silico analysis (target scan) and target proteins measured at mrna (qpcr) and protein levels (western blot). results: of the apoptosis-linked mirs found, four ( - p, a- p, - p and - p) indicated differential expression patterns between ovx and ovx+e groups. in qpcr verification, ovx had lower expression in all of the studied mirs compared with ovx+e (p= . ). accordingly, ovx had higher expression of cytochrome c and caspases , and compared with ovx+e at the mrna level (p< . ). at protein level, ovx had greater cytochrome c and active caspase compared with ovx+e (p< . ). conclusion: in muscle from e deficient mice (ovx vs. ovx+e group), several apoptosis-linked mirs were down regulated concomitant with higher mrna expression of the target proteins. furthermore, e deficiency was associated with higher cytochrome c and active caspase protein levels. to conclude, e deficiency down regulated several mirs related to apoptotic pathways that may lead to increased apoptosis and reduced skeletal muscle mass. background: although sarcopenia's pathogenesis is multifactorial, with its major phenotypes, muscle mass and muscle strength, being highly heritable, its genetic underpinning is not well studied. objectives: summarize evidence for use of zebrafish as a model system to decode the sarcopenia's gwas findings. methods: several genome-wide association studies (gwas) of muscle-related traits were published recently, providing dozens of candidate genes, many of them with unknown function. therefore, animal models are required not only to identify causal mechanisms, but also to clarify the underlying biology and to translate this knowledge into new interventions. over the past several decades, small teleost fishes had emerged as a powerful system for modeling the genetics of human diseases. due to their amenability to rapid genetic intervention and the large number of conserved genetic and physiological features, small teleosts, such as zebrafish (d. rerio), are indispensable for skeletal muscle genomic studies. results: we summarize the evidence supporting the utility of small fish model for accelerating our understanding of human skeletal muscle in norm and disease. the following stable mutants (mostly knockouts) exist for the «monogenic muscle» diseases (human gene, fish mutant, disease): for duchenne and becker muscular dystrophy (md), sapje/dmd (homology of human dmd gene); for limb-girdle md, popdc s f (bves); for bethlem myopathy and ullrich congenital md, col a ama (col a ); for nemaline myopathy, froto c (myo b), and tmod trg (tmod ); for merosin deficient congenital md, lama cl /cl ; candyfloss/lama (lama ); for limb-girdle md, bvesicl /icl (popdc ), heltg (ttn), and «foie gras» (trappc ); for native american myopathy, stac mi (stac ), as well as fish homologues of the acvr , cacnb , cavin , cms, dag , fhl , flnc, vcp and other human genes. these models provide evidence of muscle-related gene's conservancy and similarity of skeletal muscle morphology and physiological phenotypes. we will outline challenges in interpreting zebrafish mutant phenotypes and translating them to human disease. conclusion: we conclude with recommendations of future directions to leverage. centenarians exhibit extreme longevity and a compression of morbidity. we showed previously that centenarians display a unique genetic signature, in terms of mrna and mirna profile, which is similar to that found in young people and different from that found in octogenarians. centenarian offspring seem to inherit centenarians' compression of morbidity, as measured by lower rates of age-related pathologies such as hypertension, diabetes, strokes, and heart attacks. we therefore hypothesized that they will also display a lower incidence of frailty. in this study, we aimed to ascertain whether centenarian offspring are endowed which such "genetic footprint" and a lower incidence of frailty, when compared to their contemporaries. for this purpose, we collected plasma and peripheral blood mononuclear cells from septuagenarians, , age-matched centenarian offspring (but not sons or daughters of the centenarians included in this study) and centenarians. mirna expression and mrna profiles were performed by the genechip mirna . array (affimetrix) and genechip clariom s human array (affimetrix), respectively. frailty phenotype was determined by meeting three or more of the following criteria: unintentional weight loss, low grip strength, exhaustion, slow gait speed, and low physical activity. we found that mirna and mrna expression patterns in centenarians are similar to centenarian offspring and different to non-centenarian offspring (p< . ). importantly, we found a lower incidence of frailty among centenarians' offspring (p< . ), when compared to their contemporaries. taken together, our results indicate that centenarian offspring resemble centenarian characteristics and that they enjoy significantly less frailty than their less fortunate contemporaries that are not sons or daughters of centenarians. this lower incidence of frailty may be a key feature to achieve extraordinary ageing. background: hypoglycemic episodes increase in older patients and their consequences are more significant. objectives: the aim of this prospective observational study is to explore unknown hypoglycemic episodes diagnosed by continuous glucose monitoring in older type diabetic patients and to describe the link between the occurrence of hypoglycemia and glycosylated hemoglobin (hba c) level. methods: we included patients with type diabetes aged years or over hospitalized during consecutive months in a geriatric acute care unit in tours university hospital in france. demographic characteristics, type of diabetic treatment, mini mental state examination, hba c levels, albumin and creatinin level were recorded. continuous glucose monitoring (cgm) was used to detect hypoglycemia for a maximum of days, and capillary blood glucose measurements (cbgm) were also performed to times a day. patients with at least one blood glucose measure lower than mg/dl were compared with others for demographic, clinical and biological parameters. results: seventeen patients experienced hypoglycemia. these groups did not differ in demographic characteristics and in diabetic drug class. among these patients, had an episode of severe hypoglycemia (< mg/dl) and patients had nocturnal episodes, more often between and am. twelve patients had unrecognized hypoglycemia by cbgm. the average duration of hypoglycemic episodes was . hours. there was no difference in the hba c levels between the two groups (mean . %, p= . ). conclusion: the prevalence of hypoglycemia is underestimated in the oldest diabetic population receiving hypoglycemic drugs. measurements of cbgm and hba c level in the target may overlook nocturnal and prolonged hypoglycemic episodes. our study showed the benefit of cgm in older diabetic patients in order to detect unknown hypoglycemia. more prospective studies are needed to explore factors that predict hypoglycemia. catenacci, sophie le-gonidec, alizée dortignac, ophélie pereira, romain madeleine, jean-philippe pradère, philippe valet, cedric dray (umr inserm,universitéfédéral de toulouse -universitépaul sabatier toulouse iii, france) background: healthy lifespan does not increase proportionally compared to global lifespan leading to an increased number of disabled aged persons. to increase healthy lifespan, locomotion could be considered in the future as the main targetable outcome to fight against the frailty to dependency transition. the so-called sarcopenia, characterized as the loss of muscle mass and function, affects to % of the populations over . mechanistically, sarcopenia is associated with an imbalance between protein synthesis and degradation, an increase of muscle inflammatory processes, a reduction of mitochondria-driven metabolism and an exacerbated fibrosis. several therapeutic strategies have been proposed such as hormonal replacement but, regarding the adverse effects, these strategies have been abandoned. in this context, we hypothesize that, through a modified secretory profile, adipose tissue could play a crucial role in the muscle loss of function. we previously promoted an unbiased proteomic study and identified haptoglobin as an up-regulated cytokine overproduced by the adipose tissue during aging. objectives: in this context, our project proposes to better understand the role of adipocyte haptoglobin in age-related muscle weakness. methods: to do so, we used complementary in vitro and in vivo models of haptoglobin supplementation and strategies of adipocyte haptoglobin over-expression/deletion. impacts of such interventions have been monitored by measuring myogenesic processes as well as muscle aging. moreover, a human cohort in progress will help to constitute a new biobank by collecting blood, adipose and muscle from sarcopenic individuals in order to evaluate the role of hapatoglobin on sarcopenia (inspire cohort). results: the results obtained in vivo and in vitro suggest that haptoglobin treatments induced an age-dependent decrease in muscle mass. moreover, these protocols indicated a muscle-specific role of haptoglobin when we measured the fiber diameter. in addition, a direct effect of haptoglobin on differentiation alteration was also observed in in vitro human muscle cells. conclusion: these results suggest that haptoglobin induces effects according to the age, the muscle type and the dose on muscle physiology. thus, a better knowledge of adipocyte haptoglobin production could help to better apprehend the age-related muscular complications. background: sarcopenia contributes to loss of independence and is increases risk of mortality. mitochondrial dysfunction and loss of proteostasis are two interrelated hallmarks of aging with well-established roles in skeletal muscle function. mitochondrial dysfunction increases cellular oxidative stress and impairs atp-generating capacity. consequentially, oxidatively-damaged proteins accumulate; however, a dysfunctional mitochondrial reticulum cannot sufficiently provide energetic resources to repair the proteome. in skeletal muscle, this impaired proteostasis and mitochondrial dysfunction promote sarcopenia. thus, improving mitochondrial function by increasing endogenous antioxidants could attenuate age-related loss of muscle function. objectives: using a phytochemical nrf activator (nrf a), we sought to determine if upregulation of cytoprotective genes would improve mitochondrial function and gait, an integrative metric of musculoskeletal function. methods: we utilized dunkin-hartley (dh) guinea pigs that develop primary osteoarthritis and experiences age-related skeletal muscle dysfunction by months of age (~ % of their maximal predicted lifespan). we treated young ( mo) and older ( mo) dh guinea pigs for and months, respectively, daily with a nrf a. we assessed metrics of gait monthly to measure the effect of nrf a on agerelated musculoskeletal dysfunction. we evaluated the effect of nrf a on skeletal muscle protein turnover using the stableisotope deuterium oxide. we also assessed soleus mitochondrial function using high resolution respirometry. results: while nrf a did not affect gait in young guinea pigs, months of nrf a treatment maintained stride length (p= . ) in older male and stance width (p< . ) in older female guinea pigs compared to untreated controls. nrf a improved (p= . ) adp vmax in young females and old males compared to their respective controls. nrf a also increased uncoupled electron transport system capacity in both male and female guinea pigs of both ages (p< . ). nrf a augmented contractile protein synthesis in the soleus of old male and female guinea pigs (p= . ), but did not prevent the age-related declines in the gastrocnemius. conclusion: in summary, long-term nrf a treatment improved skeletal muscle mitochondrial function, increased contractile protein synthesis, and maintained aspects of gait. together, our findings provide evidence that targeting the transcription factor nrf mitigates the decline in musculoskeletal function in a model of osteoarthritis and sarcopenia, with concomitant improvements in mitochondrial function and protein turnover. . j a n n e k e v a n w i j n g a a r d e n , francina j dijk , miriam van dijk , lisette cpgm d e g r o o t , y v e s b o i r i e , , y v e t t e c l u i k i n g background: sarcopenia is a muscle disease rooted in adverse muscle changes that accumulate across the lifespan. multiple factors cause or worsen sarcopenia, with aging as the primary factor and malnutrition, inactivity and diseases as secondary factors. objectives: to design a nutritional strategy to manage sarcopenia. methods: our research program investigated ) specific nutrient deficiencies in sarcopenic older adults, ) muscle protein synthesis (mps) response in cells and rodent models, and ) effect of a specific nutrient combination (whey protein, leucine and vitamin d -actisyn(tm), present in the medical nutrition supplement fortifit(r), on mps in older adults. results: cross-sectional studies indicated a significantly lower intake of protein (- %) and vitamin d (- %) in sarcopenic versus healthy older adults (p< . ) [verlaan, clin nutr ], and higher prevalence of sarcopenia among those with lower blood levels of leucine, total essential amino acids ( the specific combination of whey protein, leucine and vitamin d (actisyn(tm)) provides the right environment for muscle building in sarcopenia, where these nutrients are often deficient. this combination acts through a proven anabolic mode of action with optimal nutrient bioavailability for the muscle to stimulate mps. fortifit and actisyn are trademarks of n.v. nutricia. background: age-related sarcopenia is a major responsible for premature death, poor quality of life and several adverse outcomes, which lead to higher health care costs. despite its recent incorporation as a muscle disease (icd- -cm m . ), early identification of this disease remains challenging. mostly, due to classification and diagnostic criteria, which are predominantly based on technically advanced assessment tools, which may not be available in all clinic settings. recently, a non-invasive technique to analyze variations in biological tissues considering the effect of physiological and biological properties on microwave signals is being studied for its potential to determine muscle mass, with possible applications in the early diagnosis of this disease. objectives: therefore, the principal objective of this study is to preliminarily test the potential of this technique as a new tool for early diagnosis of age-related sarcopenia in a clinical setting. methods: muscle surface area are going to be assessed by abdominal computational tomography (ct) on the third lumbar spine vertebra (l ) and bioimpedance measurements among men and women, aged >= years in the maastricht university medical center, the netherlands. participants will also be subjected to measurements done with the device under test (dut) (the proposed technique) in the same location. the data collected from the three different measurements are analyzed looking for correlation. laboratory experiments made from synthetic materials emulating human tissues and from ex-vivo porcine tissues are used for optimization and interpretation of the clinical measurements. results: up-tonow, the campaign has just started and there is no enough data to give a preliminary result. initial laboratory experiments prove that the thickness of the fat and muscle tissues is correlated to the system response. conclusion: this prospective device will estimate the muscle mass locally using microwave electromagnetic principles. the results of this study can contribute to reveal the potential of this approach as a tissueanalysis tool for early diagnosis and management of age-related sarcopenia. the results might also provide useful evidence to consider in a future planned prospective cohort study, which aims to examine the impact of dietary biomarkers and genetic factors on the incidence of age-related sarcopenia in older adults. background: sarcopenia has become a serious problem in this aging society. at present diagnosis of sarcopenia consist of physical performance and muscle quantity. dexa has been widely applied to examine muscle quantity in clinical but it's radioactive, inconvenient and unaffordable in remote area. as a result, there are more studies in ultrasound in replace of dexa. objectives: based on others researches csa might be a suitable parameter to evaluate the muscle quantity. we develop a cheaper ultrasonic imaging system to evaluate the cross-sectional area (csa) of rectus femoris (rf)muscle. methods: we use a cmos image sensor combing with digital signal processor to detect the displacement of single element ultrasonic transducer. therefore, we combine us a-mode signal with displacement into b-mode image. by circling region of interest (roi), we can obtain the csa of rf muscle. then, we use siemens s evaluating the csa in the same region to testify the reliability. results: we recruited young college students undergoing the experiment. the result shows that the correlation coefficient is up to . . conclusion: in conclusion, our device can successfully evaluate the csa of rf muscle. moreover, our system using single element ultrasonic transducer is much cheaper than linear transducer in practice .it can be affordable in remote village or somewhere lacking in medical resource. a case-control study. camille nicolay , sandra higuet , sandra de breucker (( ) geriatric department, hôpital erasme, brussels, belgium; ( ) geriatric department, hôpital isppc-charleroi, charleroi, belgium) background: ten percents of belgian population are considered to be informal caregivers. little is known about their frailty status and their physical health. objectives: we compared the frailty status, the clinical and psychosocial status of old caregivers with controls (> ). we analyzed the association of frailty status according to fried's criteria and rockwood frailty index (fi) with the characteristics of caregivers and controls in multiple regression analysis. methods: eighty six caregivers and gender and agematched controls were included. frailty was assessed by the frailty phenotype (fried) and the -deficit frailty index (fi). social data, sf- health survey, basic and instrumental adl, geriatric depression scale, mini nutritional assessment, mini-cog, cumulative illness rating scale-geriatric, usual gait speed, handgrip strength, and burden scale (zarit) were collected. results: the prevalence of frailty was similar in caregivers and controls with the fi (p= . ) but higher with the fried's criteria (p= . ). compared with the control group, caregiving was associated with a lower mental quality of life (p< . ), a higher risk of depression (p< . ), a higher consumption of antidepressant (p= . ), a lower nutritional status (p= . ), a more frequent help from health care providers (p= . ), and more problems to maintain physical contacts with a social network (p= . ). in multiple regression, the fried's criteria adjusted for age, gender, marital status and incomes were associated with the age, the grip strength, the physical quality of life, the gait speed and the nutritional status (r = . -p< . ), while fi was associated with the risk of depression, the use of antidepressants, the physical quality of life, the cognitive status and basal & instrumental adl (r = . -p < . ) in caregivers. conclusion: the prevalence of frailty is similar in caregivers and controls when using fi, but higher in caregivers with fried's criteria. compared with controls, caregiving is associated with poorer health and psychological issues. while fried's criteria focus on physical frailty, the fi is more related with geriatric syndromes like depression, cognitive disorders, loss of autonomy, and quality of life. this study could help researchers to choose between frailty scales before starting a study about older caregivers. background: nursing home (nh) residents are often undernourished and physically inactive contributing to sarcopenia and frailty. mobility is identified by older nh residents as being key to their quality of life and well-being. the combination of protein supplementation and physical exercise has been shown to be most effective to maintain and increase muscle mass. objectives: the older persons exercise and nutrition (open) study aimed to investigate the effects of sit-to-stand exercises (sts) integrated into daily care combined with a protein-rich oral nutritional supplement (ons), on physical function, nutritional status, body composition, healthrelated quality of life and resource use. methods: residents in eight nh were randomized by nh units into an intervention group (ig) or a control group (cg) (n= /group). the ig was offered a combination of sts (four times/day) and ons ( bottles/day providing kcal and g protein) for weeks. the participants resided in nh units (dementia and somatic care), were >= years and able to rise from a seated position. the seconds chair stand test ( scst) was the primary outcome. secondary outcomes were balance, walking speed, dependence in adl, nutritional status and body composition, health-related quality of life and resource use. data was analyzed using descriptive and inferential statistics including regression models. results: altogether residents ( ± years, % females) completed the study. no improvement in the physical function assessments was observed in the ig, whereas body weight increased significantly ( . ± . kg, p= . ) vs the cg. twenty-one (of ) participants with high adherence to the intervention, i.e. at least % compliance to the combined intervention, increased their fat free mass ( . kg ( . , . iqr), p= . vs cg. logistic regression analyses indicated that the odds ratio for maintained/improved scst was . (ci . , . , p= . ) among the participants with high adherence compared to the cg. waly dioh , cendrine tourette , carole margalef , amy chen , rené lafont , , pierre dilda , stanislas veillet , samuel agus (( ) biophytis, sorbonne université -bc , paris, france; ( background: sarcopenia is a geriatric condition characterized by loss of muscle mass and functions and can contribute to risks of falls, fractures and hospitalization. sara-obs is a multicenter, observational trial designed to better characterize age-related sarcopenia in a community dwelling population at risk of mobility disability. this is part of a clinical program that strives to provide more understanding of the target population in order to further develop a potential sarcopenia medical intervention. sara-obs study rationale, design and main baseline characteristics are presented. objectives: the objective is to characterize sarcopenia and sarcopenic obesity in older adults through evaluation of their physical performance and body composition. changes in baseline characteristics after a -month period will be assessed and used for development of a phase interventional study on the efficacy and safety of an investigational drug, bio . methods: participant recruitment was based on age (>= years), sppb score =< and body mass based on the fnih criteria. physical functions were assessed by two walking tests ( m walk test and the -minute walk test), the sppb, the handgrip strength test and the stair climb power test. patient reported outcomes were also assessed with the sf- and the sarqol questionnaires. results: subjects were included in this study and the main screen failures were sppb scores and body mass criteria. baseline characteristics indicated that the average bmi was high, ~ % of the participants were women and that the alm/bmi in men was lower than the fnih threshold ( . vs . ) but was similar in women ( . vs . ). m gait speed was . m/s, the mean total sppb score was . with the gait speed component of < . m/s and the chair stand sub-score of . . conclusion: this population has a similar m gait speed as the populations in life and sprint-t studies at baseline. however, the sppb total score and the chair stand sub-score correspond more closely with the sprint-t study. addressing the loss of physical function and preventing mobility disability is still an unmet need of older adults. sara-obs included a population representative of a suitable target for subsequent interventional studies aimed to fulfill this need. yen-lung chen, hui-hua chiang (department of biomedical engineering, national yang-ming university, taipei, taiwan) background: in whole world, the elderly formally entered the aging society , and the patients with sarcopenia were highrisk groups in the fall. more than % of the elderly suffered moderate injuries due to falls. the sarcopenia as defined by the eu's sarcopenia working group was refers to progressive reduction in muscle mass and decreased muscle function. objectives: it is expected to provide diagnostic tools and techniques for the rapid determination of sarcopenia and muscle strength. at the same time, it will also be developed toward portable devices to facilitate the diagnosis of the aging of muscle function in the elderly at home to take care of the health and well-being of the elderly. methods: at present, the clinical measurement part is assisted by the radiation department of the veterans general hospital to collect and measure the subjects. clinical testing methods are mainly for older people over years of age. the walking speed test is firstly performed on the method. if it is normal, then the grip strength test is performed. if the grip strength is too small, the femoral rectus femoris muscle volume test should be performed. generally, dual energy is used. dual-energy x-ray absorptiometry (dxa) is used for testing. if the walking speed is too slow, the dxa test should be performed directly. the test value is less than . (kg/m ) in woman and less than . (kg/m )in man. that is, it is determined as a sarcopenia patient. since dxa has a small amount of free radiation, high cost, and a large space occupation, we expect to obtain a wide range of data through ultrasonic scans. back-end development algorithms are calculated to determine if there is sarcopenia and how severe it is. results: at present, the rectus femoris muscle volume obtained by using ultrasound has a highly linear relationship with the appendicular muscle mass measured by dxa (r = . ,p< . ), and has the ability to distinguish whether it is sarcopenia. conclusion: the use of muscle volume of rectus femoris can improve the accuracy of sarcopenia prediction. in the near future, this plan will be used to develop automated ultrasonic scanners. background: although sarcopenia has multifactorial causes, the decline in physical activity has been considered a very important aspect for its development. since the promotion of higher levels of physical activity can attenuate the progression of sarcopenia, it is possible that the participation in a programmed training increases the spontaneous physical activity of the participants. objectives: to investigate if the participation of sarcopenic older women in a resistance training program and supplementation with fish oil leads to changes in the level of spontaneous physical activity (sedentary time and number of steps). methods: randomized, double-blind, placebo-controlled clinical trial. thirty-two older women, aged >= years, participated in the study. all participants were classified as sarcopenic based on the criteria of the european consensus on sarcopenia (ewgsop). the participants were divided into two experimental groups: ( ) exercise group + placebo (ep) and ( ) exercise group + fish oil (efo). both groups underwent a resistance exercise program over weeks, consisting of three weekly supervised sessions. all volunteers were instructed to take two capsules of food supplement at each main meal, lunch and dinner ( g/day). the ep group used capsules composed of sunflower oil as placebo, and the efo group fish oil capsules, (epa mg and dha mg). measurements of the level of spontaneous physical activity were made before and after the intervention by using the actipal® physical activity monitor (glasgow, uk), for a period of seven consecutive days, during which the volunteers were instructed to maintain their normal routine. the volume of the quadriceps muscle in the pre and post intervention periods was calculated from the images obtained by magnetic resonance imaging. for statistical analysis, a linear regression model with mixed effects was used to compare longitudinal data on mean intra-group differences between groups and moments. for all analyzes, a significance level of . was adopted. results: both groups showed an increase in muscle volume after the intervention ( . cm ( . %) and . cm ( . %), respectively). regarding the level of spontaneous physical activity, both groups had a similar sedentary time and number of steps, at both times (average . h and , steps in the pre-intervention period and . h and , steps in the postintervention period for the ep group, and . hrs and , steps in the pre-period and . h and , steps in the postintervention period in the eop group). conclusion: although sarcopenic older women supplemented with fish oil showed a higher increase in muscle volume, the level of spontaneous physical activity remained unchanged both in the pre and post intervention periods and between groups, indicating that the increase in muscle volume was not associated with significant changes in the level of spontaneous physical activity. background: regardless of improvements in surgical and anesthetic practices, older surgical patients often experience postoperative complications. the purpose of this study was to investigate the association between physical frailty and cognitive function using a validated upper-extremity function (uef) test with in-hospital outcomes in aging adults undergoing abdominal surgery. objectives: to recognize frailty and cognitive function as a risk factor for in-hospital adverse outcomes. methods: we administered pre-operative uef tests, within -hours after admission, among patients aged years and older undergoing emergent/urgent abdominal surgery. the uef involved two tests; -and -sec of respectively fast and consistent elbow flexion, while angular velocity was measured via two wearable motion sensors applied to the wrist and upper-arm of the dominant arm. uef physical score was calculated, based on slowness, weakness, flexibility, and exhaustion (range: resilient= -frail= ). uef cognitive score was assessed based on motor function variability within a dual-task performance that involved uef motor task and a cognitive task of counting backwards by threes (range: cognitive normal= -cognitive impairment= ). adverse outcomes included: length of stay, complications, and death during their hospital stay. a logistic regression model was used to assess the association between uef physical and cognitive scores (independent variables) and in-hospital outcomes (dependent variable). results: a total of participants (mean age . ± . years) completed the preoperative uef assessment. thirty-six participants with an average age of . ± . years experienced at least one adverse outcome while in the hospital. while age independently predicted in-hospital outcomes with receiver operating characteristic area under the curve (roc-auc) of %, this prediction improved by adding either the uef physical or the cognitive score. the physical score predicted in-hospital outcomes with a roc-auc of %, and the cognitive scores predicted in-hospital outcomes with a roc-auc of %. conclusion: the proportion of emergency surgical procedures increases with age, and population trends indicate that this demand will increase significantly. results from the current study showed that sensor-based measures of physical and cognitive function can provide an objective tool for predicting adverse outcomes, with potential applications for other surgical procedures. risk stratification can help to establish targeted management strategies to improve the healthcare system and patient-centered outcomes. background: while sensor-based daily physical activity (dpa) gait performance has been demonstrated to be an effective measure of physical frailty, it is not clear how repeatable the dpa gait parameters are between different days of measurement, especially across frailty groups. objectives: to evaluate the test-retest reliability (repeatability) of dpa gait performance parameters (stride time, variability, and irregularity) and quantitative measures (number of steps and walking duration) between two separate days of assessment among older adults. methods: dpa was acquired for -hours from older adults (age>= years) using a tri-axial accelerometer motion-sensor attached to the trunk. purposeful continuous walking bouts (>= s) without long pauses (> . s) were identified from acceleration data and used to extract gait performance parameters, including stride time, power spectral density (psd) slope (representing the variability of walking cycles), dominant frequency of walking, and gait irregularity (sample entropy, representing predictability of walking cycles). to assess repeatability, intraclass correlation coefficient (icc) was calculated using two-way mixed effects f-test models for day- vs. day- as the independent random effect. repeatability tests were performed once for all participants and once within each frailty group (non-frail and pre-frail/frail). results: data from older adults, non-frail (age: . ± . years) and pre-frail/frail (age: . ± . years) were analyzed. within all participants with purposeful walking bouts on both the days, gait performance parameters of stride-time and gait variability parameters (slope and dominant frequency of walking) showed excellent test-retest reliability values (icc>= %) while quantitative parameters, including number of steps and walking duration showed poor test-retest reliability results (icc< %). among gait performance parameters (stride time, dominant walking frequency and sample entropy), we observed higher repeatability among the pre-frail/frail group with icc> % compared to icc< % for non-frail individuals. conclusion: from our study, it is evident that gait performance parameters including average step-and stride-time and frequency-domain gait variability parameters provided higher test-retest reliability compared to quantitative measures. further, gait performance parameters showed higher repeatability among pre-frail/frail volunteers between the two days compared to non-frail volunteers, which may be attributed to a lack of functional capacity among frail individuals for performing more intense and more variable physical tasks. background: while evaluation methods for skeletal muscle characteristics which are necessary to know the pathogenesis of sarcopenia are being considered, ultrasonography is attracting attention as a method simultaneously evaluate quantitative and qualitative evaluation of skeletal muscle. although we have found many, the statements that examined the relation between muscle thickness, echo intensity, physical function, and sarcopenia by quadriceps muscle ultrasonography in the previous report, there are few reports for the lower leg muscles. objectives: we conducted a study to examine whether the lower leg muscle ultrasonography is useful for evaluating sarcopenia index and muscle quality (muscle strength per unit muscle mass) evaluation in comparison with the quadriceps ultrasonography. methods: the participants were patients over years old ( males, females). the muscle thickness of the quadriceps muscle, tibialis anterior muscle, gastrocnemius muscle, soleus, and echo intensity were measured by ultrasonography, and the relationship between lower extremity muscle mass, muscle strength, physical function, and muscle quality was examined. results: the muscle thickness of quadriceps muscle, tibialis anterior muscle, soleus muscle was related to lower extremity muscle mass, grip strength, leg muscle strength, and only quadriceps muscle was related to gait speed. the echo intensity of the quadriceps, tibialis anterior, gastrocnemius was related to, grip strength, leg muscle strength, and only the tibialis anterior muscle was related to gait speed. the muscle thickness and the echo intensity of tibialis anterior muscle and soleus muscle are highly correlated with the quadriceps. the echo intensity of the tibialis anterior muscle, as well as that of the quadriceps muscle, showed a high correlation with the muscle quality of lower extremity. conclusion: concerning the assessment of sarcopenia using ultrasonography, muscle thickness and echo intensity evaluation by tibialis anterior muscle showed the same utility as them by the quadriceps muscle, and echo intensity of the tibialis anterior muscle can be a marker of muscle quality. lucena germano , cristiano dos santos gomes , juliana fernandes de sousa barbosa , , raysa freitas , , alvaro campos c. maciel , ricardo oliveira guerra ( ( background: phase angle (pha) is emerging as a measure of great clinical relevance provided through bioimpedance assessment and its related to health adverse outcomes such as osteoporosis and sarcopenia. on the other hand, poor physical performance as gait speed and grip strength in elderly is associated with poor health conditions. we hypothesized it is plausible that those two measures might be related and can be used as a tool in clinical practice. objectives: to investigate the relationship between pha and physical performance measures in community-dwelling older adults from brazil. methods: this cross-sectional study enrolled older adults of both sexes who had a comprehensive health evaluation including physical performance tests (gait speed and handgrip strength) and electrical bioimpedance screening. linear regression models were used to estimate the associations between pha and physical performance measures. results: the mean age of . ± . and . ± . for men and women respectively. hand grip strength (n: , ; p-value < , ) and gait speed (n: , ; p-value < , ) were independently correlated with pha. conclusion: pha could help to easily identify elderly on the onset of present heath adverse outcome and guide specific interventions by clinicians. shosuke satake , , kaori kinoshita , yasumoto matsui , background: in japan, we have a simple yes/no questionnaire to assess multiple functions in daily living for older adults; the kihon checklist (kcl). in the questionnaire, questions to assess mobile functions are included. objectives: we examined whether the -item questions in the physical domain of the kcl (kcl-phys) could be a surrogate of validated measurements of physical functions. methods: subjects were independent and ambulatory seniors aged years or older who had been consulted in our frailty clinic. all of them received grip strength test, dual energy x-ray absorptiometry, physical performance tests, cognitive examination, and the kcl questionnaire. among them, we excluded subjects with missing data, and with moderate cognitive impairments. we examined the relationships between scores of the kcl-phys and usual gait speed, short physical performance battery (sppb), and timed up and go (tug) with the spearman's rank correlation. the score of the kclphys were counted when the subject meets any criteria with each question as previously reported. also, we evaluated the cutoff point of the kcl-phys equivalent to slow gait speed (< . m/s), low sppb score (sppb < ), and slow tug (tug >= sec) with the receiver operating characteristic (roc) curve analysis. results: the mean values of age, body mass index, and prevalence of sarcopenia were . years old (women . %), . (kg/m ), and . (%), which were no differences between sexes. on the other hand, physical functions of gait speed, sppb, and tug were all worse in women than in men. relationships between the scores of the kcl-phys and usual gait speed, sppb, and tug were moderate with the coefficients of - . , - . , and . , respectively (p< . for all). the area under the roc curve of the kcl-phys score equivalent to slow gait speed, low sppb score, and slow tug were . , . , and . , respectively. the cutoffs were thought to be the best at points of the kcl-phys to identify low physical functions based on the youden index. conclusion: physical domain of the kcl could be a surrogate of assessments of physical functions in older people. yuji hirano , izumi kondo , tetuya nemoto , naoki itoh , hidenori arai (( ) national center for geriatrics and gerontology, japan; ( ) nihon fukushi university, japan) background: we have developed a new type of grip strength measurement that addresses the time axis in evaluating physical function. it can measure the dynamic force, response in gripping performance, and maximum grip strength. the "kihon checklist" (kcl) is used to screening the frail elderly, based on the japanese long-term care insurance system. however, the relationship between the gripping performance and kcl has not been well investigated. objectives: the purpose of this study was to introduce a novel automatic reading method for dynamic force parameters in gripping performance and to evaluate their relationship with the kcl. methods: the subjects comprised patients ( men, women, average age . ± . years) who visited the integrated healthy aging clinic (locomo-frail outpatient clinic in japanese) of our hospital. the four indices of grip force response measured were: reaction start time (rst), time constant (tc), maximum value of force (mvf), and force rising slope (frs). we examined the relationship between these four indices and seven categories of the kcl; activities of daily living (adl), physical functions and fall, nutrition state, oral functions, outdoor activities, cognitive functions and mood, using spearman's correlation coefficient. results: in the female right hand, the mvf was only significantly correlated with adl and overall scores; whereas, in the female left hand, the mvf and the frs were significantly correlated with many items (adl, physical functions and fall, nutrition state, outdoor activities, and cognitive functions). the time-dependent items (rst and tc) were significantly correlated with outdoor activities in the female left hand and significantly correlated with adl and oral functions in the male left hand. however, in the right hand, the time-dependent items were not correlated with any of items in kcl in both sexes. conclusion: our newly developed grip strength measurement system could automatically calculate not only the maximum grip strength but also the time response of the grip force. moreover, their relationship with kcl was clearly indicated. the relationship between detailed grip strength response indicators and kcl items differed between men and women, and the left hand was correlated with more items than the right hand. ranyah almardawi, rao gullapalli, michael terrin (university of maryland school of maryland, baltimore, usa) background: rotator cuff (rc) tear and shoulder pain are both highly prevalent in older populations. routine medical screening for shoulder dysfunction is uncommon for community-dwelling older adults. the disabilities of the arm, shoulder and hand (dash) survey estimates self-reported dysfunction of both upper limbs in a composite score. dash offers a quick method to identify older adults with potential dysfunction in either shoulder, which otherwise may go unrecognized during routine medical visits. objectives: . to determine if dash, american shoulder and elbow surgeons (ases) and simple shoulder test (sst) surveys are related to one another in older adults. . to assess dash, ases and sst score relationships to the sf- physical functioning (pf) subcomponent score, shoulder forward flexion range of motion (ff-rom) and shoulder abduction range of motion (abd-rom) in older adults. methods: cross-sectional study: twenty-three community-dwelling-older-adult volunteers [mean age, . ± . years; range, to years; female, %] with no history of rc surgery and no history of shoulder injury or shoulder physical therapy in the prior months completed shoulder magnetic resonance imaging (mri) and dash, sf- , charlson co-morbidity index (cci), katz activities of daily living (adls) and lawton instrumental adls (iadls) surveys. for the shoulder ipsilateral to mri, participants completed ases, sst, visual analog scale for pain (vas) surveys; and shoulder ff-rom and abd-rom. descriptive statistics and spearman rank order correlation (rho) were performed. results: frequencies: rc tear (supraspinatus tendon) on mri: . %; shoulder pain >= on vas: . %; no limitation (score= ) on katz adls: . %; no limitation (score= ) on lawton iadls: . %. means: cci, . ± . ; dash, . ± . ; ases, . ± . ; sst . ± . ; . ± . ; . ± . ; . ± . . range of correlation among dash-ases-sst surveys: (|rho|= . - . , p< . ). range of correlation for dash-ases-sst with sf- pf(|rho|= . - . , p< . ), p< . ), abd-rom (|rho|= . - . , p< . ). conclusion: dash, ases and sst correlate well, and all three surveys show a consistent relationship with sf- physical functioning, ff-rom and abd-rom. next steps would be to evaluate the feasibility of dash to identify older adults with shoulder dysfunction during routine medical visits. background: physical performance is closely associated with chronic diseases and dysfunction of numerous organ systems. old persons with chronic renal failure have shown the apparent decline in physical performance, especially in the end-stage. however, it is unclear whether the subclinical kidney dysfunction is associated with skeletal muscle function deficit in the elderly population. objectives: the aim of this study is to determine the association between renal function and skeletal muscle function deficit in old persons without nephropathy. methods: eight hundred fifty-four korean elderlies (female, . %) aged to years were included in the cross-sectional analysis. of the participants, elderlies (female . %) were available for the -year follow-up test session. all participants were interviewed face-to-face and received measures of anthropometry, body composition and serum biomarkers of metabolic diseases. estimated glomerular filtration rate (egfr) was calculated using the chronic kidney disease epidemiology collaboration (ckd-epi) equation based on serum creatinine concentration. skeletal muscle function deficit was defined as a combination of weakness and slowness based on the handgrip strength to body mass index ratio (hs/bmi, men < . , women < . ) and converted timed up-and-go to walking speed (tugspeed < . m/s). results: the subjects with <= egfr < ml/min/ . m showed significantly lower physical performance for muscular strength and functional mobility than those with <= egfr < and egfr > ml/min/ . m , respectively (all for p < . ). logistic regression analysis indicated the significant association between egfr and skeletal muscle function status even after adjustment for potential confounders (p for trend < . ). moreover, the prospective observational analysis by ancova showed the significant effects of enhancement in hs/bmi [f( , ) = . , p = . ] and tugspeed [f( , ) = . , p < . ] on the improvement in egfr during -year followup. conclusion: taken together, skeletal muscle function status is associated with even moderately reduced egfr in an older population. these results suggest that maintenance of physical and functional fitness may be a contributory factor for preserving renal function in elderly persons. rn, brazil) background: sarc-f is a brief and useful test to identify older people at risk of sarcopenia-associated adverse outcomes. previous studies with older populations have suggested that it may be useful to screen those with severe sarcopenia. its ability to screen sarcopenia among low-income brazilian older adults is still unknown and its association with sarcopenia diagnostic criteria may be useful to understand its utility among this population. objectives: this study aims to evaluate the validity of sarc-f in screening low muscle strength and low physical performance among a low-income sample of older adults. methods: in a cross-sectional study, community-dwelling older-adults (>= years old; men and women) from santa cruz (northeast brazil) answered the sarc-f questionnaire and were classified as sarcopenic (>= ) and non-sarcopenic (< ) according to sarc-f scores. they were also evaluated in relation to the sarcopenia criteria of muscle strength (handgrip strength) and physical performance (sppb). the cutoff of < kg for women and < kg for men were used to classify those with low muscle strength. a sppb score of <= was used to classify low physical performance. a chi-square test was used to assess the association between the sarc-f and the objective parameters of sarcopenia. sensitivity and specificity of the sarc-f according to the objective functional parameters were also assessed. results: the sample was composed by % of women, with mean age of . (± . ) years old. according to sarc-f, . % of the sample was sarcopenic. low muscle mass and low physical performance were identified in . % and . % of the sample respectively. sarcopenia was significantly associated to low muscle mass (p< . ) and low physical performance (p< . ). the sensitivity of sarc-f in identifying those with low muscle mass was of % and specificity of %. for low physical performance, sensitivity and specificity were of % and % respectively. conclusion: sarc-f has a moderate ability to identify the sarcopenia criteria of low muscle mass and low physical function among older adults from a low-income setting. since it is a simple measure, it can be advantageous for low-income and rural communities. background: menopause marks a critical transition towards older adulthood for women and studies suggest that it is associated to several sarcopenia parameters, such as muscle mass and physical functioning. understanding how the menopausal transition associates to sarcopenia diagnostic criteria may help to direct screening tests for middle-aged populations and to identify earlier those at higher risk of sarcopenia. objectives: to evaluate the association between menopausal status and sarcopenia diagnostic criteria (muscle strength, muscle quantity and physical performance). methods: in a cross-sectional study, communitydwelling women from northeast brazil ( - yearsold) were evaluated in relation to menopausal status using the stages of reproductive aging workshop classification (premenopausal, perimenopausal or postmenopausal) , and in relation to sarcopenia diagnostic criteria according to european working group on sarcopenia in older people (ewgsop ): muscle strength (grip strength -handheld dynamometer), muscle quantity (appendicular muscle mass adjusted for height through bioelectrical impedance) and physical performance (gait speed). association between menopausal status and sarcopenia criteria was evaluated with multiple linear regression models adjusted for covariates (current age, education, family income, walking, bmi, reproductive history). results: among the participants, . % were classified as premenopausal, . % as perimenopausal, and . % as postmenopausal. menopausal status was significantly associated to grip strength, since premenopausal women were significantly stronger than perimenopausal or postmenopausal women, even in the fully adjusted analyses (b= . ; % ci= . : . ). muscle quantity and gait speed were not significant according to menopausal status. conclusion: perimenopausal and postmenopausal status are associated with less muscle strength among middle-aged women. muscle weakness may be the first sarcopenia parameter that is affected by women's aging and should be tracked among middle-aged to women for early identification of sarcopenia risk.. background: we speculate maintaining good postural stability is the key to good adl in elderly patients. this is a preliminary study to evaluate which factor relates to good postural stability. objectives: we evaluated patients ( males and females) over years old. the average age was . years old ranging to . methods: we measured index of postural stability(ips) using gravicoder gw- manufactured by anima. the ips was adovocated by mochizuki in . it was defined following this equation; ips=log[(area of stability limit + area of postural sway)/area of postural sway). larger ips means better postural stability. the average ips in each age was already known. ips was calculated automatically through gravicoda. we devided these patients into two groups by the results of ips. group a with the patients whose ips was larger, group b with the patients whose ips was smaller than the average in their age. we compared the following items between the two groups. nutrition(albumin, calcium, magnesium, ferritin, vitamin b ,b , , -d , zinc in blood test) , bone status(bone density, % of yam), spinopelvic parameters (pelvic incidence(pi), lumbar lordosis(ll), pelvic tilt(pt) using whole spine x-ray photograph. results: ten patients were classified into group a and patients were into group b. the average age was . ± . years old in group a and . ± . in group b. in group a , ll and pt were respectively . , . . in group b, . , . . ll and pt were significantly different between the two groups. pi minus ll is an important indicator to determine the spino-pelvic balance. it is known that pi-ll< means good spino-pelvic balance. in group a, pi minus ll was . ± . . in group b, it was . ± . . according to nutrition and bone status, albumin was significantly higher in group b. conclusion: our results showed spino-pelvic alignment related to the postural stability. this suggests good spino-pelvic alignment is likely the key to good postural stability. background: physical performance is of main relevance for quality of life and independence in the community. identification of deterioration of physical performance helps to start early interventions to stay independently in old age. objectives: to determine physical performance of communitydwelling older adults above years by using a comprehensive geriatric assessment to find most sensitive tests for functional decline. methods: older community-dwelling adults aged +. analysis of baseline and (t ) and months (t ) of followup data of hand grip strength (hgs), stair climb power test (scpt), timed up and go test (tug), short physical performance battery (sppb), m gait speed ( mgs), -time chair rise test ( tcr), minute walking test ( mwt) and frailty categories according to fried. results are shown in mean (± sd) in total numbers and percentage. results: participants ( , y.± , ) were included, ( %) female. overall physical performance was on high level, above geriatric cut-offs for physical disabilities at baseline: (hgs female: , (± , ) (- , (± , )%) followed by scpt (- , (± , )%). all tests showed a decline except tcr (+ , (± , )%). conclusion: physically active, communitydwelling older people show a high level of functional performance, far from geriatric cut-offs indicating physical disabilities. nevertheless, after two years a clinically relevant reduction of strength in upper (handgrip) and lower extremities (stair climb) was detected. these data may be relevant for the identification of older individuals who may benefit from early intervention exercise programs to keep them physically independent as long as possible. tcr showed divergent results and could be of special interest for continuous measurements to identify gradual decreases in functional performance. background: sarcopenia is characterized by loss of skeletal muscle mass and strength and it is a frequent finding in oncology, being associated with reduced quality of life, impairment in the response to antineoplastic therapy and increased toxicity, especially in older patients. objectives: the aim of the present study was to evaluate the association between low muscle mass (lmm) assessed by computed tomography (ct) analysis and sarcopenia considering the revised european consensus published by the european working group on sarcopenia in older people (ewgsop ) with the variables of the comprehensive geriatric assessment (cga) in older oncological patients. methods: for this purpose, patients ( . % female; mean age of . ± . years) followed at the oncogeriatric outpatient clinic of a university hospital were enrolled. clinical data were obtained from electronic medical records and the skeletal muscle mass evaluation was performed using ct (in the height of the third lumbar vertebra). for lmm and sarcopenia classification, specific cutoff points were adopted. cga variables were compared between lmm and normal skeletal muscle mass (nsmm) and between sarcopenic and non-sarcopenic individuals. groups were compared by the independent t test (r core team®, p< . ). results: the most frequent tumors were breast, intestine, stomach and lung, at different stages of the disease. the prevalence of lmm was . % and the prevalence of sarcopenia was %. of all cga variables evaluated, hand grip strength ( , ± , ) and katz scale ( , ± , ) were associated with lmm and sarcopenia. conclusion: the results highlight the importance of early geriatric clinical assessment of older cancer patients, considering the association of cga variables with low muscle mass and most important, to sarcopenia, for the possible reversal of functional and nutritional impairments and for the indication or appropriate planning of cancer therapy. lygia paccini lustosa , patricia parreira batista , jéssica rodrigues de almeida , andré gustavo pereira de andrade , aimée de araújo cabral pelizari , stephanie aguiar , leani de souza máximo pereira (( ) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; ( ) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: functional tests in the older person reflect the integrity of the interrelationship between muscle mass and function, vascular, endocrine and neurological aspects of central and peripheral command. the reduction in functionality, muscle mass and strength associated with advancing age is related to the increase of circulating proinflammatory cytokines in plasma, which in turn predisposes the individual to negative repercussions, such as the development of chronic diseases, falls and disability. they can identify changes in the intrinsic capacity of the older people. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated community older women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all responded to clinical and demographic information, performed the short physical performance battery (sppb), timed up and go (tug) and plasma tests of stnfr and il- (elisa method). correlation analysis by spearman test. % significance level. approval by the research ethics committee/ ufmg (caae: . . . ). results: older women participated, with a mean age of . ± . y; number of comorbidities . ± . and medications in use of . ± . . mean of body mass index were . ± . kg/m . there was a significant negative relationship between the sppb test and stnfr (rho= . ; p= . ) and a significant positive relationship between tug and stnfr (rho= . ; p= . ). other relationships were not significant (p> . ). conclusion: older women with better functional capacity presented lower plasma dosage of stnfr . the results suggest influence between these variables -functional capacity, mobility and inflammatory process -and no causal factor can be attributed. in these case, longitudinal studies are needed to verify functional performance vulnerability factors and their causal relationship with circulating inflammatory mediators in plasma. however, these results point to the importance of evaluating these variables in daily clinical practice. patricia parreira batista , stephanie aguiar , andré gustavo pereira de andrade , jéssica rodrigues de almeida , leani de souza máximo pereira , lygia paccini lustosa (( ) physical therapy department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil; ( ) sports department -universidade federal de minas gerais, ufmg, eeffto, belo horizonte, mg, brazil) background: perceptions of health and well-being in the older people are identified as subjective aspects by the international classification of functioning (icf), with direct and indirect interference with overall performance, activities of daily living, social relationships and independence. subjective well-being is associated with the form of coping adopted with a health condition, adaptability and resilience. positive and negative physiological repercussions on functionality and interaction with the family and social network may be consequences of inadequate adaptation and perception of subjective well-being. objectives: to explore the relationship between subjective well-being, functionality and plasma indices of inflammatory mediators in community older wowen. methods: participated community older women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive changes (mini-mental state examination). all answered about clinical and demographic data and information about subjective well-being. they performed tests of functional capacity (short physical performance battery -sppb) and mobility (timed up and go -tug). plasma dosages of stnfr and il- were by elisa method. correlation analysis by spearman test. significance level of %. approval by the research ethics committee/ ufmg (caae: . . . ). results: elderly women participated, with a mean age of . ± . years; number of comorbidities . ± . , final sppb score . ± . , tug of . ± . seconds; body mass index of . ± . kg/m . there was a significant positive relationship between subjective well-being and sppb (rho= . ; p= . ) and tug (rho= . ; p= . ). other associations were not significant (p> . ). conclusion: the results showed a significant association of subjective well-being with functional capacity in the older women. however, this condition was not associated with inflammatory markers, suggesting the need for further studies. on the other hand, it can be thought that the identification of personal strategies and perception of health and well-being act as barriers and/ or facilitators in a functional rehabilitation process, indicating the need for a multidisciplinary approach. background: the united states census bureau projects a rise in the population aged and over from . million in to . million by . the projected rise in the elderly population represents an accompanying increase in geriatric syndromes. frailty is a common geriatric syndrome defined as a clinically recognizable state of increased vulnerability to adverse outcomes related to a decline in physiologic reserve. this decline in reserve places the individual at increased risk for poor health outcomes including falls, disability, hospitalization, institutionalization and mortality. various effective interventions for frailty are established in the literature. the body of knowledge on the role of technology in reducing frailty is less abundant. objectives: to summarize available evidence on frailty and technology use for community dwelling older adults. methods: a comprehensive search of computerized databases was conducted in the following databases published between - : cinahl, pubmed, and academic search complete. the prisma search strategy was utilized for this review. articles were included if they met the following criteria: ) focused on community dwelling adults aged and over; ) peer-reviewed; ) published in the english language; ) featured randomized controlled trials (rcts), cohort studies or qualitative research; and ) included an operationalized definition for frailty. results: the database searches yielded a total of articles. duplicates were removed. results were excluded based on title and abstract. relevant articles were retrieved for full text examination. articles were excluded based on inclusion/exclusion criteria. references of included articles were hand searched for relevant works. four additional relevant articles were identified. the final analysis included articles. conclusion: current research focuses on assessment and diagnosis as opposed to intervention studies. methodological weaknesses limit generalizability and validity of findings. few studies utilize frailty as an outcome measure thus, limiting available research directly related to frailty. emerging technologies represent potentially effective, flexible and integrative solutions for frailty assessment, monitoring and intervention in the home environment. more research is needed on the potential for technological tools as interventions for frailty in community dwelling elderly specifically, for the purpose of detection and prevention of pre-frailty. a study protocol. inae c. gadotti , raquel aparicio ugarriza , , fernanda civitella , jorge g. ruiz , , edgar ramos vieira ( ( ) background: there are several studies on the association of balance and gait impairments with frailty and falls in older adults. however, little is known about the associations between postural alterations, frailty and falls in older adults in general and among older veterans. also, inter-relations among postural alterations, balance, strength, gait impairments, falls and frailty in older adults are not well known. objectives: the objective of this study is to evaluate if postural alterations, gait and balance impairments are associated with falls and frailty in older veterans. methods: sixty veterans, years old or older, will participate on a voluntary basis. one-hour long assessments will be completed at baseline, , and months. participants will fill out a questionnaire including information on demographics (age, sex, height, and weight), health conditions, falls (history, characteristics, and fear of falls), mobility impairments, physical activity level, medication history, medication changes and adherence, and health care utilization. frailty status will be assessed based on fried's frailty phenotype. the following physical health variables will be assessed: sagittal head and neck posture using photogrammetry, spinal curvatures using flexicurve, deep neck flexors activation by performing the craniocervical flexion test with a pressure biofeedback, grip strength using a dynamometer, usual and fast gait analysis using a gaitrite, balance using a force plate, and lower limb functional strength based on chair stands in s. differences among the variables by frailty status and falls history will be assessed using manovas. results: the results will be presented at conferences and published in scientific journals. conclusion: the results of this study may inform interventions to reduce frailty and falls in older veterans and possible among non-veterans as well. background: the number of deaths caused by pneumonia is increasing. the guidelines for pneumonia recommend optimal application of antibiotics based on a pathogenoriented strategy. despite wide distribution of these guidelines, pneumonia demonstrates high mortality in aged people. thus, for developing the next strategy for pneumonia management in aged people, new targets are required. with aging, the loss of skeletal muscle mass and strength occurs, which is named sarcopenia. the sarcopenia phenotype is associated with malnutrition. little is known about relationship between muscles and pneumonia, however, we reported that aspiration pneumonia induced respiratory muscle atrophy. impaired swallowing and/or cough functions often induce pneumonia in aged people. the swallowing muscle weakness is associated with impaired swallowing function. the strong respiratory muscles generate effective cough, which clears the airways and prevents pneumonia. objectives: to investigate presently unknown relationships between onset or recurrence of pneumonia in aged people and; respiratory muscle strength; swallowing muscle strength; and malnutrition. methods: a cross-sectional cohort study consisted of patients aged -year-old and older admitted to the hospital by pneumonia, and controls. the respiratory muscle strength was measured by a hand-held multi-functional spirometer with a pressure sensing transducer. the swallowing muscle strength was evaluated by measuring tongue pressure. a bioelectrical impedance analysis evaluated muscle and body fat masses. malnutrition was evaluated by serum albumin level and body fat mass. results: the respiratory (both the inspiratory and the expiratory) and the tongue muscle strengths, body trunk muscle mass, serum albumin level, and body fat mass divided by height were lower in aged pneumonia patients than in controls. body trunk muscles include the respiratory and swallowing muscles. the multivariate logistic regression model showed the low inspiratory and expiratory respiratory muscle strengths, the low body trunk muscle mass divided by height , and the low serum albumin level as risk factors for onset of pneumonia. for recurrence of pneumonia within months after the onset of pneumonia, low body fat mass divided by height was a risk factor. conclusion: above findings suggest that the respiratory muscles and malnutrition as new targets of the new management strategy for pneumonia in aged people. background: more than % of the people with hiv are older than fifty years. data about this population are still scarce and mainly focused on comorbidity instead of on physical function and frailty. hiv-funcfrail cohort is one of the four european cohorts of older hiv adults launched in . objectives: our main objective in this work was to know the factors associated to physical impairment. methods: longitudinal prospective cohort study. patients from the "hiv-funcfrail: multicenter spanish cohort to study frailty and physical function in years or older hiv-infected patients" were included. eleven centers participated. we recorded sociodemographic data, comorbidities and variables related to hiv infection. physical function was measured by gait speed and sppb and frailty according to frailty phenotype. other components of the comprehensive geriatric assessment such as depression and cognitive impairment were evaluated too. results: were included. median age was . ( . - . ). . % were women. at baseline median cd count was . ( . - . ). viral load was undetectable in . %. % of the patients had > comorbidities and . % had polypharmacy. . % of the patients were able to walk independently and % were completely independent for the activities of daily living. more than half were prefrail, . % prefrail and . % were robust according to frailty phenotype. . % of the patients had a sppb score < and . % had a gait speed < . m/sg. in the univariate analysis we found association between physical impairment defined as sppb score < with: diabetes, copd, osteoarthritis, comorbidities number, moca test < , gds-sf > and age. but in the multivariate analyses the factors associated were just: polypharmacy ) p= . ], gds-sf > [ . ( . - . ) p= . ]. conclusion: functional impairment was prevalent among older adults with hiv in their middleage. polypharmacy doubles the risk of functional impairment and depression increases the risk three-fold. therefore, polypharmacy, depression and physical function should be assessed in all the older adults with hiv in order to implement early prevention intervention to avoid physical impairment. sophie bastijns, anne-marie de cock, maurits vandewoude, stany perkisas (university of antwerp, antwerp, belgium) background: acute sarcopenia is defined as a decline in muscle mass and muscle function within days after hospitalization or acute illnesses, sufficiently to meet the sarcopenia criteria. muscle ultrasound is an objective and non-invasive technique that can measure muscle quantity and quality. muscle elastography can furthermore measure muscle stiffness, which is regarded as an important qualitative parameter. objectives: the primary aim of the study is to assess the effect of acute hospitalization on muscle stiffness. the secondary aim is to evaluate other influencing parameters. methods: this study is a prospective, observational study. patients admitted for at least days to one of the geriatrics departments of the zna antwerp hospitals are included. rectus femoris (rf) and vastus lateralis (vl) muscle stiffness are measured through elastography on day of admission, and then every days until discharge. results: preliminary results show significant differences between rf and vl values in men, but not in women. in rf, a non-significant downwards trend is seen for elastography between day and day . in vl, a non-significant downwards trend is seen in women, but also a non-significant upwards trend is seen in men between day and day . in rf, a non-significant trend of decreasing stiffness is seen with increasing age in men, but an increase is seen in women. a significant negative correlation is seen between elastography of rf and vl on day and hand grip strength on day . conclusion: this study seeks to gain insight in parameters affecting muscle stiffness and of the evolution of muscle stiffness after acute illness or hospitalization. a trend of decreasing muscle stiffness is seen after seven days of hospitalization and illness. this study showed no direct relation between age and muscle stiffness. a decrease in muscle stiffness results in higher hand grip strength and therefore better muscle performance. more data and longer follow-up periods are needed and are expected by march . ainhoa indurain , , jennifer linge , mikael petersson , thobias romu , fredrik uhlin , , anders fernström , mårten segelmark , , olof dahlqvist leinhard (( ) departments of nephrology and medical and health sciences, linköping university, linköping, sweden; ( ) departments of acute internal medicine and geriatrics and medical and health sciences, linköping university, linköping, sweden; ( ) background: sarcopenia is a prevalent condition in hemodialysis patients and it´s associated with poor quality of life, hospitalization and mortality. recent research using magnetic resonance imaging (mri) has demonstrated the importance of proper body size-adjustment in the assessment of muscle mass, and that the addition of muscle fat infiltration reflecting muscle quality, improves functional correlations and prediction of hospitalization in sarcopenia. it is not yet demonstrated if this new mri method, combining body sizeadjusted muscle volume and muscle fat infiltration, improves the evaluation of sarcopenia in hemodialysis patients. objectives: to investigate if adverse muscle composition, defined using mri, predicts survival and comorbidity in hemodialysis patients. methods: in , patients on hemodialysis were scanned using rapid whole body fat and water separated mri. following years, survival and comorbidity index (nci) were recorded using electronic health care records. thigh muscle fat infiltration (mfi) and fatfree muscle volume (ffmv) normalized with height was assessed using amra research (amra medical, linköping sweden). a z-score describing the deviation from expected ffmv/height was calculated using sex and bmi-matched virtual controls (ffmvvcg) and mfi adjusted (mfiadj) was calculated using the sex-specific population mean. for these calculations, normative data from subjects in uk biobank was used. to estimate a combined muscle score (musclecomb), mfiadj and ffmvvcg were projected on the linear regression line describing the normal population relationship between mfiadj and ffmvvcg in the uk biobank dataset. spearman rank correlation was estimated comparing mfiadj, ffmvvcg and musclecomb to nci. wilcoxon signed-rank test was used to estimate the association to survival. roc values and confidence interval were also calculated. results: musclecomb (combined muscle score) was significantly correlated to comorbidity (p< . ) and predicted survival (p< . ) while mfiadj (adjusted muscle fat infiltration) and ffmvvcg (deviation from an individual´s expected muscle volume) did not reach significant level on either test. the roc values for predicting survival were . ( . - . ) for ffmvvcg, . ( . - . ) for mfiadj, and . ( . - . ) for musclecomb. background: frailty is a risk factor for cardiovascular disease (cvd). as declines in bone metabolism and impaired inflammatory response are often associated with frailty, bone analytes and inflammation markers involved in these signaling pathways may act as biomarkers of frailty-related disease progression. objectives: this study sought to examine differences in systemic bone analyte and inflammation marker concentrations based on cvd risk profile and frailty status. methods: females with no prior cvd were stratified into low or high cvd risk groups based on their framingham risk scores. frailty was assessed using the fried phenotype of frailty. greedy matching with pre-frailty as the exposure variable was used to identify a set of closely matched pairs in both the low and high cvd risk groups for a total of females in a case-control design. factorial anova was used to compare differences in log transformed concentrations of bone and inflammation analytes based on frailty status, cvd risk, and their potential interaction. results: differences for il- ( . ± . vs. . ± . pg/ml, p= . ), leptin ( . ± . vs . ± . pg/ml, p= . ) and tnfα ( . ± . vs . ± . pg/ml, p= . ) systemic concentrations were found with high cvd risk status compared to low. no differences in bone or inflammation analyte concentration were found based on frailty status, nor were any interaction effects. conclusion: there was a difference in inflammatory marker concentrations based on cvd risk status indicating that higher cvd risk is associated with impaired inflammatory response in females. there was no difference in bone or inflammation analytes in the pre-frail group compared to their robust peers as these females may be too early in the progression of frailty to have these signs of impaired bone health and inflammation. ( ) pancreato-biliary cancer center, gangnam severance hospital, yonsei university college of medicine, seoul, korea) background: biliary tract cancer (btc) is a highly lethal disease, and improved prognostication methods should be sought. sarcopenia (low muscle mass), poor muscle quality (low muscle attenuation) and excess adiposity (subcutaneous and visceral) can be surrogate markers of sarcopenia and related frailty. however this hypothesis has not been demonstrated conclusively in btc patients. objectives: to evaluate associations of all four body composition measures, derived from clinically acquired ct at the time of initial diagnosis, with overall survival in advanced btc patients. methods: we measured skeletal muscle index (smi), mean muscle attenuation (ma), visceral adipose tissue index, and subcutaneous adipose tissue index via computed tomography at the level of the l vertebra. clinical data were extracted from patients' charts. results: a total of patients ( % males, median age [range - ]) were included in this study, % were metastatic and % were recurrent disease. during the follow-up duration (median of . months; range . month to months), patients ( %) died. sarcopenia, defined as low l smi (lower than cm /m for women and lower than cm /m for men) was noted in patients ( %), and patients ( %) had low muscle radiodensity. for adiposity, % and % of patients had low subcutaneous and visceral fat, respectively. when we combined this four factors and grouped the patients, no risk group (n = ) had the best overall survival (median . months, % ci, . - . ), while the patients who suffered all the risk factors (n= ) showed the poorest survival (median . months, % ci, - . ) which was statistically significant (log-rank test < . ). this classification was independent factor for survival in multi-variate analysis along with other clinical factors, carcinoembryonic antigen (cea), neutrophil-to-lymphocyte ratio, white blood count, platelet, and cholesterol (hr . , % ci . - . ). conclusion: sarcopenia, ma, and adiposity independently predict mortality in patients with btc and can be utilized as surrogate markers for prognosis. background: frailty is a clinical syndrome of reduced systemic physiological reserve that phenotypically overlaps with heart failure. nt-probnp is a cardiac-specific marker that increases with ventricular stress, whereas growth differentiation factor (gdf- ) is a non-tissue specific systemic marker that increases with inflammation, tissue injury and possibly inflammageing. objectives: this study aims to determine if combination of nt-probnp and gdf- organised in a x matrix can classify cardiac dysfunction with and without frailty, non-cardiac frailty, and non-frailty. methods: this is a cross-sectional analysis of a prospective cohort study (phase ), undiagnosed heart failure in older adults (ufo), that recruited community-living older adults aged >/= years in a ratio of : : for robust, pre-frail and frail status classified by the frail scale. participants without a history of heart failure and meeting the eligibility criteria were entered into the study. nt-probnp and gdf- levels were measured using the roche cobas elecsys platform. echocardiography and -minute walk distance ( mwd) were documented. informed consent was obtained from all participants. the study was approved by the local institutional review board. ) was ascertained by correlation with abnormal echocardiographic diastology represented most prominently by increased left atrial volume index (r= . , p= . x e- ). conclusion: a x dual biomarker approach utilising nt-probnp and gdf- may assist in subclassification of cardiac (diastolic) dysfunction and frailty. background: frailty was occurred frequently in elderly and known as higher risk of mild cognitive impairment (mci) and dementia than healthy elderly. hippocampus, parahippocampus and entorhinal cortex as memory system is considered one of the key regions of dementia especially alzheimer's disease. in addition, atrophy of these regions presumably related to higher risk of alzheimer's disease. on the other hand, it is poor understood about neural substrates of relationships frailty and higher incident rates of mci and dementia. objectives: the purpose of this study, therefore, to clarify differences of atrophy level of hippocampus, parahippocampus and entorhinal cortex and total gray matter between healthy, pre-frail and frail in elderly. methods: a total , elderly were measured brain structure with t-mri, and , were fulfilled inclusion criteria in this study. structural brain images were preprocessed and total hippocampal volume was estimated using freesurfer v . . and ubuntu . lts. we classified participants into three groups as healthy, pre-frail and frail characterized by , or and or more of the following domains respectively: low activity, slowness, weight loss, exhaustion and weakness. we compared total gray matter or hippocampal volume between healthy, pre-frail and frail in elderly with one way analysis of covariance (ancova) adjusted for sex, age, educational years, drinking and smoking habit, geriatric depression scale points and estimated total intracranial volume (etiv) and multiple comparison using bonferroni correction. results: the prevalence of pre-frail and frail was . % and . % respectively. hippocampus, parahippocampus and entorhinal cortex volume were significantly decreased in elderly with frail compared healthy and pre-frail (hippocampus: p= . and p= . ; parahippocampus: p= . and p< . ; entorhinal cortex: p= . and p= . respectively). in contrast, total gray matter volume was not significantly difference between three groups. conclusion: hippocampus, parahippocampus and entorhinal cortex were atrophied in elderly with frailty compared healthy or pre-frail elderly. it might be neural substrates of higher risk of dementia in elderly with frailty. rasekh kashkosh , irina gringauz , jonathan weissmann , gad segal , , michael swartzon , abraham adunsky , , dan justo , (( ) geriatrics division, sheba medical center, israel; ( ) biomedical engineering department, israel; ( background: low alanine aminotransferase (alt) blood levels prior to rehabilitation are associated with poor rehabilitation outcomes in terms of low mobility and function in older adults following hip fracture. objectives: we have hypothesized that low alt blood levels prior to rehabilitation are also associated with -year mortality in this population. methods: included were older adults (age >= years, median age years, . % women) admitted for rehabilitation following hip fracture. alt blood levels were documented between one and six months prior to rehabilitation. excluded were patients with alt blood levels over iu/l possibly consistent with liver injury. the study group included patients with low ( iu/l or lower) alt blood levels, and the control group included patients with high-normal ( - iu/l) alt blood levels. the main outcome was all-cause mortality one year following rehabilitation admission. results: the study group included ( . %) patients with low alt blood levels, and the control group included ( . %) patients with high-normal alt blood levels. overall, ( . %) patients died within one year following rehabilitation admission. compared with the control group, patients with low alt blood levels had significantly higher -year mortality rates ( . % vs. . %, or . , %ci . - . ). cox regression analysis showed that low alt blood levels prior to rehabilitation were associated with -year mortality (hr . , %ci . - . ) together with peripheral vascular disease (hr . , %ci . - . ) -independent of age, gender, albumin serum levels, length of rehabilitation, and rehabilitation outcomes. conclusion: low alt blood levels prior to rehabilitation are associated with -year mortality in older adults following hip fracture. fawaz azizieh , dia shehab , khaled al jarallah , renu gupta , raj raghupathy (( ) gulf university for science & technology, mubarak al-abdullah area, kuwait; ( ) faculty of medicine, kuwait university, jabriya, kuwait) background: in addition to some well-characterized bone turnover markers, cytokines and adipokines have also been suggested to be linked to osteoporosis seen in menopause. however, there is much controversy on the possible association between these markers and bone mineral density (bmd). objectives: this study was aimed at measuring circulatory levels of selected cytokines and adipokines in postmenopausal women with normal and low bmd. methods: the study population included post-menopausal women, of whom had normal bmd, had osteopenia and had osteoporosis. circulatory levels of selected pro-resorptive (tnf-a, il- b, il- , il- , il- , il- ), anti-resorptive (ifng, il- , il- , il- , tgf-b) and five adipokine markers (adiponectin, adipsin, lipocalin- /ngal, pai- and resistin) were measured using the multiplex system and read on the magpix elisa platform. further, two bone turnover markers (p np, ctx) as well as estradiol levels were assayed from the same samples. results: while circulatory levels of cytokines were comparable between groups, women with low bmd had statistically significantly higher median circulatory levels of adipokines as compared to those with normal bmd. further, while levels of ctx were not different between the two groups; p np, p np/ctx ratio and estradiol levels were significantly lower in women with low bmd. levels of adiponectin, p np, p np/ctx ratio and estradiol correlated significantly with bmd of the hip and spine. conclusion: while the associations between the studied markers and bmd may be complex and multivariate, our data provide insights into the possible use of circulatory levels of cytokines, adipokines and bone turnover markers on the pathogenesis of postmenopausal osteoporosis. background: with the application of diffusion tensor imaging (dti), a few studies have found that some white matter (wm) structures were closely related to impaired gait speed. however, the evidence is still sparse and the wm structural association with overall lower-body physical function, which can be evaluated by short-physical performance battery (sppb), has never been investigated among older adults. objectives: the aim of this study is to explore the associations between wm structures (evaluated by dti parameters) and sppb scores among older adults. methods: data of participants ( ± years old), who were recruited in the multidomain alzheimer's preventive trial (mapt) study and with no dementia at baseline level, were analysed in this study. based on the functional magnetic resonance imaging data, dti parameters of fractional anisotropy (fa), mean (md), axial (ad) and radial diffusivity (rd) were calculated in wm structures that were annotated by the john hopkins university white matter parcellation atlas. linear regression was used to analyse the association between sppb score and each dti parameter while controlling for age, gender, body mass index, physical activity level, total intracranial volume, cardiovascular risk and time interval between the dti and sppb measurement. results: three dti parameters (the md and rd of left corticospinal tract, and the md of right cerebral peduncle) were associated with the sppb score at a p-value < . . conclusion: the findings indicate that wm structures of corticospinal tract and cerebral peduncle might be related to overall lower-body physical function of older adults. further studies on the changes of these wm structures with physical function alterations during ageing will be more informative. background: ct-derived skeletal muscle index and skeletal muscle density (smd) have been independently associated with mortality in older adults. although smd is a commonly used measure of myosteatosis on ct images, more novel muscle texture (i.e., radiomic) features may provide an alternative measure of muscle quality, independent of smd. there have been no prior studies on the association of ct-derived muscle texture features and mortality. objectives: to examine the association of skeletal muscle texture features with all-cause mortality in older adults from the national lung screening trial (nlst). methods: the relationship between ct-derived skeletal muscle texture and all-cause mortality over years was determined in , participants ( % women, age range - years, mean age . ) in the nlst. using ct images at the level of t vertebra, paraspinous muscle was automatically segmented using machine learning algorithm, and muscle texture features determined using pyradiomics. second order (and higher) texture features were grouped into categories: gray level dependence matrix (gldm), gray level co-occurence matrix (glcm), gray level run length matrix (glrlm), gray level size zone matrix (glszm), and neighbouring gray tone difference matrix (ngtdm). muscle texture features often indicate greater or lower heterogeneity/complexity of an image. associations between standardized muscle texture variables and all-cause mortality were determined using cox proportional hazards models, adjusted for age, sex, race, body mass index, pack years of smoking, presence of type diabetes, chronic lung disease, cardiovascular disease, cancer at enrollment, and smd. multiple comparisons were accounted for using false discovery rate testing. results: after a mean . ± . years of follow-up, ( . %) participants died. in fully adjusted models, the following muscle texture features were associated with mortality: gldm-dependenceentropy (hazzard ratio (hr) per standard deviation (sd)= . , p< . ), gldm-dependencenonuniformity (hr per sd= . , p= . ), gldmsmalldependencelowgraylevelemphasis (hr per sd= . , p< . ), glrlm-graylevelnonuniformity (hr per sd= . , p< . ), glszm-small area low gray level emphasis (hr per sd= . , p= . ), ngtdm-coarseness (hr per sd= . , p= . ), ngtdm-strength (hr per sd= . , p= . ). each of these associations were in the direction that suggested greater heterogeneity of the image was associated with increased mortality. conclusion: in a large multicenter cohort of community-dwelling older adults, ct-derived muscle texture features indicating greater heterogeneity were associated with mortality, independent of common covariates including skeletal muscle density. background: growth differentiation factor (gdf ) has been related with disease progression, mitochondrial dysfunction, and mortality. elevated gdf- level was recently reported to be associated with poorer physical performance in very healthy community-dwelling adults. however, until now, the relationship of serum gdf- level with sarcopenia in community-dwelling older adults has not been well characterized. objectives: this study aimed to investigate the association between serum gdf- levels and sarcopenia in community-dwelling older adults. methods: we analyzed participants (mean age, . ± . years; . % men) who underwent measurement of serum gdf- level and sarcopenia parameters, using their baseline data from the korean frailty and aging cohort study. participants with reduced kidney function, specifically an estimated glomerular filtration rate (egfr) from creatinine of < ml/min/ . m , were excluded. serum gdf- level was quantified with an enzyme-linked immunosorbent assay kit. appendicular skeletal muscle mass was measured using dual-energy x-ray absorptiometry. sarcopenia status was determined in accordance with the asian working group for sarcopenia (awgs) guidelines. results: according to the awgs algorithm, ( . %) of the participants in the whole study population were classified as having sarcopenia. gdf- concentration had significant negative correlations with appendicular lean mass (men, r = - . , p < . and women, r = - . , p = . ), grip strength (men, r = - . , p = . and women, r =- . , p = . ), and gait speed (men, r = - . , p = . and women, r = - . , p = . ). in the multivariate analysis adjusted for potential confounders, the highest gdf- quartile (>= pg/ml) was associated with a greater risk of sarcopenia (odds ratio [or] = . ; % confidence interval [ci], . - . ) than the lowest quartile (< pg/ml). these associations remained unchanged (or = . ; % ci, . - . ) after further adjustment for potential biomarkers (e.g., myostatin, dehydroepiandrosterone, and insulin-like growth factor- ). the or per unit increase in log-transformed gdf- level was . ( % ci, . - . ). conclusion: higher circulating gdf- levels were independently associated with a greater risk of sarcopenia in community-dwelling older adults. gdf- may be considerate a promising biomarker of sarcopenia. background: frailty has been recognized as an emerging public health problem in rapidly aging populations worldwide. use of biomarkers to identify frailty has been suggested for early frailty screening. among multiple risk factors of frailty, inadequate nutrition such as inadequate intake of protein and vitamin d has been shown to be associated with increased risk of frailty. therefore, nutritional biomarkers could be useful for early screening of frailty. objectives: to review the evidence of potential biomarkers, especially nutritional biomarkers for early screening of frailty in community-dwelling older adults. methods: a literature search was conducted using pubmed and scopus databases. studies evaluating blood biomarkers and frailty in community-dwelling older adults from to were included. information on the definition of frailty, study design, characteristics of the study populations, and the associations between biomarkers and frailty was summarized. results: in total, studies were identified in which observational studies were published since . majority of studies used physical frailty. other definitions such as multidimensional, social and frailty were also used. biomarkers were identified. cross-sectional and longitudinal studies consistently showed that low level of vitamin d was associated with frailty. emerging scientific evidence suggested that abnormal level of albumin, low levels of high-density lipoprotein (hdl), beta-hydroxy beta-methylbutyrate (hmb), vitamin b (measured by pyridoxal- -phosphate), carotenoids, or a-tocopherol (vitamin e), and high level of dp-ucmgp (marker of vitamin k) could have the potential for frailty screening. besides nutritional biomarkers, the evidence showed that inflammatory markers such as c-reactive protein (crp), interleukin- (il- ), and fibrinogen, and endocrine-related markers such as hemoglobin, dehydroepiandrosterone sulfate (dheas), and hemoglobin a c could be useful for screening frailty. additionally, there is evidence suggesting that some oxidative or immune-related markers were associated with frailty. conclusion: vitamin d could be a useful nutritional biomarker for early frailty screening in the community setting. other nutritional biomarkers, inflammatory markers and endocrine-related markers could be associated with frailty. further research is needed to validate and refine other potential biomarkers. jonathan quinlan , , , amritpal dhaliwal , , felicity williams , , matthew armstrong , , leigh breen , , , ahmed elsharkawy , , carolyn greig , , , janet lord , , ( ( ) background: end stage liver disease (esld) is associated with reduced muscle mass with a reported incidence of sarcopenia of - % (bhanji, ). loss of muscle mass in esld patients has a negative impact on clinical outcomes including mortality and recovery rates from liver transplantation (montano-loza, ) . previous research has investigated loss of muscle mass in esld via appendicular skeletal muscle mass and psoas muscle cross sectional area (csa) using dxa and magnetic resonance imaging (mri) respectively. however, the quadriceps muscle group has high functional significance and thus should be investigated in esld patients in whom function may be limited. ultrasound (us) offers a non-invasive, bedside imaging assessment of quadriceps muscle mass. however, esld may be associated with increased subcutaneous fat which can present an operational challenge for us and thus its application in esld patients requires validation. objectives: the aim of this research is to validate the accuracy of ultrasonographic measures of quadriceps muscle mass by comparison with the gold standard of mri. methods: parallel mri and us were collected from patients with an esld diagnosis and awaiting liver transplant ( patients, age ± yrs, bmi . ± . ). participants underwent us scanning of both left and right quadriceps followed directly by an mri. specifically, measures of vastus lateralis (vl) muscle thickness (mt) and quadriceps csa were obtained at % femur length during longitudinal and extended field of view us respectively. to enable direct comparison with quadriceps csa obtained during mri, an oil capsule was placed upon the leg to mark the exact location of us image collection. all procedures received research ethics committee approval and written informed consent from the participants. results: a significant (p< . , n= ) positive correlation was found between vl mt and quadriceps csa obtained via mri (r = . ). similarly, there was a significant positive correlation (p< . , n= ) between csa obtained via extended field of view us and mri (r = . ). bland-altman plots demonstrated a bias of - . ± . cm , with % limits of agreement of - . cm and . cm . conclusion: our data demonstrate that the assessment of quadriceps csa and vl mt via us may offer a suitable bedside alternative to mri in patients with esld. background: sarcopenia is defined as the gradual ageassociated loss of both muscle quantity and strength in older adults, and severe sarcopenia affects subject performance (such as reduced gait speed). it is a devastating condition, predicting an increase in mortality, falls, fractures and hospitalizations. current clinical criteria diagnose sarcopenia through dual x-ray absorptiometry (dxa) measures of muscle mass, a test that cannot be performed at the bedside and is rarely used to find this condition. point-of care ultrasound (pocus) is rapidly becoming a standard part of the physical exam, and has the potential to become a quick, noninvasive marker for both muscle mass and function. objectives: we examined the relationship between ultrasound measures of muscle mass (vastus medialis thickness, mt) and other measures of muscle quantity (appendicular skeletal mass, asm; mid-arm biceps circumference, mabc). we also examined the association between mt and measures of muscle strength (grip strength) and muscle performance (gait speed) in an older adult population. methods: older adults (age >= ; mean age . ± . years, women, men) were recruited sequentially from geriatric medicine clinics. each subject had appendicular skeletal muscle mass (asm, by bioimpedance assay), grip strength, mid-arm biceps circumference (mabc), gait speed, and an ultrasonic measure of muscle quantity (mt, vastus medialis muscle thickness) measured. our initial models contained age, sex, bmi, and mt as predictor variables, and our outcome variables were asm, grip strength, mabc and gait speed. results: in our final parsimonious models, mt showed a strong significant correlation with all measures of muscle mass, including asm(standardized ß= . ± . , r = . , p< . ) and mabc(standardized ß = . ± . , r = . , p= . ). with respect to measures of muscle quality, there was a strong significant correlation with grip strength (standardized ß = . ± . , r = . , p= . ) but not with subject performance (gait speed). conclusion: mt showed strong correlations with both measures of muscle mass (asm and mabc) and with muscle strength (grip strength). riki kosugi , yung-li hung , toshiharu natsume , shuichi machida (( ) faculty of health and sports science, juntendo university, inzai, chiba, japan; ( ) institute of health and sports & medicine, juntendo university, inzai, chiba, japan; ( ) coi project center, juntendo university, bunkyo-ku, tokyo, japan; ( ) graduate school of health and sports science, juntendo university, inzai, chiba, japan) background: loquat (eriobotrya japonica) leaves are commonly used in teas and folk medicines. recently, loquat leaf extract (lle) has been reported to promote muscle protein synthesis in vitro. additionally, resistance exercise has been shown to promote muscle protein synthesis in vivo. it is considered that lle and resistance exercise might have a synergistic effect on activating muscle protein synthesis. however, this has never been investigated. objectives: the purpose of the present study was to investigate whether lle enhances the muscle contraction-induced activation of muscle protein synthesis signaling in rats. methods: male wistar rats ( weeks old, n= - /group) were categorized into a control (con) group, an lle-administered (lle) group, an electrical muscle stimulation (ems) group , and an ems with lle (ems+lle) group. rats were administered lle ( . g/kg/ day) or distilled water once in a day by oral gavage for days. on the seventh day, h post-lle administration, the gastrocnemius muscle of the right legs of ems group and ems+lle group rats were stimulated by ems ( hz, v) through sets of isometric contractions ( s contraction, s rest) with min inter-set intervals. rats were then sacrificed and their gastrocnemius muscles were rapidly excised h post-ems. expression levels of muscle synthesis-related proteins [protein kinase b (akt), mammalian target of rapamycin (mtor), and ribosomal protein s kinase beta- (p s k)] were determined by western blotting. results: no significant differences were observed in body weight, water intake, and diet intake among the groups. akt phosphorylation at ser was found to be significantly increased in the ems+lle group compared to that in con group; mtor phosphorylation at ser did not show a significant difference. p s k phosphorylation at thr was found to be significantly increased in the ems group compared to that in con group, while the ems+lle group was observed to have significantly higher p s k phosphorylation at thr than the ems group. conclusion: our study suggests that lle enhances the muscle contraction-induced activation of p s k phosphorylation. background: metabolic aging has emerged as a new sedentarity related syndrome combining metabolic diseases and sarcopenia, a degenerative loss of skeletal muscle mass, quality, and strength associated with aging. it has been recently shown that kynurenic acid (ka), a key metabolite of tryptophan/ kynurenine pathway, improved glycemic control and lipid profile in rodents. objectives: to show that ka has a key role in metabolic aging, we have evaluated its effect on muscle function and mass in vitro and in vivo in muscle cell line and in a model of hindlimb immobilization in mouse. methods: in vitro in c c muscle cells we measured the ability of ka to inhibit myostatin gene expression (endogenous inhibitor of muscle growth), stimulate protein synthesis and enlarge muscle cell size. differentiated cells were exposed to ka for h for protein analysis, h for gene study and the days of differentiation for cell enlargement examination. in vivo, muscle mass (tibialis and soleus) was measured after a week-hindlimb immobilization in mice treated or not with ka ( mg/kg.day per os). results: in vitro, ka significantly and dose-dependently inhibited myostatin gene expression, stimulated protein synthesis and enlarged c c muscle cells. in mice, ka treatment significantly reduced tibialis and soleus muscle wasting induced by immobilization. conclusion: we demonstrated for the first time the positive impact of ka on muscle function and mass preservation offering a promising therapy for patients affected by metabolic aging, who do not currently benefit from relevant therapeutic solutions. Â n g e l a m a r i a p e r e i r a , , , a n a f r e i t a s , a n a p a c i f i c o , c a t a r i n a c o s t a , m a r g a r i d a a l m e i d a (( ) physiotherapy departement, escola superior de saúde egas moniz, portugal; ( ) centro de investigação interdisciplinar egas moniz, monte da caparica, portugal; ( )hospital garcia de orta, almada; portugal) background: as people age they are more likely to fall. although most fall-related injuries are minor, they can cause significant pain and discomfort, affect a person's confidence and lead to loss of independence. some falls can cause serious long-term health problems. one strategy to promote greater adherence and motivation to intervention in physical therapy is the use of virtual environment (ve) programs associated with a balance exercise programs as an effective method of preventing falls. objectives: the purpose of this study was to analyze the benefit of a virtual environment exercise program in non-institutionalized elderly at the end of six weeks. methods: in this randomized controlled trial non-institutionalized elderly were included. subjects, age . ± . yrs constituted the experimental group (eg); and , age, . ± . yrs constituted the control group (cg). the eg was submitted to weeks of a ve exercise program performed on a nintendo wii, and to a set of recreational activities. the cg only performed the activities. the instruments used in the present study to evaluate performance were tinetti's index, which evaluates the static balance and the gait to quantify the risk of fall, and the fullerton's functional fitness tests to assess physical parameters such as strength, aerobic endurance, flexibility and agility/ balance. results: at the end of the weeks of intervention in a virtual environment, significant improvements in upper limb strength, agility and static balance were observed. in the intragroup comparison, it was possible to verify improvements in all physical fitness battery tests. the values of functional fitness tests were significantly different (p<. ) between eg and cg groups for the following variables: -second chair stand . ± . vs. . ± . times; arm curl . ± . vs. . ± . times; -foot up-and-go . ± . vs. . ± . sec; two min. step . ± . vs. . ± . steps, respectively; as well as for the tinetti index. conclusion: this study, suggests that exercise in ve context applied to non-institutionalized elderly, promotes improvements in mobility, in lower limbs muscular strength, and may help to reduce the risk of falls by improving the static and dynamic balance. background: the small non-coding micrornas (mirs) are endogenous regulators of gene expression. they bind to complementary sequence on target messenger rna transcripts resulting in translational repression or target degradation. they are involved in the skeletal muscle response to training in animals and humans (kirby, ) . objectives: the aim of our study was to measure the effects of high intensity interval training (hiit) associated or not with l-citrulline on the expression of serum and muscle mirs in a group of men. methods: we selected men (mean age: . ± . years, men in the placebo group and in the l-citrulline group, gr/day) from a cohort of men and women submitted for weeks to hiit (buckinx, ) . we evaluated the expression of serum and muscle mirs before and after training. the quantification of mir expression was performed using the next generation sequencing (ngs) technique (exiqon). for statistical analysis, the measurements were normalized with the tmm method (trimmed mean of m-values). results: we identified mirs from serum and mirs from muscle above the detection limit (>= tpm, tags per million). after benjamini-hochberg correction, serum mirs from the l-citrulline group had a significantly different level of expression before and after training: - p, b - p, , a- p and - a- p (p < . , % fdr). no mir of the placebo group had a significantly altered expression. in muscle, our approach revealed mirs with a significantly different level of expression before and after training in the placebo group and in the l-citrulline group, of which were common to both groups. these mirs were different from those highlighted at the serum level. the most-expressed muscle mirs with the greatest difference in expression before and after training were - p, - p, - p, - p and b- p (p < . , % fdr). conclusion: with the ngs approach, we identified mirs differentially expressed before and after hiit. expression of circulating mirs appears to be influenced by l-citrulline. the next validation step will be to measure these specific mirs in the entire cohort to determine the clinical utility of these markers. background: recent interventional studies on frailty used multicomponent programs (physical exercise, cognitive stimulation, and nutritional supplementation) with some promising results. however, these emerging programs developed to counter the multidimensional concept of frailty still need methodological improvements to be completely effective. objectives: the objective of this innovative project is to develop personalized multicomponent interventions that could be easily used by frail older adults in order to reverse physical, cognitive and psychosocial symptoms associated with frailty. three original and specific action levers will be used to insure a better effectiveness: /to target a key population (hospitalized frail older adults who will be discharged to home), /to use a real multicomponent program (physical exercises simultaneously associated with cognitive and social components that mimic daily gestures), and /to encourage adherence through medical prescription. methods: one hundred and twenty frail older adults (>= ) will be recruited from the geriatrics unit of the university hospital of tours (france), and randomly assigned to one of the two study arms: the intervention group (ig), who will receive a medical prescription of an adapted multicomponent intervention, vs the control group (cg; no intervention). twelve-week programs will be adapted according to observed intrinsic capacities of the frail older adults. including exercises will be based on effective international physical programs, with original cognitive and social components added to the physical exercises. all participants will perform pre-and post-tests to compare their physical health (gait speed, balance, and strength), cognitive health (global cognition and executive functions), and psychosocial health (self-efficacy and quality of life) before and after the three-month program. results: a pilot study to this rct has already started in tours. the international conference on frailty and sarcopenia research would be the perfect opportunity to share preliminary results. the intervention will be considered as feasible if ig participants adhere to > % of the prescribed exercise and as effective if we observe significant improvements in all clinical outcomes for ig participants, compared to the cg. conclusion: final objective will be to disseminate to a large number of individuals the idea that several concrete ways exist to age well. amanika kumar, clarissa polen-de, gladys asiedu carrie langstraat, aminah jatoi (mayo clinic, rochester, minnesota, usa) background: frailty in patients with advanced stage ovarian cancer (oc) is common and associated with increased oncologic and surgical morbidity and mortality. prehabilitation is one option to reverse frailty in this subset of patients. objectives: our aim was to investigate potential barriers and facilitators of prehabilitation during neoadjuvant chemotherapy (nact) in oc patients. methods: we identified patients who underwent nact from - at a large volume single institution. patients underwent a semi-structured one-on-one phone interview. transcripts from interviews were read by independent reviewers to identify emerging themes related to patients' experience, functioning and exercise during chemotherapy. results: five primary themes emerged following analysis of the participants transcripts. participants were overall willing to participate in exercise during chemotherapy, with / patients stating they would walk or did walk at least minutes daily during treatment; this was linked to a strong motivation to improve surgical and survival outcomes. only / patients stated they were not interested in exercise during treatment. most notable, patients' motivations were tied closely to physician recommendation. patients prominently identified a shift in health as a priority following their ovarian cancer diagnosis, which subsequently lead to an increase in daily activities and exercise. surgery and improvement in mental well-being were strong motivators for patients to start or continue an exercise program. participants also identified barriers to exercise during treatment including a variety of treatment related and nontreatment related concerns, including neuropathy, nausea, pain, program availability, time and most significantly fatigue. despite this, most retrospectively thought they would have been willing to exercise with modifications. almost all participants voiced the importance of a supportive treatment community, including their medical care team, family, friends and the local community. conclusion: patients with advanced ovarian cancer demonstrated high motivation and willingness to exercise during chemotherapy when there was a perceived benefit to overall survival. prehabilitation may be a helpful to improve outcomes, but a prehabilitation strategy should be designed specifically for the patients with the most need and designed with barriers and motivators in mind. randomized control trial. kosuke fujita , , hiroki umegaki , aiko inoue , huang chi hsien , , hiroyuki shimada , masahumi kuzuya , (( ) institute of innovation for future society, nagoya university nagoya, japan; ( ) department of community healthcare and geriatrics, nagoya university graduate school of medicine nagoya, japan; ( ) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology obu, japan) background: gait disorder in older adults could lead fatal consequence following falling or reducing physical activity, especially in individual with pre-clinical / clinical cognitive decline. effectiveness of exercise intervention for the gait characteristics has been examined in previous studies, however, evidence about differences between exercise modality such as aerobic training (at) and resistance training (rt) for the acute and long phase is unclear. objectives: the aim of the present study was to compare the effect of different exercise modality on the gait characteristics of older adults with preclinical cognitive decline. methods: individuals (mean age, . years) with self-reported cognitive decline were enrolled in randomized controlled trial. subjects assigned to at group (n = ), rt group (n = ) and at+rt group (n = ) underwent exercise intervention days a week for weeks. subjects assigned to control group (n = ) were provided information about healthy aging. gait characteristics were examined before, just after the intervention and after the weeks of follow-up period using an electronical walkway system. results: in the analyses about the change between pre and just after the intervention period, all of three exercise groups significantly improved gait velocity (at, p < . ; rt, p < . ; at+rt, p < . ), stride time (at, p < . ; rt, p = . ; at+rt, p < . ), cadence (at, p < . ; rt, p = . ; at+rt, p < . ), stride length (at, p < . ; rt, p = . ; at+rt, p < . ) and double support time (at, p < . ; rt, p < . ; at+rt, p < . ), and at+rt group improved significantly with cv of step width (p < . ). in the analyses about the change between pre and follow-up period, rt group only had improvements with gait velocity (p < . ), stride length (p = . ) and double support time (p = . ). conclusion: all exercise interventions could improve gait characteristics of older adults with pre-clinical cognitive decline. for the purpose of maintain improved gait characteristics for a long phase, rt is likely to be recommended. activity and a broader array of physical and psychological outcomes among nursing home residents. however, some limitation of this game should be acknowledged (e.g. too long, too bulky, exercises too simple). taking into account these weaknesses, we decided to develop and validate a new version of a giant exercising board game: the gamotion. objectives: to evaluate the impact of gamotion on physical capacity, motivation and quality of life among nursing home residents. methods: a one-month randomized controlled trial was performed in two comparable nursing homes. eleven participants ( . ± . years; men) meeting the inclusion criteria took part in the intervention in one nursing home, whereas participants ( ± . years; men) were assigned to the control group in the other institution. the gamotion required participants to perform strength, flexibility, balance and endurance activities. the assistance provided by an exercising specialist decreased gradually during the intervention in an autonomy-oriented approach based on the selfdetermination theory (ryan & deci, ) . physical capacity (i.e. quantitative evaluation of walking using locometrix; grip strength using jamar dynamometer; knee extensor isometric strength using microfet ; fall risk using tinetti test; dynamic balance using timed up and go test (tug) and physical abilities using sppb test), motivation (i.e. using behavioral regulation in exercise questionnaire- ) and quality of life (i.e. using eq- d questionnaire) were assessed at baseline and at the end of the intervention. a two-way repeatedmeasure analysis of covariance (ancova) was used to assess time*group (intervention vs. control group) effects. results: globally, during the intervention period, the experimental group displayed a greater improvement in symmetry of steps (p= . ), tinetti score (p< . ), tug (p= . ), sppb (p< . ), knee extensor isometric strength (p= . ), grip strength (p= . ), domains of the eq- d (i.e. mobility, self-care, usual activities : p< . ) and intrinsic motivation (p= . ) compared to the control group. conclusion: the effects of gamotion on physical capacity, motivation and quality of life of nursing home residents confirm the results obtained with the previous version of the giant exercising board game. in-hospital stay, even in short stays, is associated with functional impairment in older patients. objectives: the agecar plus study aims to evaluate the effectiveness of a program of physical exercise and health education to prevent the functional deterioration during the in-hospital stay. methods: randomized clinical trial. patients older than years admitted to the ace of the general university hospital gregorio marañón were included and randomized at admission in control group (cg) or intervention group (ig). exclusion criteria were baseline barthel ( days before admission) less than points, severe cognitive impairment or unable to walk. both groups received usual care, and patients in intervention group also performed simple supervised exercises (strengthening of lower limbs, walking, and inspiratory muscle training). in the preliminary analysis, we analyzed the effect of the intervention on changes in short physical performance battery (sppb) and alusti test, at admission and discharge, by t-test of repeated measures in the study periods. results: from may to february , patients were included: gc and ig. the cg and ig were homogeneous in sex (women . %), age ( . ± . vs. . ± . ), comorbidities (charlson: . ± . vs. . ± . ), cognitive impairment (pfeiffer: . ± . vs. . ± . ), fragility (fried >= : % p= . ), and functional-physical capacity (sppb: . ± vs . ± . ; alusti, . ± . vs . ± . ). p < . for all variables. a significant effect of the intervention was found, with a higher mean score in the alusti test in the ig (cg: . ± . vs . ± . ; f( , )= . ; p= . ), not finding such differences with the sppb ( . ± . vs . ± . ; f( , ) = . ; p= . ). conclusion: the preliminary analysis shows that the alusti test could be used as an evaluation test for functional capacity in hospitalized elderly patients. a physical exercise program during hospitalization in an acute unit improves the functional capacity assessed by the alusti test at discharge significantly. funding: instituto de la salud carlos iii (pi / ), ciberfes, fondo europeo de desarrollo regional (feder). the authors declare no conflicts of interest. a. sampaio , i. marques-aleixo , , j. carvalho (( ) ciafel -research center in physical activity, health and leisure, faculty of sport, university of porto, portugal; ( ) faculty of psychology, education and sports, lusófona university of porto, portugal) background: cognitive impairment is a highly prevalent, poorly managed, and disabling consequence of dementia. exercise training that improves physical fitness can represent a promising approach for managing cognitive impairment in persons with dementia. objectives: the aim of this crosssectional study investigated the association of physical fitness and balance with cognitive function. methods: sixty-four institutionalized older adults, aged . ± . years, with dementia, predominately female ( %) and with dementia due to alzheimer's disease ( . %). regression analyses were used to examine associations between physical fitness components (senior fitness test), balance (tinetti index) and cognitive function (mini-mental state examination). results: univariate regression indicates a significant association between the strength of the upper body (p= , ) and aerobic endurance (p= , ) with the cognitive function in older people with dementia. conclusion: these results suggest an association between the specific dimensions of physical fitness and cognitive function. consequently, multicomponent exercisebased therapeutic strategies aiming to improve physical fitness could be an important nonpharmacological strategy for dementia management. satoshi kurita, takehiko doi, kota tsutsumimoto, sho nakakubo, hideaki ishii, hiroyuki shimada (section for health promotion, department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan) background: women had higher risk of cognitive impairment or dementia compared to men. although studies reported physical activity (pa) and/or cognitive activity (ca) had protective association with cognitive impairment among older adults, it is unknown whether the association is depended on sex or not. objectives: the purpose of the present study was to examine the sex differences in the association of pa and/or ca with cognitive impairment in community-dwelling older adults. methods: a community-based cohort survey was conducted in a total of participants (mean age . ± . years; . % female) who met the study criteria. time of moderate-to-vigorous intensity pa was measured using an accelerometer. ca was assessed by the frequency of engaging in activities using a ca scale including reading, doing crossword puzzles, and playing board games or cards. participants were categorized into four groups based on quartile (low) and to (high) values of pa and ca. cognitive impairment was defined by at least out of neuropsychological tests having a result at least . standard deviation below the reference threshold. results: in both sex, the prevalence of cognitive impairments showed significant differences among groups; that of low pa/low ca group, low pa/high ca group, high pa/low ca group, and high pa/high ca group were respectively . %, . %, . %, and . % for male (p < . ) and . %, . %, . %, and . % for female (p < . ). in binomial logistic regression models for male, all groups showed a low odds ratios of cognitive impairment compared to the low pa/low ca group (odds ratio = . to . , all p < . ), while for female, only high pa/high ca group had significant association with cognitive impairment (odds ratio = . , % confidence interval = . to . , p = . ). conclusion: in male, pa and ca are associated with cognitive impairment even in the case of low engagement in either pa or ca. in female, higher engaging in both activities are associated with cognitive impairment. female older adults may need to engage in more activities than male to acquire benefit on preventing cognitive impairment. ( interventions) were included in the systematic review and in the meta-analyses ( interventions). there was considerable heterogeneity in the number for interventions that detected significant increases in muscle mass ( / , %) and muscle strength ( / , %). of those muscle strength interventions / ( %), / ( %), / ( %) and / ( %) interventions reported a significant increase in handgrip strength, lower body muscle strength, upper body muscle strength and whole body muscle strength respectively. ret factors associated with the greatest gains in muscle mass and muscle strength were: use of combination of equipment, seven to eight exercises per session with three lower body exercises, a volume of three to four sets and to repetitions per exercise, a frequency of two-three days per week, intervention length of greater than six weeks, progressive intensity, intervention duration of - minutes, and in a supervised individually training structure. these results align with current guidelines provided by american, australian, japanese, british, canadian and japanese societies. conclusion: not all ret interventions are effective for improving muscle mass and strength, but our meta-analysis suggests that adhering to the current ret guidelines for older adults are likely to be most effective. duarte barros, andreia pizarro, arnaldina sampaio, joana carvalho (research center in physical activity, health and leisure, faculty of sports, university of porto, portugal) background: sedentary time (sed) and low physical activity (i.e. low levels of moderate-to-vigorous physical activity [mvpa] ) are different behaviours associated with negative health outcomes, but how synergetic combinations of these behaviours impact the risk of frailty are still unexplored. objectives: to examine the relationship between different combinations of sedentary time and mvpa in the risk of being frail. methods: a cross-sectional study including community dwelling elders ( . ± . years; . % female) accessed frailty through the phenotype of frailty. daily sed and mvpa were objectively measured using accelerometry. sed and mvpa were ranked by the median and then participants were categorized into one of four groups: lowsed+lowmvpa, l o w s e d + h i g h m v p a , h i g h s e d + l o w m v p a a n d highsed+highmvpa. results: overall, . % of the participants were frail. mvpa was associated with reduced odds of being frail (or . ic: . - . , p < . ). moreover, compared to the highsed+lowmvpa, the groups lowsed+highmvpa (or . ic: . - . , p = . ) and highsed+highmvpa (or . ic: . - , p < . ) were associated with reduced odds of being frail. conclusion: mvpa seems associated with reduced odds of being frail, irrespective of sedentary time. background: sarcopenia is central to frailty and the strongest evidence for reversal lies in the combination of resistance exercise and protein supplementation. unfortunately, uptake amongst older adults remains low, partly due to a lack of suitable exercise programs. delivery by health professionals alone will not achieve widespread participation. objectives: defrail aims to develop a novel exercise program (focused on resistance training), feasible for delivery to frail older adults in a group setting without the input of health professionals, and to examine its effect when combined with commercially-available protein-supplemented milk. methods: a multi-component exercise program was designed by expert consensus using a modified delphi process. participants were recruited from geriatric medicine clinics and primary care, with assessments at baseline, after eight weeks of regular activity and then after the eight-week intervention. the primary outcome measure was the change in the fried frailty criteria (ffc) during the intervention compared with the period of regular activity. secondary outcome measures included the timed up & go (tug) and -second sit-to-stand ( sts) tests. results: the first participants to complete the program ( females, males, mean age , range - ) had a median ffc score of (interquartile range (iqr) , ), i.e. frail, both at baseline and after the period of regular activity period, but had improved to (iqr , ), i.e. pre-frail, following the intervention. similarly, the median tug was . (iqr . , ) at baseline, increasing to . (iqr , . ) after the period of regular activity, improving to . (iqr . , . ) following the intervention. the median sts was (iqr , ) at baseline, (iqr , ) after the period of regular activity, improving to (iqr , ) following the intervention. conclusion: median frailty improved from frail to pre-frail for the first defrail participants. this program could allow increased community-based participation in resistance exercise for frail older adults. further work now includes completion of the intervention and analysis of data on a range of secondary outcome measures (assessments of cognition, mood, pain, body mass composition and biochemical markers of frailty). background: exercise interventions have been shown to improve functional status and quality of life of frail older people, and in some cases to reverse frailty status. it is important that such interventions are targeted to those people who would benefit the most. objectives: the objective of this pilot study was to assess the effectiveness of a physical activity intervention given to mildly frail older people, who were identified using electronic health records (ehr). methods: the electronic frailty index (efi) was used to identify mildly frail older people and offer them a physical activity intervention of their choice. the pilot study was offered in one area of luton (uk), with invitation letters sent by the participants gp. participants were tested before and after a -week programme of strength, balance and mobility, delivered in a weekly session lasting one hour. participants were assessed at baseline for motivation using the patient activation measure (pam), physical function using the short physical performance battery (sppb), and fear of falling using the falls efficacy scale international (fes-i). each test was carried out in a follow-up test after the programme had concluded. bootstrapped paired t-tests were used to assess the effect of the intervention. results: twenty-seven people aged . ± . years took part in the intervention. the pam scores improved from . % to . % ( . , % ci: . , . ), which is twice the minimal clinically important difference (mcid) of . for sppb, there was an improvement from . to . ( . , % ci: . , . ). the average increase was greater than the mcid for a substantial improvement of . . when fes-i was assessed, only three people ( %) had high concern about falling. there was no significant improvement in fes-i after the intervention (- . , % ci: - . , - . ). after the intervention, % of participants choose to pay for the continuation of the programme. conclusion: the findings of this study suggest that a targeted exercise programme including strength and balance training can significantly improve motivation and functional status among mildly frail older people identified using the efi, with the majority choosing to continue exercising. background: despite frailty has traditionally been examined from a physical standpoint, recent studies advocate for the existence of cognitive frailty ( ), and suggest that both physical and cognitive frailty are interrelated. thus, interventions should aim to prevent or attenuate the effects of frailty from a multidimensional perspective. objectives: to evaluate the effects of three different exercise programs on frailty among older adults living in long-term nursing homes (ltnh). methods: participants ( . % female) met the following criteria: aged years, scored on the barthel index, scored on mec test (an adapted version of mmse in spanish) and capacity to stand up and walk m independently. participants were randomly assigned to a progressive multicomponent group (mcg; n= ), a multicomponent dual-task group (dtg; n= ), or to a walking group (wg; n= ). the mcg underwent a -month moderate intensity strength and balance exercise program twice a week. the dtg performed simultaneous cognitive training (attention, inhibitory control, calculations and semantic memory) to the mc program. the wg walked up to minutes per day for days a week. frailty was measured though the following tests: fried frailty index (ffi), the tilburg frailty index (tfi) and the study of osteoporotic fractures (sof). results: the ffi revealed reductions in frailty in all groups, although only the mcg and the wg reached statistical significance (p< . ). as for the tfi and sof tests, no statically significant differences were found in any of the groups. however, there was a positive trend in tfi in the dtg (p= . ). no group-by-time interactions were found in any of the frailty tests used (p> . ). conclusion: our study showed no differences between interventions regarding frailty. however, the mcg and the wg showed significant reductions in phenotypic frailty, whereas the dtg showed a positive trend in the tfi, which takes into account physical, psychological and social domains. therefore, further studies should explore the effects of different exercise modalities on frailty from a broad perspective in older adults living in ltnhs. references: kelaiditi et al . j nutr health aging. ( ) : - . noirez , , iraj hashemi , deborah kopoin , pierrette g a u d r e a u , m a r c b é l a n g e r , g i l l e s g o u s p i l l o u , josé a morais , aubertin-leheudre ( ( ) background: aging leads to a loss of muscle strength and functional capacity. these phenomena can be slow down by daily exercise practice or resistance training intervention. objectives: the aim of this study was to investigate in elderly men muscle fiber size and type after resistance training. methods: among sedentary older men who completed a -week mixed power training program, were biopsied in the vastus lateralis before and after the program. cross sections were performed on these muscles, followed by triple immunohistochemical staining with antibodies directed against laminin, myosin heavy chain (myhc)- and myhc- a coupled with staining with secondary fluorescent antibodies. immunostaining analysis of laminin allowed us to determine fiber size and these of myhcs to determine fiber type. results: the size of the muscle fibers remained the same between before and after the mixed power training (p= . ).there was no significant difference in the percentage of expression of myhc- , a, x (p= . , p = . , p = . ) between before and after intervention. in addition, there was no difference in the size of fiber expressing myhc- between before and after the training (p = . ). however, significant increase in the sizes of fiber expressing myhc- a and myhc- x (respectively p = e- , p <. ) after the mixed power training was observed. conclusion: in elderly men, an increase of the size in fibers both expressing myhc- a and myhc- x in vastus lateralis muscle could explained the improvement on muscle mass observed previously (carvalho et al. acer ) . to confirm the mechanism explanation of this promising exercise modality, mitochondrial parameters should be also analyzed. background: muscle (in)activation related with sedentary behavior (sb) and physical (in)activity (pa) is a risk for sarcopenia in older adults. although age is not yet a risk factor for sarcopenia in adulthood, other factors such as lifestyle may significantly contribute to its progression. objectives: considering the primary and secondary prevention of sarcopenia, the aim of this study was to analyze associations of sb and pa with markers of muscle strength (lower limb muscle power) and muscle mass (fat mass (fm) to fat free mass ratio (ffm) in adult women and men with and without deficits in these markers. methods: participants were apparently healthy adults ( women) with a mean age . ± . yrs, employed in activities requiring office work. fm and ffm were evaluated by bioelectrical impedance analysis (bia, khz bia rjl, akern bioresearch, florence, italy akern). muscle power relative to body mass (pmax/mass) was assessed during a single two-legged jump on a force platform (leonardo mechanograph, novotec medical, pforzheim, germany) . sb and pa were assessed by accelerometry (actigraph, gt x model, fort walton beach, fl, usa) during four consecutive days ( -week+ -weekend days). the variables analyzed were time spent per day in sb, in light-, moderate-, vigorous-, moderate to vigorous-intensity pa, total pa and breaks per day of sb. multiple linear regressions were performed by stepwise to examine associations of sb and pa with muscle power and fm/ffm, separately for men and women with and without muscular deficits. for the identification of deficits (<- . sd), muscle power and fm/ffm were standardized separately for men and women having as reference their respective mean. results: linear regressions by stepwise evidenced an association of sb with muscle power in women with muscular deficit (β = - . , p = . , adjr = , %%) and an association of vigorous pa with fm/ffm in men without muscular deficit (β = . , p < . , adjr = , %). no associations were observed between sb or pa with muscle power or fm/ffm in other groups. conclusion: sb was negatively evidenced in women with muscle power deficit while vigorous pa revealed to be associated with fm/ffm in men without ffm deficit. funded by portuguese science and technology foundation; project c mup-eri/hc i/ / patricia parreira batista , andré gustavo pereira de andrade , jéssica rodrigues de almeida , aimée de araújo cabral pelizari , leani de souza máximo pereira , lygia paccini lustosa (( ) physical therapy department, ufmg -eeffto, belo horizonte, brazil; ( ) sports department ufmg -eeffto, belo horizonte, brazil) background: the practice of regular physical activity in the older people leads to the decreased of the loss of muscle mass and function with advancing age, and enhances the functionality in activities of daily living and social interaction. in addition, exercise promotes gains in the quantity and quality of muscle fibers and improves muscle strength and power, acting as a protective factor for negative health-related outcomes such as falls, frailty, and hospitalizations. regular practice of physical activity is known to modify the chronic proinflammatory condition common in the older people. probably, exercise reduces the drive of catabolic stimuli from this proinflammatory cascade, modifies the metabolism and production of cytones in tissues and organs, promoting protective and anti-inflammatory effect in the body. objectives: to compare older women who reported being active or sedentary regarding functional capacity and plasma indices of inflammatory mediators. methods: participated women ( years or older), recruited for convenience. those unable to walk were excluded; acute musculoskeletal diseases; lower limb fractures in the last year; neurological diseases and sequelae; history of cancer in the last five years and cognitive impairment (mental state mini-exam). all informed clinical and demographic data and performed the tests short physical performance battery (sppb) and timed up and go (tug). plasma dosages of stnfr and il- were by elisa method. comparison was by independent student t test. approval by the research ethics committee / ufmg (caae: . . . ). results: fiftytwo sedentary older women participated ( . ± . ys.); number of comorbidities of . ± . ; body mass index of . ± . kg/m . from the active group were elderly women ( . ± . ys.); comorbidity number of . ± . ; body mass index of . ± . kg/m . there was significant difference between groups in sppb (p = . ), tug (p = . ) and stnfr (p = . ). conclusion: the results showed that the active older women had better functional and mobility performance and worse plasma stnfr levels. in this case, one can think about the possible influence of body mass index in these older women, which should be explored in future studies. background: our research group designed a comprehensive geriatric intervention program (cgip) consisting of resistance exercise, physical activity increments, oral functional care, and a nutritional guide. we conducted a -week intervention and investigated the effects. after the short-term intervention, we followed up the all participants. we hypothesized that the follow-up could mitigate the loss of short-term intervention effects. objectives: the aim of this study was to compare physical functions before and after the -week intervention, and the end of the follow-up. methods: a total of were willing to participate in the -week cgip. we encouraged them to increase their daily steps and to carry out the program by using daily self-monitoring logs. the participants were randomly assigned to two groups [class-styled session (cs) group ; home-based (hb) group ] based on their residential districts. while cs group attended -minute weekly sessions and independently executed the program on other days, hb group did not attend the weekly sessions but received instructions on program execution. after the shortterm intervention, all participants were instructed to carry out the gcip habitually. also, three optional sessions for all participants were held in order to recommend implementation of the program. physical functions, such as knee extension strength (kes), maximum walking speed (mws), and anterior thigh muscle thickness (mt) were measured before and after the short-term intervention, and the end of the follow-up. results: of the participants identified, (cs ; hb ) took part in the measurements after the follow-up. thus, we analyzed their data. a significant interaction were observed in mws (p= . ). the -week cs intervention significantly improved mws (p< . ). but, mws in cs group significantly decreased after the follow-up (p= . ). there was no significant difference between before the intervention and after the follow-up in mws in cs group. on the other hand, no significant change was observed in hb group. significant time effects were observed in kes and mt (p< . ). both -wk interventions significantly improved kes and mt. while kes was maintained even after the follow-up, mt was significantly decreased. conclusion: the results suggested that appropriate follow-up helps to preserve short-term intervention effects. background: with the increasing prevalence of alzheimer disease and the current absence of drugs therapeutic, nonpharmacological strategies are definitively necessary. physical intervention is often proposed to aid in preventing or slowing cognitive decline. recent studies suggest that combining physical exercise with cognitive stimulation may have more global effect. objectives: we aimed at assessing effect of aerobic exercise alone or combined to intellectual exercises on major cognitive functions: attention (stroop), problem solving (hanoi tower) and working memory (digit span). subjects were trained twice a week for eight weeks. cognitive functions were assessed before training (base line), at the fourth and at the eighth weeks. to evaluate persistency of the effect, subjects were assessed one month after the end of training. methods: two groups were randomly constituted mild cognitive impairment subjects (mci) and alzheimer disease moderate patients (adm). each group was subdivided into three sub groups according to the task to be performed. aerobic exercise (pedaling) alone or combined to cognitive games presented on screen. control groups performed a reading task. results: an effect of training on cognitive functions was observed in adm as well as in mci subjects. however, only adm patient's performances were further improved by adding cognitive games. after four weeks, the observed effects were still maintained in both groups. mci results were obviously better than those of adm. there was no significant change in performances for control groups. conclusion: aerobic exercise induce cognitive improvement in adm and mci patients. combined physical exercise and cognitive games potentiated this effect mainly in adm group. this procedure has long lasting beneficial effect. this supports the necessity of regular aerobic exercise to prevent cognitive deficits in aging cognitive deficits. background: increasing physical activity represent a key therapeutic intervention to prevent the loss of mobility disability for enhancing health related quality of life. hence, we have set up a primary and secondary prevention care path through exercise training and nutrition to improve mobility and physical performances. objectives: our primary goal is to integrate a prevention care path into daily life of elders who may present a mobility disability risk. we aim to improve quality of life and mobility. methods: our program includes years or more who present a risk of developing a mobility disability. initially, we identify and screen a risk of mobility disability in wide elders communities. we diagnose mobility disability risk factors, sarcopenia and frailty, in day hospital (dietician, geriatrician and a kinesiologist). we use the ewgsop algorithm to diagnose sarcopenia. the patient then attend a -months training program, including sessions per week. sessions combine resistance exercises and balance training during minutes. we support the patient for his own project of long-term maintenance quality of life between physical activity and nutrition. results: patients have been seen after sessions. physical performance was significantly improved after months of intervention (sppb p< , , gait speed p< , and time-up-and-go p< , ) likewise grip strength (p< , ). the "sarqol" score was also significantly higher (p< . ). sub-group sppb ≤ with severe sarcopenia improve significantly more its score (+ . ± . p< , ) comparing to the overall population (+ . ± . ). moreover, there was a significant difference (p< , ) for sppb at baseline between responders ( . ± . ) and nonresponders ( . ± . ). conclusion: our intervention enhances mobility through physical performance benefits. we can make the assumption that adverse events will be occurring less and physical dependence will be delayed, regarding gait speed improvement. patients with lower physical performance are responding better than the overall population meaning that our intervention is more specially indicated for patients with severe sarcopenia. furthermore, our program sustains motivation for physical activity and exercise after months. we were able to show that it was possible to set up a comprehensive and effective care path for frail and sarcopenic elderly people. background: middle-aged adults who are pre-sarcopenic are at the highest risk of developing sarcopenia due to the progressive nature of the syndrome. objectives: to determine whether high intensity interval training (hiit) results in greater improvements in body composition, compared to a control group, in middle-aged adults with pre-sarcopenia. methods: eighty-two sedentary adults ( - yrs) with a low appendicular skeletal muscle mass index (asmi) were randomized into control (n= ) or intervention group (n= ) using stratified randomization based on age, sex and bmi. low asmi (asm/ht ) was determined by dxa (lunar prodigy, ge healthcare) using age-and sex-specific cut-scores as proposed by prado. the control group received one education session on general physical activity recommendations. the intervention was supervised, group-based, high-intensity aerobic and resistance interval training (hitt), times weekly for -weeks. an intention-to-treat mixed model linear regression, with a random effect, was used to analyse group differences for body composition. results: . % of the sample were female, the mean age was . yrs ( . ) and the mean bmi at baseline was . kg/m ( . ). people ( %) completed the intervention, people in the hitt group and in the control group. no adverse events were reported. significant group differences were observed for total muscle mass ( . kg, %ci: . - . ), leg muscle mass ( . kg, %ci . - . ), asmi ( . kg/m , %ci . - . ) and visceral fat mass our study indicated that group-based hiit is an effective, tolerable and safe exercise modality to increase total body and appendicular muscle mass, and to decrease visceral fat, in middle-aged adults with pre-sarcopenia. background: aging is related to body composition modifications and functional capacities declines. it is recognized than being active can prevent these changes and improve quality of life. however, it is unclear if gender or age influence this relationship and if a sub-type of voluntary physical activity is more efficient to maintain these physical parameters. objectives: to assess the association between current physical activity level or type and functional capacities and body composition among elderly people and to examine if age (< or >= yrs old) or sex modulate the relationship. methods: functional capacities using different validated tests (i.e. grip strength, timed up and go, sit-to-stand, muscle power, alternate step test, leg extension, vo max), body composition (fat & fat-free masses) using dxa were assessed. current global (total) and specific (aerobic, resistance or body and mind) physical activity levels (duration) were obtained through a questionnaire. multiple regressions, adjusted on age, sex and bmi, were performed to assess the relationship between current physical activity level and functional capacities or body composition. sub-group analysis, according to the sex and age (< y vs. >= y) were also performed by means of pearson correlations. results: a total of subjects ( . ± . years; women: . %; bmi= . ± . kg/ m²) were enrolled. after adjustment on confounding factors, total current physical activity level has positive impact on total fat mass (%; β=- . , p= ) and balance (β= . ; p= . ). moreover, current body & mind activities influence total fat-free mass (kg; β=- . , p= . ) and balance (β= . ; p= . ) whereas resistance activities influence fat-free mass (kg; β= . ; p= . ), fat mass (%; β=- . ; p= . ) and sitto-stand test (β=- . ; p= . ). sub-analysis shows that total physical activity level was significantly associated with fat mass, sit-to-stand test, balance and vo max in women but not in men. moreover, among people under y, the time spent on cardio activities does not affect functional capacities and body composition. nonetheless, among people aged y and over, the time spent on resistance activities is associated with functional capacities and body composition. conclusion: being active is associated with body composition and functional capacities, especially among women aged years and over. itxaso mugica-errazquin , nagore arizaga , janire virgala , julen gomez , garbiñe lozano , yune aranburu , udane elordi , maider kortajarena , ana rodriguez-larrad , jon irazusta ( ( ) background: low physical fitness, frailty and dependency are highly prevalent in people living in long term nursing homes (ltnh). multicomponent physical exercise, including strength, balance and endurance, has demonstrated to be effective for improving physical fitness and reducing frailty in ltnh. however, there is no evidence that this type of programs are capable to improve or even maintain the levels of autonomy in activities of daily living (adl) of this population. objectives: the major aim is to ascertain whether a new approach of months, individualized and progressive multicomponent program focused on functioning maintains autonomy in older adults living in ltnhs; the secondary aim is to assess the effects on frailty and physical fitness. methods: people living in ltnh, between and years, participated in this single group interventional study. inclusion criteria were: >= years, >= barthel index, >= mec- and be able to stand up from a chair and walk meters with or without one person/technical assistance. the intervention consisted of months of a progressive multicomponent physical exercise program (ep) aiming to improve the physical condition, followed by months of physical exercises focused on functional adl with the objective of maintaining/improving autonomy of the participants. barthel index was used to assess autonomy level in adl, frailty was measured by fried frailty index and short physical performance battery (sppb) was used to assess physical fitness. the study is registered in u.s clinical trial (nct ) and approved by the committee on ethics in research of the university of the basque country (m / / ). results: during the first months of ep participants lowered the score in the barthel index (p< , ). however, participants showed significant improvements in frailty (fried frailty index p< , ) and in physical fitness (sppb p< , ) . from the rd to th months, while physical fitness of participants did not change, they improved autonomy in adl, and decreased frailty non-significantly. when comparing the effects of the entire intervention, barthel index did not change significantly and physical fitness and frailty improved (sppb p< , ; fried p< , ). conclusion: this new approach of months of individualized and progressive multicomponent program focused on daily functioning maintains autonomy in activities of daily living, improves physical fitness and reduces frailty in older adults living in ltnhs. shuji sawada , hayao ozaki , , toshiharu natsume , daiki nakano , pengyu deng , toshinori yoshihara , takuya osawa , shuichi machida , hisashi naito (( ) juntendo university, chiba, japan; ( ) tokai gakuen university, aichi, japan; ( ) japan women 's college of physical education, tokyo, japan) background: in previous study, we found that low-load resistance training using own body weight and elastic band even only biweekly could induce muscle hypertrophy in older adults after weeks of training. however, it is unclear whether levels of different blood parameters before training associated with the effects of training. objectives: this study aimed to clarify whether levels of different blood parameters before training influenced the effect of low-load resistance training on lower limb muscle thickness (mt). methods: sixty-nine communitydwelling japanese subjects aged . ± . years ( women and men) volunteered for this study and participated in a lowload resistance training program using their own body weight and elastic band. the training was performed biweekly for weeks. each participant's mt at the anterior aspects of the thigh (at) was measured using a b-mode ultrasound device. further, the levels of the following blood parameters were assessed before and after the training program: serum albumin (alb), hemoglobin (hb), total cholesterol (tc), and hemoglobin a c (hba c). we checked the first quartile value of each blood parameter to establish the cutoff criteria for reduced levelsserum alb = . g/dl, hb = . g/dl, tc = mg/dl, and hba c = . %. participants were divided into low or normal groups in each blood parameter, and their data were analyzed using two-way analysis of variance. results: when using the abovementioned criteria, biweekly low-load resistance training increased mt at the at in every group after training. the interaction between time and groups was only detected with low (< . g/dl) versus normal (>= . g/dl) serum alb levels. in this case, there was no difference in mt at the at before training, but participants in the normal serum alb level group had greater mt after training than those in the low serum alb level group. conclusion: the effect of low-load resistance training on lower limb mt appears to be limited in participants with low pre-training serum alb level. objectives: it was to estimate the affect of complex -week treatment with kinesiotherapy methods on body weight loss and muscle function in patients with obesity. methods: men and women aged - years old with alimentary obesity were enrolled in the study (mean age . ± years, weight . ± . kg, bmi . ± . kg/m , waist circumstance wc . ± cm, hip circumstance hc . ± cm). the complex kinesiotherapy administered daily for week and included interactive sensorimotor trainings on double unstable platform, kinesiohydrotherapy in a pool, special complex of physical exercises in a gym and ergocycle trainings. weight, wc, hc, fall number for last weeks were measured at baseline and after the treatment was completed. muscle strength and walking speed functional tests results assessment ( -meters-walk test, up-and-go test, special tests for back and abdomen muscle endurance to static and dynamic loading) were performed at baseline and in weeks. results: there was a significant reduction in body weight ( . ± . kg at baseline vs . ± . kg in weeks; p= , ), in bmi ( . ± . vs . ± . kg/m ; p= . ), in wc ( . ± . vs . ± . cm; p= . ) and in hc ( . ± . vs . ± . cm; p= . ) in treated obese patients. -meters-walk speed increased from . ± . m/sec at baseline to . ± . m/ sec in weeks (p= . ). up-and-go test results improved from . ± . to . ± . sec (p= . ). we registered statistically significant elevation of the endurance to static loading in abdomen muscles from . ± . to . ± . sec (p= . ) and in back muscles from . ± . sec to . ± . sec (p= . ). the endurance to dynamic loading increased in abdomen muscles from . ± . to . ± . times (p= . ) and also in back muscles from . ± . to . ± . times (p= . ). fall namber markably decreased from . ± . at baseline to . ( %ci: . ; . ) after completion of treatment. conclusion: investigated complex treatment with kinesiotherapy methods promotes body weight loss, wc and hc reduction in obesity. -week special training of obese patients is associated with increasing in gate speed and lower extremities muscle strength, and it also causes improvement in static and dynamic loading endurance of back and abdomen muscles. those changes may probably improve balance function and decrease risk of falling in obese patients. thaiana pacheco, candice medeiros, rummenigge dantas, inae c. gadotti, edgar r vieira, fabrícia costa cavalcanti (department of physical therapy, florida international university, miami, usa) background: integrating technological advances into clinical practice can be challenging. physical therapists have been developing serious games/exergames for a variety of rehabilitation purposes, but uptake has been slow. games with virtual scenarios are an engaging and affordable way to encourage and increase physical activity levels. serious games have been developed to adapt virtual gaming environments to patients' needs and evolving capabilities. games can improve adherence and therapy effectiveness. the sensory and motor stimulation while playing serious games can help geriatric rehabilitation to improve mobility and balance. objectives: this study analyzed the effects of a new serious game on the balance of older adults. methods: this was a pilot quasiexperimental design study in which older adults completed six sessions of dynamic balance training using the virtualter serious game that uses the kinect sensor for motion capture. this game was developed by researchers from the federal university of rio grande do norte in brazil. the game consists of static and dynamic tasks for training balance. it involves stationary walk, lateral reaching and climbing steps up and down. it has phases with increasing the level of difficulty. the participants were evaluated before and after the program using the berg balance scale (bbs) and the short physical performance battery (sppb). t-test for dependent samples was used to analyze the pre vs. post data. results: twenty three participants participated in the study (age = ± ; sex = % women). the results indicate improvement in bbs scores (pre: ± ; post: . ± ; p = . ) and sppb scores (pre: ± ; post: ± ; p = . ). conclusion: playing the virtualter serious game improved balance in older adults. helen chan , duncan wong , cindy fan (( ) the nethersole school of nursing, the chinese university of hong kong, hk; ( ) silver yoga lab, hk) background: evidence showed that both frail and prefrail significantly increase the risk of developing or worsening disability in activities of daily living, poor quality of life and institutionalisation. yoga has been consistently reported as effective intervention in improving physical functioning in terms of balance, lower limb strength, mobility and body flexibility. objectives: to assess the feasibility of silver yoga in older adults and to examine the preliminary effects of silver yoga on their physical health. methods: this was a one group pre-test post-test study conducted in a community centre. people who aged and above, were mentally competent, home-living, and classified as prefrail based on physical phenotypes using fried criteria, were eligible to the study. the silver yoga class included eight . -hour weekly sessions delivered by two experienced yoga instructors with specialized training in silver yoga. senior fitness test (sft) was conducted to assess changes in physical health. paired t-test was used to compare the within-subject differences across -month time. results: a total of older adults were recruited. there were significant improvement in six dimensions of the sft, including upper extremity muscle strength, lower extremity muscle strength, upper body flexibility, lower body flexibility, agility and dynamic balance, and aerobic endurance (ps < . ). all participants except one completed the yoga programme, with high level of satisfaction. in addition to the effects of physical conditions, the participants also appreciated it as mind-soothing and relaxing. conclusion: the findings showed that silver yoga is well-received by older adults generally, with significant effects in improving their physical fitness. more rigorous study is needed to examine its effects in a longer term and also in a more holistic manner. ku leuven, leuven, belgium; ( ) physical activity, sports and health research group, department of movement sciences, ku leuven, leuven, belgium) background: with aging skeletal muscle tissue becomes less responsive to anabolic stimuli, eventually contributing to muscle wasting. inflammation is considered an important player in this age-related anabolic insensitivity. recent reports provide a promising role for omega- polyunsaturated fatty acids (ω- ) in (muscle) health, as they possess systemic anti-inflammatory properties and stimulate muscle anabolic signaling. objectives: we investigated whether ω- supplementation improves the systemic inflammation and muscular adaptations (i.e. strength, mass, molecular signaling) to resistance exercise in an elderly population. methods: twenty-three elderly ( - y; ♀) were randomized to receive either ω- (~ g/d) or an isocaloric amount of corn oil (plac) during weeks. after two weeks of supplementation, participants engaged in resistance exercise (re; x/week) for weeks. prior to and after completion of the intervention, muscle and blood tissue, parameters of body composition, muscle strength and functionality were assessed. results: upon re, -rm significantly improved in plac (+ . %) and in ω- (+ . %), irrespective of condition. isometric strength significantly improved in ω- (+ . %), but not in plac (- . %). muscle volume did not change following re. plasma crp levels decreased, though not non-significantly, in ω- (- . %), whereas only a small increase was observed in plac (+ . %). ω- supplementation nor re affected the muscle anabolic sensitivity (akt phosphorylation) in response to a protein bolus. conclusion: this study confirms that ω- pufas improve the gains in isometric but not in dynamic muscle strength upon re in elderly. however, this was not associated with changes in anabolic sensitivity or systemic inflammation. further analyses will investigate whether the ω- induced gains in strength can be related to systemic hormones or muscle molecular signaling (mtor signaling, inflammation). meera suresh, clarence chikusu, caroline goodger (nutrition and dietetics, st. peter's hospital, chertsey, uk) background: deconditioning is a common phenomenon in patients over years old in acute settings. it is well known that poor nutritional status has a major impact on adverse outcomes in frailty and can exacerbate sarcopenia ( ). currently, there is limited research exploring the impact of dietitians on optimising nutritional status in acute settings in older populations for frailty and sarcopenia. objectives: compare the impact of dietetic intervention on the change in frailty scores between a patient group (n= ; mean age . years) who received dietetic intervention (di) and a patient group (n= ; mean age . years) who did not receive dietetic intervention (ndi). methods: a -month retrospective study (august-december ) was undertaken at the older persons short stay unit at a district hospital in england. frailty scores were calculated based on the rockwood model of clinical frailty. dietary intake was recorded and analysed using a standardised nutritional profile of hospital meals. the di group was given standardised dietetic care including oral nutrition support and build up dietary advice. descriptive statistics were used to determine frequencies. results: the di had higher frailty scores (mean of . ; range: - ) and a higher mortality rate ( %).the ndi had a mean score of . (range: - ) and mortality rate of %. the average oral intake for energy and protein for patients in the di group prior to dietetic intervention was % lower than the espen recommendations. despite the higher frailty scores and mortality rates in the di group, progression in their frailty score was slower compared to the ndi group ( % vs %). conclusion: the results highlight the importance of a timely referral for early dietetic intervention which is crucial for optimisation of better clinical outcomes in these patients. a dietitian is a key member of the mdt and can prevent further deterioration in muscle mass and the impact on patients' frailty and independence and also slow down the progression of sarcopenia and frailty. this has long term impact on health and social services by reducing length of stay, hospital re-admissions and the increasing burden on social care. uz leuven, leuven, belgium) background: while the protein recommended dietary allowance (rda) for healthy adults is . g protein/kg bodyweight (bw)/day (d), expert groups recommend a protein intake up to . g protein/kg bw/d for older people with chronic diseases. in addition, at least - g protein (whereof at least . g of leucine) is recommended per meal. objectives: we aim to assess in (pre)sarcopenic older people the daily energy and protein quantity and quality intake, and their change due to supplementation. methods: dietary protein quantity, and quality (plant/animal source, amount of amino acids, amount of leucine and leucine distribution over a day) and dietary energy intake were calculated from four day estimated dietary records of (pre)sarcopenic participants of the enhance study (clinicaltrials.gov nct ) before and after a -week supplementation period. participants received an individualized protein supplement (resource® instant protein, nestlé) , to achieve a total (dietary + supplemental) intake of . g protein/kg bw/d. results: (pre)sarcopenic adults ( . ± . years, % female) had an average dietary protein intake of . ± . g/kg bw/d, which is higher than the rda, but below the . g/kg bw/d recommended by experts. (pre)sarcopenic adults were supplemented with protein powder, which improved the total protein intake to . ± . g/kg bw/d without affecting dietary protein or energy intake. moreover, supplementation increased the protein intake to at least g protein/meal without affecting dietary intake. more than % of dietary protein intake was of animal origin. leucine intake at baseline was insufficient at all meals, but increased to at least . g at lunch and dinner by supplementation without affecting dietary leucine intake. conclusion: community-dwelling (pre)sarcopenic older people do not reach the recommended protein intake proposed by expert groups. individualized protein supplementation results in adequate intake of protein without substantial change in dietary intake. nutrition and dietetics, internal medicine, amsterdam university medical centers, amsterdam, the netherlands) background: weight loss is a main treatment goal in obese older adults with dm . combined lifestyle interventions (cli) may be more effective in preserving muscle mass during weight loss. whether severe obese benefit similar to less obese is unknown. objectives: our probe-study showed an increase in muscle mass during cli in obese older adults ( +) with dm . do severe obese (bmi > kg/m ) benefit similarly to less obese. methods: in a post-hoc analysis, out of enrolled older adults had both body weight and protein intake data before and after a -month cli consisting of dietary advice (- kcal/day) and resistance exercise. a selection of assessments were appendicular skeletal muscle mass (asmm, by dxa), physical performance (wmax; by cycle ergometer steep ramp test), quality of life (rand- physical component summary score (pcs), visceral adipose tissue (vat, by dxa), crp, insulin sensitivity and resistance (matsuda, homa-ir; by ogtt), blood pressure (sbp, dbp). linear regression analysis was used with protein intake (g/kg, except for asmm being included in kg) as independent and assessments after -months as dependent (with assessment before intervention as confounder) for both groups bmi> (severe obese n= ) and bmi<= (n= ). results: mean age was , mean bmi was . , sex m/ f and protein intake during intervention was + gram/day. mean weight loss was - . + . kg and fat loss - . + . kg. per g protein intake increase + g muscle was preserved (p= . ). however, this appeared + (p= . ) vs + g (p= . ) for severe obese vs not severe obese. severe obese showed higher response for wmax (+ . + . (p= . ) vs - . + . ) and pcs (+ . + . (p= . ) vs - . + . ), for vat (- . + . (p= . ) vs + . + . ) and crp (- . + . (p= . ) vs + . + . ), for insulin sensitivity (matsuda + . + . (p= . ) vs + . + . ) and insulin resistance (homa-ir - . + . (p= . ) vs + . + . ), sbp (- . + . (p= . ) vs - . + . ) and dbp (- . + . (p= . ) vs + . + . ). while whole group and not severe obese group showed no significant effect. conclusion: these results suggest that severe obese might benefit even more from combined lifestyle intervention compared to less obese older adults with dm . further investigation is needed to confirm these findings and identify potential mechanisms. background: nutritional interventions have been shown to stimulate muscle protein synthesis. to optimize muscle mass preservation and gains, several factors, including type, dosage, frequency, timing, duration and compliance have to be considered. objectives: this systematic review and meta-analysis aimed to summarize these factors influencing the efficacy of nutritional interventions on muscle mass in older adults. methods: data sources: a systematic search was performed using the electronic databases medline, embase, cinahl, cochrane central register of controlled trials and sportdiscus, from inception date to nd november , in accordance with the prisma guidelines. inclusion criteria included randomized controlled trials, mean/median age >= years and reporting muscle mass at baseline and post-intervention; exclusion criteria included genetically inherited diseases, anabolic drugs/hormone therapies, neuromuscular electrical stimulation, chronic kidney disease, kidney failure, neuromuscular disorders and cancer. data extraction: extracted data included study characteristics (population, sample size, age, sex), muscle mass measurements (method, measure, unit) , effect of the intervention versus the control group, and nutritional intervention factors i.e. type, composition, dose, duration, frequency, timing and compliance. data analysis: standardized mean differences and % confidence intervals were calculated from baseline to post-intervention for the intervention and control group. a meta-analysis was performed using a random-effects model and grouped by the type of intervention. results: twentyeight articles were included encompassing participants (mean age . years, sd . ). amino acids, creatine, betahydroxy-beta-methylbutyrate, and protein with amino acids supplementation significantly improved muscle mass. no effect was found for protein supplementation alone, protein and other components, and poly-unsaturated fatty acids. high inter-study variability was observed regarding the dose, duration and frequency, coupled with inconsistency in reporting timing and compliance. conclusion: overall, nutrition alone is an effective intervention to improve muscle mass in older adults. due to the substantial variability of the intervention factors among studies, the optimum profile is yet to be established. background: physical and functional capacities decline with age. one new potential intervention is oral citrulline supplementation (cit) since cit seems to increase muscle protein synthesis, mass, size and strength, improve mobility but also decrease adipose tissue mass, particularly visceral depot in old rats. furthermore, exercise is known to be another efficient intervention. however, studies assessing cit supplementation combined or not with exercise on muscle function and mobility in older human adults are emerging and literature conclusions are needed to help health professionals. objectives: establish the potential effectiveness of citrulline supplementation combined or not with exercise on muscle function and physical performance via a systematic review of randomized controlled trials (rcts) in human aged years and older. methods: the preferred reporting items for systematic reviews and meta-analysis (prisma) statement has been followed. medline, cochrane central register for rcts and scopus databases have been searched. studies selection and data extraction have been performed by two researchers independently. methodological quality of each included studies was assessed using the quality assessment of diagnostic accuracy studies- (quadas- ) tool. results: based on prisma guideline, references have been identified. among this number, only rcts ( participants) matched the inclusion criteria (e.g rcts, age> yrs, human, cit supplementation, muscle or physical parameters) and were included in the systematic review. among these studies, / reported beneficial effects of cit on muscle mass. effects on muscle strength is reported on / studies but when cit is combined to exercise better improvements in upper muscle strength are observed. finally, / studies reported beneficial effect of cit on physical performance but suggested that cit with exercise displayed greater improvements in walking speed than exercise or cit alone. the overall quality of studies was rather high. conclusion: cit supplementation seems able to improve muscular and physical factors in specific elderly people (malnourished, women, hypertensive, obese, dynapenic-obese) compared to placebo. more importantly, cit with exercise is more efficient than exercise or cit alone. however, due to the small number ( ) and heterogeneity (dose, duration, population) of the studies, further investigations are needed to confirm its promising intervention for health professionals. background: the medical nutrition supplement fortifit (r), containing the specific nutrient combination actisyn™, is designed to support muscle building in sarcopenia (muscle loss). actisyn (whey protein, leucine and vitamin d) provides high bioavailability of leucine and essential amino acids for the muscle; the nutrients in actisyn act together to optimize the muscle protein synthesis response in a state of sarcopenia where these nutrients are often deficient. preclinical and acute human studies confirmed this mode of action. objectives: to demonstrate the longer-term effects of fortifit supplementation on muscle building in healthy and sarcopenic older adults and on muscle preservation in obese (diabetic) older adults during a weight-loss lifestyle intervention. methods: our clinical research program investigated the effects on muscle mass, strength and function in healthy and sarcopenic older adults and in obese and type diabetic patients. muscle mass was measured by dexa; strength and function by handgrip strength, -times chairstand test and short physical performance battery (sppb). all studies were randomized-controlled trials with an intervention duration of to weeks. results: a significant increase in appendicular lean mass and leg lean mass was observed in healthy older adults after weeks supplementation (p< . vs non-caloric control) [chanet, jnutr ]. in sarcopenic older adults, -week intervention increased appendicular lean mass ( . kg, %ci . - . kg; p= . vs iso-caloric control) [bauer, jamda ] . moreover, during a -week lifestyle intervention of energy restriction and resistance exercise training in obese older adults with or without type diabetes, fortifit preserved appendicular lean mass (p< . vs iso-caloric control) [verreijen, ajcn ; memelink, clin nutr ] . a significant improvement was observed in chairstand time after -week intervention in sarcopenic older adults (- . s, %ci - . to - . s; p= . vs isocaloric control), but improvements in handgrip strength and sppb (primary outcomes) were only significant versus baseline (p< . ) and not versus control [bauer, jamda ] . conclusion: the medical nutrition supplement fortifit effectively supports muscle building in healthy, sarcopenic and obese older adults. moreover, the improvement in chair-stand time observed in sarcopenic older adults is clinically relevant. background: chronic kidney disease (ckd) is commonly found in older persons and it affects the quality of life and economic burden. knowledge and health literacy have been reported as fundamental factors for persons with chronic illness to perform health behavior. however, from a literature review, relationships among knowledge, health literacy, and health behavior in older persons with non-dialysis ckd have rarely been reported. objectives: to examine relationships among knowledge, health literacy, and health behavior in older persons with chronic kidney disease. methods: nutbeam's conceptual framework of health literacy was used to guide the study. the sample recruited by purposive sampling consisted of older persons with non-dialysis stage to ckd, who sought healthcare services at a ckd clinic in a university hospital, thailand. data were collected by interviews using the questionnaires about the demographic data, knowledge about care of ckd, health literacy, and health behavior of older persons with ckd and then were analyzed using descriptive statistics and spearman's rho correlation coefficients. results: the sample consisted of men and women with their age ranging from to years (m = . , sd = . ). the analysis revealed that the sample had the mean scores of total knowledge about care of ckd, health literacy, and health behavior at a high level. health literacy was positively associated with health behavior (r = . , p = . ), but knowledge about care of ckd was not significantly associated with health literacy (r = . , p = . ), nor health behavior (r = . , p = . ). conclusion: only health literacy was significantly positively related to health behavior. although knowledge is fundamental of health literacy, it was not significantly related to health literacy nor health behavior in this study. it is explained that health literacy is the ability and skills that might link knowledge of individuals to perform behaviors. thus, healthcare providers should find strategies for enhancing health literacy of older persons with ckd to promote appropriate health behavior, thereby delaying complications. background: handgrip strength (gs) is linked to the vitality domain of the intrinsic capacity (ic) construct and is a marker of sarcopenia and frailty. low gs is a predictor of adverse health outcomes like disability onset and mortality. small increases in gs have been reported after exercise interventions, suggesting that life-course determinants rather than short-term determinants influence gs. objectives: to assess social inequality in the distribution of gs and the association of gs levels with a proxy of social determinants of health (sdh) among adults and older adults. methods: secondary analysis from wave ( - ) of the world health organization (who) study on global ageing and adult health (sage), which is nationally-representative of six countries, including , participants aged >= years and , < y. gs was computed in kg. wealth quintiles were assigned according to ownership of household assets. the last level of education of the participant and his/her mother was self-reported (the latter was used as a marker of early life sdh). social inequality was estimated using pairwise comparisons among the average of gs of the extreme social groups; and gradient inequality by the slope index of inequality (multivariate linear regression to adjust for age, sex, body mass index). estimations were weighted to consider the complex design of the sample. results: average gs was . kg for participants >= y and . kg for < y. participants >= y who reported a postgraduate level of education or higher showed % ( . kg) higher gs than their illiterate counterparts ( %, . kg, for participants < y). gs was on average % higher in participants >= y in the most top wealth quintile compared to those in the lowest quintile ( % in < y). in the multivariate models, gs was . kg higher in urban than rural participants and . kg higher among participants whose mothers had completed >= years of education compared to those whose mothers were illiterate. slope coefficients were significant after controlling for confounders. conclusion: grip strength displayed an unequal distribution among social groups and also among groups of early life exposures, which suggests that vitality as a domain of ic is shaped by the sdh and built through the life course. background: intrinsic capacity (ic) is the composite of the physical and mental abilities of an individual. the distribution and correlates of ic in older adults (oa) have not been reported using an integrative score with routinely-collected clinical data. it is not clear how ic is associated with multi-systemic biochemical age-related processes captured by alterations in standard clinical laboratory tests. objectives: to describe the distribution and correlates of ic in a population of older adults from the frailty day hospital of toulouse and to test its cross-sectional association with low or high haemoglobin or high crp, accounting for frailty status. methods: using routinely collected cross-sectional data of , first visits of oa aged + to the frailty day clinic of toulouse ( - ), we calculated an index of ic (biomarkers and validated scales for five who domains). low/high haemoglobin levels or high crp levels served as indicators of acute and middleterm multisystem disruption. we used descriptive statistics to learn the distribution of ic across sex, age, education and fried frailty categories. multivariate linear models were used to test the hypothesis that higher ic holds a negative association with the multi-system deficits depicted by altered laboratory tests. results: % of the population was female, and % was frail. our ic score has theoretical limits ( - ). overall, the ic was: mean= . ,sd= . ,min= . , max= . . on average ic men scored . (ic % . , . ) and women . (ic % . , . ). the relationship found between ic and age was not linear. frail older adults displayed % less ic than their robust counterparts and % less ic than their pre-frail counterparts. if frail oa would return to robust in this population, the average ic would potentially* rise %. disruption in haemoglobin or crp was inversely and significantly associated with the ic score after adjusting for age , sex, level of education and fried frailty status. conclusion: the population attending the toulouse frailty clinic displayed highly-heterogeneous ic levels, with frail oa showing significantly lower levels than robust oa. the association between ic and age is not linear. sex, age, education, frailty status and disruption in haemoglobin or crp levels were all significantly associated with ic in a multivariate model. background: older persons tend to be hospitalized increasingly because of the complex interaction among acute problems, age-related changed, and chronic diseases. qualified nursing care needs knowledge, understanding, and a positive attitude towards the care of older persons. however, little is known factors predict the caring behavior of nurses to care for hospitalized older persons. objectives: to examine the predictability of selected factors to explain intention to care and caring behavior for older persons of professional nurses. methods: the theory of reasoned action was used to guide the study. the proportionate stratified random sampling was used to recruit a sample of professional nurses from clinical wards providing care for older patients in a university hospital. data were collected using questionnaires and then, analyzed with descriptive statistics, pearson's product-moment correlation, and multiple regression analysis with the enter method. results: almost all of the sample were female, with their age ranged from to years (m = . ). factors related to professional nurses' intention to care were perceived caring climate in organization and attitude toward caring for older persons. also, factors related to caring behavior for older persons were perceived caring climate in an organization, intention to care, and attitude toward caring for older persons. through multiple regression analysis, perceived caring climate in an organization, attitude toward caring older persons, and basic knowledge about older persons jointly predicted . % of the variance in intention to care. together, perceived caring climate in an organization, intention to care, attitude toward caring for older persons, and basic knowledge about older persons accounted for . % of the variance in caring behavior for older persons of professional nurses. the perceived caring climate in an organization was the strongest predictor of caring behavior, whereas basic knowledge about older persons was not a significant predictor. conclusion: the findings support the notion of the theory of reasoned action. it is suggested that strategies to promote perceived caring climate in an organization, attitude toward caring for older persons, and intention to care should be established and maintained to promote caring behavior for older persons of professional nurses. background: environmental and social conditions play a major influence in the development and progression of negative health-related outcomes. they represent crucial elements when taking clinical decisions and planning the care plans of frail patients. nevertheless, they still often remain overlooked because priority is given to the clinical manifestations. objectives: the aim of this study is to explore the importance of social support in the definition of major health-related outcomes among hospitalized patients compared to other critical factors of older persons (i.e., frailty, age). methods: data were retrospectively collected from the medical records of patients aged years and older admitted to the geriatric unit of the fondazione irccs ca' granda ospedale maggiore policlinico (milan, italy). a -items frailty index (fi) was computed from clinical variables recorded during the first days of hospitalization (i.e., medical history, cognitive, functional and social assessment, physical examination, laboratory tests). mortality, length of hospital stay above the median, and risk of institutionalization were the outcomes of interest. results: we included patients (mean age . , sd . years, women . %). six patients died during the hospital stay ( . %). the median duration of hospital stay was (iqr - ) days. twenty-seven patients were discharged to other institutions ( %). the mean fi was . (sd . ). the fi showed a statistically borderline association with mortality (or . , % c.i. . - . , p= . ), and was predictive of longer length of stay (or . , % c.i. . - . , p= . ), even after adjustment for confounders. the presence of a caregiver was the only factor significantly associated with the discharge at home of patients (or . , % c.i. . - . , p= . ) at the multivariate analysis. age had no significant association with the three studied outcomes. conclusion: health systems should be organized according to an integrated model of care in order to adequately address the complex health needs of older people. social and environmental context plays a critical role in determining the person's health trajectory. social factors (as the presence of a caregiver) may play a stronger role in clinical decisions than biological or clinical aspects. background: the acute therapy team was formulated after the integration of an older persons assessment and liaison team (opal) with medical ward therapists. the team was spread across all acute areas. this team worked closely with the acute geriatric and frailty clinical team and it was recognised that length of stay, and improved patient experience and overall outcomes would be improved with earlier assessment and cga planning at the front door allowing closer collaborative working between the clinicians and therapists. objectives: to enhance service improvement and prevent the impact of sarcopenia and frailty syndromes leading to greater hospital stay and disability as a consequence of a delay to assessment by clinicians and therapists in the acute setting. through the screening of frailty syndrome risk and sarcopenia risk patients by the ed geriatrician and junior doctor, there would be a speedier response to therapy led interventions thereby reducing the conversion rate from ed and also therefore improving overall outcomes in length of stay and reduced disability through prolonged hospital stay. methods: consultant geriatrician and junior doctor (opssu team) to go to the emergency department in the mornings and see up to patients in cdu/a&e beds; the use of a the rockwood frailty score template identified those patients at risk of frailty syndrome and likely to benefit from early therapy intervention. these patients would have been highlighted as having the potential to be discharged within hours. a month data collection period from was chosen with data collected monday to friday only. data examined was categorised as follows: new patients, follow-ups; how many patients were seen on day of ed attendance vs after day of attendance?; number of patients seen by therapists same day of ed attendance number of patients not seen by therapists day of attendance; which team was looking after the patient from a clinically; how much time spent with patients; therapy led plan after initial assessment; an integrated assessment too was instrumental in the cga component of the therapy and clinical assessments. results: % of patients seen by therapists in ed are new patients referred. % of patients referred are seen on the actual date of ed attendance. the rest are seen later admission episode. % of therapy time is spent doing non-face to face tasks such as documentation. but up to % of patients have a discharge plan put in place after being seen by therapists in the ed. conclusion: a great deal of time is spent by therapists on documentation during assessment. this has a negative impact on the amount of time dedicated to clinical assessments and physiological and functional assessments required in the cga. there is a large number of patients referred by the clinical team to the therapists for review but a majority of patients are seen elsewhere during an admission episode and not in the ed. streamlined assessments and screening tools are recommended & planned for the future model of care. yi-chun cheng , li-ning peng , (( ) center for geriatrics and gerontology, taipei veterans general hospital, taipei, taiwan; ( ) aging and health research center, national yang ming university, taipei, taiwan) background: older people with frailty are at risk of adverse outcomes, such as falls, disability, hospital admission, long term care placement, poorer quality of life, and mortality, which denotes the importance of sarcopenia in the health care for older people, and integrated intervention program may prevent those. objectives: to evaluate the effectiveness of an integrated intervention program among those communitydwelling frail older people in north taiwan. methods: a total of participants over years old mild to moderate disability and mild cognitive impairment persons were recruited from a community-dwelling frail older people in north taiwan during august and july , frail older people were invited for the study. a weeks integrated intervention program was provided for all participants. they attended the hours program once per two weeks and physical activity, high protein diet education, and cognitive stimulation activity were included in the integrated intervention program. comprehensive geriatric assessments were performed before and after the intervention program, including basic demographic data, risk for malnutrition (by mna-sf), mood condition (by gds- ), cognitive condition (by mmse), weakness (by handgrip strength), exhaustion (by self-report in chs) slowness (by gait speed) and time-up-go test. pretest on the st week before intervention and post-test on the th week to compare the difference between twice evaluate consequence. results: overall, participants were identified as having pre-frailty ( . %) and frailty ( background: low appendicular skeletal muscle mass (asm), an integral component of current sarcopenia definitions, is commonly measured using bioimpedance analysis (bia). bia equations for estimation of asm are not generalizable across population groups and instrument types, potentially giving rise to inaccurate results when applied inappropriately. there is a lack of bia prediction equations for asian populations, none of which have been developed or validated for singaporean older adults. objectives: to develop a bia prediction equation for estimation of asm in communitydwelling older singaporean adults. methods: we studied healthy community-dwelling subjects (mean age . years) from the gerilabs- cohort. bia was performed using a single-frequency instrument. the reference method used for asm measurement was dual-energy x-ray absorptiometry (dxa). we first identified independent asm predictors by assessing the correlation of demographic, anthropometric and bia variables with dxa-measured asm. the best-fitting prediction equation was derived from these variables using stepwise (backward elimination and forward selection) linear regression with bootstrap validation. using asian working group for sarcopenia (awgs) cutoffs, we then compared anthropometric, strength and physical performance parameters between normal and low bia-derived asm groups. results: the derived bia equation incorporated predictorsimpedance index, weight, gender and body mass index (bmi), i.e. asm(kg) = . + ( . x impedance index) + ( . x weight) + (- . x gender) + (- . x bmi), where males = , females = and impedance index = height(cm )/resistance. the r and standard error of the estimate of this regression model were . and . kg respectively, with impedance index accounting for . % of its variability. individuals with low bia-derived asm have significantly smaller mid-arm and calf circumference and weaker grip strength, compared to individuals with normal bia-derived asm (p< . ). physical performance was similar in both groups. conclusion: we have developed a valid single-frequency bia prediction equation which can provide good estimates of asm in communitydwelling older singaporean adults. validation of this prediction equation in an independent sample of population is required to establish its accuracy and precision. ( ) faculty of sport sciences, waseda university, tokorozawa, japan) background: it has been well known that appendicular lean mass (alm) and skeletal muscle mass index (smi), which is the ratio of alm to height (m), is positively proportional to regional bone mineral density (bmd) in elderly men. however, there is limited information about these relationships in middleaged men. objectives: the purposes of this study were to investigate the difference in bmds (arms, lumbar spine, pelvis, legs, and subtotal: total body without head area) in middleaged men with low and normal smi (alm/height ≤ . kg/ m from asian working group for sarcopenia: awgs), and to determine the associations between alm, smi, and bmds. methods: three hundred and two middle-aged japanese men between and years of age participated in this study. alm and bmd measurements were taken using dual-energy x-ray absorptiometry (dxa, delphi a-qdr, hologic). results: based on the definition from awgs, the prevalence of low smi was approximately % in middle-aged men. the subjects with low smi (low smi group, n = , . kg/m ) had significantly lower body weight ( . vs. . kg), bmi ( . vs. . kg/m ), and fat mass ( . vs. . kg) compared to the normal group (n = , . kg/m ), although there were no differences in age ( vs. years), standing height ( . vs. . cm), and body fat percentage ( . vs. . %) between the two groups. bmds were significantly lower in low smi group than normal group for regional body parts (arms . vs. . g/cm ; lumbar spine . vs. . g/cm ; pelvis . vs. . g/cm ; legs . vs. . g/cm ) and subtotal ( . vs. . g/cm ). moreover, body weight, fat mass, alm, and smi were positively correlated with bmds using partial regression analysis controlling for age in all subjects, except for fat mass vs. lumbar spine bmd. in a stepwise multivariable model, alm was more closely related to bmds, except in the case of pelvis. conclusion: these results suggest that in order to maintain the regional bmd in middle-aged men, a key factor is to maintain or increase both alm and smi. background: the societies on sarcopenia have recently accepted the use of bioelectrical impedance analysis (bia) in the assessment of appendicular skeletal muscle mass (asm). several bia equations and devices have been introduced, which analyze the whole body composition, including the trunk and excluding the left arm and left leg at khz. it is necessary to measure the appendicular body segments of impedance parameters with a specific frequency (hz) that optimally analyze the muscle for valid assessment of asm. prior our study, literature-based bia equations and the two devices estimated asm at > % of r (coefficient of determination) with the significant constant-errors rated as «poor». objectives: thus, the aims of this study were ( ) externally cross-validate the equations and devices of bia on the appendicular skeletal muscle mass and ( ) develop valid equations based on appendicular bioimpedance parameters at the specific frequency (khz) that reflects the muscle for estimating asm; methods: community dwelling koreans over -year-old ( + . yrs, females and males) participated. asm was predicted using bia-based equations available in literature and bia devices and compared to dxa outcomes which is the gold standard. we conduct internal cross-validation and stepwise multiple linear regression to develop asmformulas with segmental multi-frequency bias. results: our new prediction formulas were developed by the appendicular impedance(z) index = height / (z of right arm + z of left arm + z of right leg + z of left leg)) at higher than khz and the appendicular reactance(xc) = xc of right arm + xc of left arm + xc of right leg + xc of left leg at khz. r s were over %, see wes under . kg of asm with the subject rating as «excellent» for men and «good» for women. conclusion: we found that our new protocol resulted in higher agreement with dxa and improved bia accuracy for this specific age group. clinicians can use this lower cost protocol and equations to better diagnose sarcopenia in larger cohorts with comparable to measurement of dxa. background: greater protein intake throughout the lifespan may be related to better body composition through the preservation of lean body mass during aging. objectives: we sought to determine whether an association between dietary protein intake (pi) and body fat percentage (bf) exists among women when controlling for dietary and lifestyle factors. methods: body composition and lean body mass were examined via dual-energy x-ray absorptiometry, grip strength (gs) was assessed using a hand grip dynamometer, and moderate-to-vigorous physical activity (mvpa) was measured by accelerometry. dietary intakes were estimated via threeday food logs and esha software. multiple linear regression and stepwise linear regression models were used. results: a total of women (mean ± sd; age . ± . years) finished all assessments. a full regression model (i.e., containing all covariates; r = . ; adjusted r = . ; f( , ) = . ; p < . ) was created using fat, carbohydrate, protein and leucine intake (g/day), protein quality (g/day of leucine over g/day of protein), energy intake (kcal/day), age (years), lean body mass (kg), bmi (kg/m ), gs (kg), and mvpa (min/day). only bmi (mean ± sem; beta = . ± . ; p < . ), gs (mean ± sem; beta = - . ± . ; p < . ), and pi (mean ± sem; beta = - . ± . ; p = . ) were significant to the full regression model. to verify their importance, a stepwise regression using the same variables was performed and resulted in a model (f( , ) = . ; p < . ; r = . ; adjusted r = . ) that included bmi (mean ± sem; beta = . ± . ; p < . ), gs (mean ± sem; beta = - . ± . ; p < . ), and pi (mean ± sem; beta = - . ± . ; p = . ). conclusion: greater protein intakes are associated with lower bf in women when controlling for various covariates. we theorize that greater protein intakes preserve lean body mass which results in improved body composition. more specifically, a one gram per day increase in dietary protein is predicted to decrease bf by . % when controlling for all other variables. background: muscle aging and the increased prevalence of obesity in the geriatric population create a new area of research: sarcopenic obesity. in prospective cohorts of nonhospitalized subjects, it is associated with an increased risk of developing physical limitation. hospitalization is an event with high risk of loss of independence. the impact of sarcopenic obesity during this episode isn't known yet. objectives: analyze the evolution of functional independence during a hospitalization in an acute geriatric ward, looking for a link between the presence of sarcopenic obesity and a decline of independence. early readmission, length of stay and changes in body composition during hospitalization were also examined. methods: prospective descriptive monocentric cohort study carried out in an acute geriatric ward of the pau hospital. sarcopenia was diagnosed using the european working group on sarcopenia in older people algorithm by an impedancemeter. a bmi over was used to report obesity. functional independence was rated on the adl katz scale. results: patients were included. sarcopenic obesity was diagnosed in . % of cases, sarcopenia and obesity in % and % of patients, respectively. the greatest variation in functional independence during hospitalization was observed in sarcopenic obese patients (mean variation of out of points, p= . ). a total of early readmission at month were counted, with the highest rate for sarcopenic obese ( %, but % at the sample level) (p= . ). the average length of stay was . days. conclusion: sarcopenia is common in patients hospitalized in geriatrics, and when associated with obesity, there is greater variation in functional independence and more readmissions. background: known that is sarcopenic obesity, excessive accumulation of adipose tissue is detected, with a decrease in muscle mass and strength, which is already over the age of years. modern diagnostic methods have their drawbacks for the diagnosis of sarcopenic obesity. bodpod quality and timeliness of diagnosis of signs of sarcopenia in obese patients is improved, which ultimately will contribute to an earlier targeted treatment of sarcopenia and an improvement in its prognosis. bodpod methodology can be recommended for use in complexes for the diagnosis of sarcopenic obesity. objectives: to compare the effectiveness of three methods of body composition assessment such as bioimpedans analysis (bia), air-replacement bodyplatismography (bodpod) and dual x-ray absorptiometry total body program (dxa total body) in the verification of reducing of skeletal muscle mass as sign of sarcopenic obesity in obese patients. methods: the study group included patients aged - y.o. (average age , ± , years) with bmi>= . kg/m . the control group included patients aged - y.o (average age , ± , years) of the same age without obesity with bmi . - . kg/m . body composition was tested using bia, bodpod and dxa with calculating fat, lean and skeletal muscles mass (kg) and % in all the patients. (bodpod) is the most sensitive in the verification of skeletal muscle mass reduction in obese patients. this method shows that patients with obesity have a significantly reduced muscle mass compared with normal weight or overweight subjects. background: in overweight and obesity excess energy and changes in body composition may favor the onset of metabolic derangements. combined with excess adiposity, the age-related decline in lean body mass can accelerate the development of insulin resistance and the consequences in terms of cardiovascular risk. objectives: the aim of our study was to investigate the association between the phenotype of sarcopenic obesity and cardio-metabolic risk in postmenopausal women. methods: postmenopausal women were recruited among subjects admitted to the high specialization centre for the care of obesity (casco), at the sapienza university, rome, italy. fat mass (fm) and fat-free mass (ffm) were assessed by dxa. obesity was defined as body fat >= %. appendicular skeletal muscle mass (asmm) was calculated. sarcopenia was defined as asmm/weight < sd than the sex-specific mean of a young population. the cut-point was asmm/weight< . . the lipid accumulation product was calculated: lap = (waist circumference cm - ) × triglycerides mmol/l]. the estimated glucose disposal rate (egdr) was calculated. high-sensitivity c-reactive protein (hs-crp) was measured. results: women were included (age: . ± . years, bmi: . ± . kg/m ). sarcopenia was diagnosed in . % of study participants. sarcopenic obese women were older than nonsarcopenic women ( . ± . vs. . ± . years, p= . ). lap was higher in sarcopenic obese women compared to their nonsarcopenic counterparts ( . ± . vs. . ± . , p= . ) after adjustment for age, body fat, and hs-crp levels. estimated gdr was significantly lower in sarcopenic obese women ( . ± . vs. . ± . , p= . ) after adjustment for age and body fat. an inverse association emerged between the index of sarcopenia, asm/weight, and lap (beta: - . * - , se: . * - , p= . ), independent of age, body fat, and hs-crp levels. a positive association was observed between asm/weight and egdr (beta: . * - , se: . * - , p= . ) adjusting for age, body fat, and hs-crp levels. conclusion: postmenopausal sarcopenic obese women exibithed a high lap and a low egdr, indicating increased cardiometabolic risk and decreased insulin sensitivity, respectively. l e a t h a a . c l a r k , , , todd m. manini , nathan p. wages , , janet e. s i m o n , , d a v i d w . r u s s , , b r i a n c . c l a r k , , , ( ( ) background: muscle weakness strongly contributes to mobility limitations and physical disability. the role of neural mechanisms contributing to age-related weakness have not been fully delineated to sufficiently target interventions that enhance strength and physical function in older adults. objectives: we sought to compare differences in voluntary inactivation and measures of motor corticospinal excitability in older adults with clinically meaningful muscle weakness compared to young adults and stronger adults without muscle weakness. methods: maximal voluntary isokinetic and isometric leg extensor strength, electrical stimulation of the leg extensors, and transcranial magnetic stimulation (tms) of the motor cortex were performed in older adults and young adults. outcome measures of leg extensor strength relative to body weight, voluntary inactivation (via), motor evoked potential (mep) amplitude and silent period (sp) duration during isometric leg extension contractions at %, %, and % of maximum voluntary contraction (mvc) were obtained. older adults were classified into three weakness groups based on previously established isokinetic leg strength/ body weight cut points (severely weak, moderately weak, or not weak). group differences were examined after controlling for sex. results: the older adults had % lower isokinetic strength/body weight when compared to the young adults. the severely weak older adults were % and % weaker than the moderately weak and older adults who were not weak, respectively. severely weak older adults exhibited higher levels of leg extensor via than older adults who were not weak ( . + . % vs. . + . %). severely weak older adults exhibited % longer sp's compared to the older adults who were not weak, but this difference was not statistically significant (p= . ). the severely weak older adults' mep's were approximately half the amplitude of the older adults who were not weak. regression analyses demonstrated that mep amplitude and sp duration -indices of hypoexcitability-were associated with relative strength. conclusion: weak older adults have significant deficits in their nervous systems' ability to fully activate their leg extensor muscles. additionally, motor corticospinal hypoexcitability is associated with age-related weakness, suggesting that interventions targeting the nervous system could be used to enhance muscle strength and prevent future health risks in older adults with muscle weakness. model. results: we evidenced oxidative stress in a mouse model of the pathology at different ages ( , and months) and aimed to identify the consequences of opa inactivation on redox homeostasis. increased ros levels were observed in cortices of the murine model opa +/-as well as in opa down-regulated cortical neurons. this increase is associated to a decline in mitochondrial respiration and an increase of antioxidant enzyme levels. upon exogenous oxidative stress opa -depleted neurons did not further up-regulated antioxidant defenses. finally, low levels of antioxidant enzymes were observed in fibroblasts from patients supporting their role as modifier factors. moreover, the simulations obtained with our mathematical model of complex i are able to reproduce biological experiments of quantification of ros production by complex i. conclusion: our study shows: (i) the prooxidative state induced by opa loss can be considered as a pathological mechanism (ii) differences in antioxidant defenses can contribute to the variability in expressivity and (iii) antioxidant defenses can be used as prognostic tools to gauge the severity and the evolution of the disease. (iv) furthermore, our mathematical model model of ros porduction by complex i will help to understand the dysfunctions of oxidative metabolism in opa gene related disorders. we will present the last results of our algorithm and wet laboratories experiments. amanika kumar, deepa m narasimhulu, michaela e. mcgree, amy l.weaver, aminah jatoi, nathan k lebrasseur (mayo clinic, rochester, mn, usa) background: patients with advanced ovarian cancer (eoc) are often frail and require multi-agent chemotherapy. objective: to evaluate the relationship between frailty and adjuvant chemotherapy tolerance and toxicity among women with advanced epithelial ovarian cancer. methods: women who underwent primary debulking surgery for stage iiic or iv eoc and received adjuvant chemotherapy at the same institution were identified. a frailty deficit index (fi) was derived from items representing comorbidities and activities of daily living. frailty was defined as a fi ≥ . . if data were unavailable for frailty index calculation, patients were excluded. relative dose intensity (rdi) for carboplatin and paclitaxel was calculated as the percentage of the standard dose that was actually administered and compared between frail and non-frail using the wilcoxon rank sum test. results: of the women who met inclusion criteria, . % ( / ) were frail. frail women were older ( . vs . years, p= . ), had a higher bmi ( . vs . kg/m , p= . ), and were more likely to have american society of anesthesiologists (asa) score ≥ ( . vs . %, p= . ) compared to nonfrail women. frail patients were less likely to complete cycles of adjuvant chemotherapy, ( % versus %, p< . ). despite the decrease in total cycles of chemotherapy, we did not observe significant differences in dose delays ( . vs. . %), dose reductions ( . vs . %), and severe neutropenia ( . vs. . %) between frail and non-frail women. we analyzed a subset of patients ( frail and non-frail) women received both intravenous carboplatin and paclitaxel. we observed that frail women were less likely to have a carboplatin rdi of % or higher ( . % vs. . %, p< . ) and less likely to have a paclitaxel rdi of % or higher ( . % vs. . %, p= . ). conclusion: frail women with advanced eoc undergoing adjuvant chemotherapy receive reduced rdi and are less likely to complete cycles of chemotherapy despite no increase in dose reduction, delays, and neutropenia. physician bias and patient choice may influence chemotherapy intensity decisions. further studies are needed to explore the association between frailty, chemotherapy, and survival. background: gait speed is a core component of physical frailty (pf) and, as a single measure, is correlated with important health outcomes, including mortality. immune dysregulation has been previously associated with pf -including increased il- production in peripheral blood mononuclear cell (pbmc) lipopolysaccharide (lps) stimulation assays. it is not known whether gait speed is associated with lps-stimulated cytokine production. objectives: this pilot study evaluated whether gait speed is correlated with dysregulated immune response in two populations of older adults undergoing procedures -knee osteoarthritis (oa) scheduled for knee replacement, and chronic kidney disease (ckd) approaching hemodialysis initiation. methods: older adults with ckd and older adults with knee oa underwent preoperative evaluation including gait speed (usual pace, -meter walk, best of two trials) and immune stimulation testing (in vitro, thawed pbmcs stimulated with lps at doses , . , and ug/ml, with il- quantified by elisa at , , , and hours; reported as area under the curve (auc)). correlation coefficient and p-value were calculated. results: for ckd, the il- auc of lps stimulated pbmcs was negatively associated with gait speed (lps . ug/ml r = - . , p= . ; lps ug/ml r= - . , p= . ). for oa, the correlation between il auc and gait speed was positively correlated for lps dose . ug/ml (lps . ug/ml r = . , p= . ; lps ug/ml r= . , p= . ). none of these associations were statistically significant. similar results were obtained when age was included as a covariate. conclusion: in people with ckd, increased cytokine production was correlated with decreased gait speed. in people with knee oa, results do not support this hypothesis. further studies with larger sample size are warranted. for participants with knee oa, future studies should account for severity of knee pain at time of gait speed assessment. background: skeletal muscle drives fuel utilization, and carbohydrate (cho) is a major fuel source. metabolic flexibility describes the ability to balance cho and fat oxidation efficiently in response to changes in metabolic demands or conditions. despite its role in long-term metabolic health, little is known about cho oxidation or metabolic flexibility in sarcopenic older adults. objectives: to examine resting metabolism and metabolic flexibility from a fasted to fed state after a cho-rich meal in sarcopenic versus nonsarcopenic older adults. methods: twenty-two men and women (age ± sd= ± y) were enrolled into this pilot study with either normal (non-sarcopenic, n= ) or low (sarcopenic, n= ) handgrip strength, gait speed and relative skeletal muscle index. resting metabolism was assessed in a fasted state at baseline, and metabolic flexibility was assessed after ( min, post-prandial) consuming a meal containing g of fat, g of protein, and g of a rapidly-digestible cho. respiratory quotient (rq), cho, and fat oxidation were measured with open-circuit spirometry, indirect calorimetry. fat and fat-free mass were measured with dual x-ray absorptiometry. blood glucose was assessed from venous samples using glucose oxidase methodology. results: rq was - % higher (p= . - . ) in sarcopenic participants throughout the experiment. after adjusting for fat-free mass, fat oxidation was % lower (p= . ), while cho oxidation was % higher (p= . ) at baseline for sarcopenic men and women. sarcopenic participants also exhibited delayed and limited (p< . ) postprandial increases in cho oxidation, despite greater (p< . ) increases in blood glucose. conclusion: sarcopenic individuals are more reliant on cho and less reliant on fat oxidation than non-sarcopenic adults, which is generally consistent with poorer metabolic health. when compared to non-sarcopenic adults, sarcopenia delayed and truncated cho utilization after a meal, indicating impaired metabolic flexibility in this population. impaired metabolic flexibility could be a mechanism underlying the losses of strength and physical function accompanying sarcopenia. anton de spiegeleer , , , hasan kahya , , nele van den noortgate , evelien wynendaele , tine decruy , srinath govindarajan , dirk elewaut (( ) unit for molecular immunology and inflammation, vib-center for inflammation research, ghent, belgium; ( ) department of geriatrics, faculty of medicine and health sciences, ghent university hospital, ghent, belgium; ( ) drug quality and registration (druquar) group, faculty of pharmaceutical sciences, ghent university, ghent, belgium) background: acute and chronic muscle wasting represent an important unmet clinical health problem. most pathophysiological studies suggest an effect of the immune system, primarily through catabolic cytokine productions such as il- . also endoplasmic reticulum (er) stress is considered to be an important pathway favouring muscle wasting. er stress in turn plays an important role in innate-like t cells, particularly invariant natural killer t cells (inkt cells), by controlling their cytokine production [govindarajan et al., nat. commun. ]. as such we reasoned that inkt cells may play a pivotal role in muscle homeostasis through their excessive cytokine production. previous studies have already highlighted the importance of these cells in a wide range of diseases such as cancer and metabolic disorders such as obesity. objectives: the aim of this study was to investigate the in vivo role of inkt cells in muscle homeostasis. methods: we compared wild-type (wt) versus inkt cell depleted mice (jα ko) for clinical, histological and gene expression differences in lower limb skeletal muscle. results: interestingly, we found that inkt cell depleted mice (jα ko) had a lower relative muscle weight, i.e. a muscle wasting phenotype, compared to wt mice. this clinical muscle wasting was associated with a decrease in oxidative enzymatic activity (succinate dehydrogenase histology). moreover jα ko mice showed a decreased transcription of genes involved in skeletal muscle growth and differentiation (follistatin and myogenin), sarcomere assembly (myosin- ) and neuromuscular junction function (neuronal acetylcholine receptor subunit alpha- ). conclusion: taken together, our results suggest a role for inkt cells in muscle wasting diseases and put innate-like t cells at the centre stage of immune cells controlling skeletal muscle biology. a r m a n d a t e i x e i r a -g o m e s , , s o l a n g e costa , , bruna lage , , dietmar fuchs , vanessa valdiglesias , , blanca laffon , joão paulo teixeira , ( ( ) background: frailty is a multidimensional geriatric syndrome characterised by increased vulnerability and functional decline that may be reversed if addressed early. it has been identified to be the most common condition leading to disability, institutionalisation and death in older adults. despite its known biological basis, no particular biological trait has been consistently associated with frailty syndrome so far. objectives: on this basis, the main objective of the present work was to evaluate the possible association between immunological: biomarkers and the frailty status in a group of community dwellers. methods: a group of older adults (>= years old) was engaged in this study. frailty status was assessed via fried's frailty model. the levels of several immune activation molecules -neopterin, tryptophan, kynurenine -were analysed. results: the classification of the study population was . % robust, . % pre-frail and . % frail. no significant differences were found between robust and pre-frail groups regarding serum concentrations of neopterin. although, the kynurenine/tryptophan ratio was significantly higher in pre-frail individuals as compared with robust subjects. conclusion: the preliminary data obtained suggest the activation of immunobiochemical pathways and are in agreement with previous studies that report alterations of the immune response in frail older adults. nevertheless, further investigation is encouraged and required to consistently demonstrate these findings. in future studies physical activity, nutritional, psychological, sociological and clinical features should also be considered when evaluating changes in immune biomarkers and frailty. the work developed by armanda teixeira-gomes and solange costa is supported by fct under the grants sfrh/bd/ / and sfrh/ bpd/ / , respectively. vanessa valdiglesias was supported by beatriz galindo research fellowship beagal / . background: frailty and hemoglobin count, above what would be considered clinical anemia, are two common findings in older patients and lead to an increased risk of negative health outcomes. objectives: evaluate whether hemoglobin concentration is an independent predictor of frailty and investigate possibe causal pathways in particuliar the relationship between inflammation and nutrition with hemoglobin concentration. methods: communitydwelling participants aged years or older who visited the toulouse frailty clinic between and were included in this analysis. patients underwent a comprehensive geriatric assessment and had a blood sample. a series of multivariate logistic regression models were perfomed after minimizing potential influence from age, gender, kidney function, inflammation, cognition, nutritionnal status and certain socioeconomic factors. results: hemoglobin count and frailty are significantly associated after minimizing potential influence from other covariates (p< . ). an increase in one point of hemoglobin concentration is associated with a % risk decrease of being frail (or= . , %ic= . - . ). there were no evidences of significant impact of inflammation and nutritional status in the relationship between hemoglobin concentration and frailty status (p> . ). conclusion: hemoglobin concentration is strongly associated with frailty in older adults. these results can have potentially important implications for prevention policies targeting frailty, by identifying potential patients with high risk of adverse outcomes and functional outcomes. juliette tavenier , line jee hartmann rasmussen , jan nehlin , morten baltzer houlind , aino leegaard andersen , ove andersen , janne petersen , , anne langkilde ( ( ) background: chronic inflammation is thought to be involved in the development of frailty. we hypothesized that increased monocyte inflammatory activity plays a role in chronic inflammation and thereby in frailty. objectives: to study the potential role of chronic monocyte inflammatory activity in frailty. methods: two groups of elderly adults (>= years) were included: patients with a recent admission to the emergency department (ed) and age-and sex-matched controls, without recent ed admission. data was collected at baseline and after year. participants were considered frail if they had or more of the following: hand grip strength ≤ kg for men or ≤ kg for women, gait speed ≤ . m/s, unintentional weight loss of > kg within the last months. frailty was also assessed using the frailty index (fi)-outref. we measured cognitive function (mini mental state examination -mmse) and chronic inflammation (soluble urokinase plasminogen activator receptor -supar). monocyte inflammatory activity was assessed by nf-κb phosphorylation (pnf-κb) using flow cytometry. results: participants had a mean age of . years (range: . - . ) and % were women. preliminary results show that at baseline, the patient group had a greater proportion of frail individuals compared to the control group ( vs. , p< . ). fi-outref was on average . points higher (p< . ) and supar levels % higher (p< . ) in the patient group, however, there was no difference in mmse score between the groups (p= . ). at year, although the proportion of frail individuals decreased in the patient group, it was still greater than in the control group ( vs. , p= . ). fi-outref remained elevated in the patient group (p= . ), but there was no difference in supar levels (p= . ). pnf-κb was positively associated with age in the control group (p= . ), but not in the patient group (p= . ). pnf-κb was % higher in the patient group compared to the control group (p< . ), and this was unchanged when adjusting for frailty, supar, and mmse. conclusion: the patient group was more frail and had elevated monocyte inflammatory activity compared to the control group. however, none of the frailty measures were confounders for the difference in monocyte inflammatory activity between groups. background: aging is most often accompanied by a loss of body weight: a decrease of fat deposits and muscle body weight. body mass index (bmi) in adults is considered normal if it is in the range of . to . kg / m (according to the who classification). bmi is widely used in the diagnosis of obesity. the association of bmi and cardiovascular and cerebrovascular diseases is known. objectives: the purpose of research is to identify the relationship of bmi with physical abilities and cognitive functions in long-livers. methods: long-living subjects aged . ± . years were examined. in long-livers, height, body weight were measured, calculated bmi. the level and direction of cognitive disturbances was determined by the mmse test (mini mental state examination). physical abilities were determined by the questionnaire and physical tests (tests the muscular strength in forearms and of the hands, chair stand test). results: bmi in long-livers had a normal distribution. the median bmi was . kg / m , the minimum value was . kg / m , and the maximum value was . kg / m . . % of long-livers had a bmi ranging from . to . kg / m . . % of long-livers have lost weight during the past year, including . % by kg or more. . % of long-livers could stand up of the chair. however, only . % of long-livers were able to complete the test correctly. amongst them, . % had a normal bmi. indicators of muscular strength in forearms and of the hand in long-livers who completed the chair stand test were significantly higher compared to long-livers who did not completed the chair stand test (r = . , p < . ). bmi had a positive correlation with the ability of a long-lived to wash without anyone's help (r = . , p < . ), go up and down the stairs (r = . , p < . ), do light housework (r = . , p < . ). mmse indicators also positively correlated with bmi (r = . , p < . ). the average mmse . ± . was observed with average bmi . ± . . conclusion: against the background of a decrease in the bmi indicator in long-livers, a decrease in physical abilities and cognitive functions is observed. however, there is a problem in determining the boundaries of the ratio of height and body weight for elderly people. in all likelihood, there are not linear, but more complex dependencies between bmi and functional abilities of long-livers. suparb aree-ue , inthira roopsawang , jansudaphan boontham , surinrat baurangtheinthong , yuwadee phiboonleetrakun (( ) ramathibodi school of nursing, faculty of medicine ramathibodi hospital, mahidol university, bkk, thailand; ( ) faculty of graduate studies, mahidol university, bkk, thailand) background: depressive symptom results in increasing poor outcomes and care dependency in older adults. the prevalence of depressive symptoms is common with its associated multiple factors. however, this conundrum problem is underestimated, particularly in older people living in rural areas. to promote healthy aging, understanding of the conundrum problem is essential in strengthening care quality and enhancing the quality of life in this population. objectives: to determine the relationships of the number of medication use, pain, frailty, and locomotive syndrome and their effects on depressive symptoms among community-dwelling thai older adults. methods: a cross-sectional study was employed. the sample consisted of community-dwelling thai older adults who met the inclusion criteria. data were assessed by using demographics questionnaire, thai version -question geriatric locomotive function scale: glfs- ; numeric rating scale; the reported edmonton frailty scale: refs-thai version; and the -item geriatric depression scale, tgds- . a path analysis was employed to determine the pathways linking the number of medication use, pain, locomotive syndrome, frailty to influence depressive symptoms. results: there were significant positive direct paths from pain (beta = . , p <. ) to locomotive syndrome and from locomotive syndrome to the number of medication use (beta = -. , p <. ). an inversely, the locomotive syndrome was a negative significant direct to depressive symptoms (beta = -. , p <. ). pain had an indirect effect on depressive symptoms (beta = -. , p <. ). additionally, the model explained . % of the variability in depressive symptoms. conclusion: the locomotive syndrome is a major factor influencing depressive symptoms. the complex relationship among pain, number of medication use, locomotive syndrome, and depressive symptoms should be taken into account for designing an appropriate intervention to reduce depressive symptoms among community-dwelling thai older adults. background: total knee arthroplasty (tka) is a clinical curative treatment for severe knee osteoarthritis. however, the outcomes are differences in each patient's perception. preoperative patients' expectations to functional abilities are one of important factors influencing on postoperative outcomes and satisfaction. objectives: to investigate the association among preoperative patients' expectations, postoperative functional abilities, and satisfaction to functional abilities among older adults undergoing tka at -week after surgery. methods: participants were older adults who were diagnosed with knee osteoarthritis and required to receive tka at a university hospital in bangkok, thailand. the sample was purposely selected based on the following criteria: were aged years or over, received tka for the first time, and had no cognitive impairment. the data were collected at preoperative and postoperative tka by using the demographic data questionnaire, the hospital for special surgery knee replacement expectations survey, and the knee and osteoarthritis outcome score in the part of function in daily living (koos adl) thai version. the data analysis was performed by using descriptive statistics, paired t-test, and pearson product moment correlation coefficient. results: before surgery, patients' expectations to postoperative functional abilities had a high level with the total mean score of . (sd = . ), and the item of improving ability to walk in a short distance was rated as the highest expectation. at -week after surgery, the overall functional ability had a significant improvement (t = - . , p = . ). satisfaction to functional ability also had a high level (mean ± sd = . ± . ), and the improving ability to walk in a short distance item had the highest. patients' expectations to functional abilities had a significantly low positive correlation to postoperative functional ability and satisfaction (r = . , p < . ; r = . , p < . , respectively). moreover, there was a significant moderate positive correlation between functional abilities and satisfaction to functional abilities (r = . , p < . ). conclusion: a better understanding of expectations may be beneficial in gaining knowledge, paving expectations on possible outcomes, and developing trust resulting in enhancing quality of care for thai older adults undergoing tka. background: identifying low muscle strength is a key step in many operational definitions of sarcopenia including the one recently proposed by the european working group on sarcopenia in older people- (ewgsop ). grip strength is widely used to identify people with low muscle strength. however, it is unclear what impact variation in the type of hand-held dynamometer used to measure grip strength has on the prevalence of low muscle strength. objectives: we aimed to assess the impact of estimated differences of between and kg in the measurement of grip strength when using different types of hand-held dynamometer on the case-finding of low muscle strength. methods: study participants were men and women aged - from a randomised, repeated measurements cross-over trial. maximum grip strength was assessed using four hand-held dynamometers (jamar hydraulic; jamar plus+ digital; nottingham electronic; smedley) in a randomly allocated order. ewgsop recommended cutpoints (< kg men; < kg women) were applied to estimate prevalence of low muscle strength for each device. agreement between devices was assessed using kappa statistics. results: prevalence of low muscle strength varied by dynamometer type ranging between % and % for men and, % and % for women. of the men identified as having low muscle strength by at least one of the four dynamometers, only % were identified by all four and % by just one. of the women classified as having low muscle strength by at least one of the four dynamometers, only % were identified by all four and % by only one. when comparing pairs of devices, kappa statistics ranged from . to . suggesting poor to moderate agreement. conclusion: case-finding of low muscle strength is influenced by the type of hand-held dynamometer used. it is important to identify the sources of variation in the measurement of grip strength and consider the implications of these for sarcopenia. further research is required to understand how best to standardise the assessment of each of the different components of commonly used operational definitions of sarcopenia and take account of sources of variation in these measures where standardisation cannot be achieved. background: sarcopenia is characterized by a progressive loss of skeletal muscle mass and strength associated with mortality and severe adverse events on health. for a healthy aging, the quality of life (qol) is essential and it is associated to autonomy of persons, social relations, and socioeconomic factors. objectives: to compare the qol of chilean older people with sarcopenia living in santiago de chile, according to an adapted version of the european working group on sarcopenia. methods: community-dwelling older people (mean ± sd: . ± . years; . % females) were interviewed, registering self-reported chronic diseases and the questions of short-form- health survey (sf- ). anthropometry, dynamometry and physical performance were measured. qol was measured using sf- , validated in chilean older adults. norm-based score of subscales and two summaries components -mental and physical (mcs and pcs; respectively)-were calculated using the chilean-specificscoring for older people. low score was defined as having a score ≤ th percentile of mcs and pcs. logistic regressions were estimated. results: sarcopenia was identified in . % of the sample ( . % women; . % men; p= . ). the average score of the subscales were significantly higher in non-sarcopenic adults than sarcopenic. the average of mcs and pcs were also significantly higher in non-sarcopenic adults than sarcopenic (mcs: . vs . ; p= . ; respectively; pcs: . vs . ; p< . ; respectively), and were significantly higher in men than women non-sarcopenic (mcs: . vs . ; p= . ; respectively; pcs: . vs . , p= . ; respectively). there were non-significant differences in sarcopenic adults by sex. logistic regressions demonstrated an association between sarcopenia and low mcs and pcs (or = . ; %ci: . - . ; or = . ; %ci: . - . ; respectively), adjusted by age, sex, multimorbidity, body mass index and lean/fat mass ratio. conclusion: sarcopenia was associated with a worse quality of life, which shows the impact of this pathology and the importance of developing programs for its prevention, delay or reversal. funded by fondef i p -munich sarcopenia registry (idsar): first results. uta ferrari , , marina schraml , ralf schmidmaier , , navina röcker , , sigrid adler-reichel , , christian lottspeich , , martin bidlingmaier , , benedikt schoser , , sabine krause , , martin reincke , , michael drey , (( ) department of medicine iv, university hospital, lmu munich, germany; ( ) friedrich baur institute at the department of neurology, university hospital, lmu munich, germany; ( ) preventive geriatrics study group, germany) background: since sarcopenia can be coded as disease in germany (icd-gm . ). in the same year we established the first sarcopenia registry linked with a biobank to identify modifiable, crucial risk factors for sarcopenia and its adverse outcomes. objectives: objectives of the registry are (i) how to optimize and standardize the diagnosis over in-and outpatient settings for musculoskeletal health, (ii) identification of clinical and molecular modifiable risk factors (iii) improvement of interdisciplinary treatment and prevention of sarcopenia as a new icd-code-based geriatric syndrome here we present the design as a practical approach for diagnosis in out-and inpatient care and a first descriptive analysis of influencing factors and comparison between in-and outpatients data. methods: patients older than years of age from outpatient clinic and acute geriatric ward at munich university hospital were consecutively screened by the sarc-f questionnaire. patients with high risk (sarc-f score >= ) were further assessed for sarcopenia in line with the european consensus definition (ewgsop ). among further factors assessed in the registry, we retrieved presence of further comorbidities, daily medication, nutritional status, sppb, frailty, and quality of life. results: at time of analysis, patients have been screened and within the first patients with high risk ( % women) % had sarcopenia. patients screened positive for sarcopenia have lower quality of life, even in a subclinical condition (mean euroqol (eq d-vas) = . ± . ). lower bmi ( . ± . , p= . ) and sex (p= . ) were statistically significant different for sarcopenia status, but not age (mean . ± . years, p= . ) or number of medication (p= . ) and comorbidities (p= . ). but the latter two were the most significant factors for inpatient status (both p< . ). the results underline the need for an early screening for sarcopenia in all patients older than years of age, suggested by hand grip strength in inpatients and sarc-f for outpatients. sex differences and further laboratory factors are necessary to add in sarcopenia diagnosis for precision medicine approaches. hospitalised older adults. we consider acute sarcopenia to be the last remaining acute organ insufficiency, with potentially devastating impact on function. characterising this condition will enable development of targeted interventions to ameliorate these changes. mobility disability, and incident mobility disability over . + . years. factor was associated with incident and prevalent mobility disability only, and factor was associated with only prevalent mobility disability. conclusion: muscle mass by d cr co-segregated with strength and physical performance measures, and together was associated with mobility and disability outcomes in older men. body composition measures (including dxa alm) did not co-segregate with strength and physical performance measures and together was associated with only mobility disability. background: currently, there are no registered drug treatments for the loss of skeletal muscle mass, strength and function that occurs during sarcopenia and cachexia. moreover, they are only limited relevant pharmacological screening options available. objectives: to improve in vitro pharmacological screening options, we developed a model of muscle wasting using donor primary muscle cells and our myoscreen™ platform that generates standardized myotubes for high-throughput phenotypic screening (young et al., slas discov. ( ) : - ). methods: myoblasts from four donors aged , , and years were compared in terms of proliferation, differentiation, size of formed myotubes and achr cluster formation using imaging and high content analysis. we then established an assay for muscle wasting: in each of the four donors various molecular pathways implicated in the pathogenesis of sarcopenia were activated using tnfa, tgfb or dexamethasone. results: myotubes formed from elderly patient's myoblasts displayed a reduced capacity to proliferate and differentiate, thinner myotubes and fewer acetylcholine receptor clusters. therefore, myotubes cultured using the myoscreen system continue to reflect age-related properties of donor muscle. interestingly, we also found that myotube sensitivity to atrophy stimulation increased with increasing age. myotubes were then co-incubated with growth/ repair factor igf- or hdac inhibitor, trichostatin a (tsa). both agents attenuated tnfa-induced myotube atrophy and differentiation inhibition in a dose-dependent manner. the extent of fusion index and myotube size increase was highest in myotubes from elderly subjects while myotubes from young subjects were more resistant to the protective effects of igf- and tsa. conclusion: myoscreen can be exploited to quantify age-dependent modifications in skeletal muscle fibers in vitro and identify candidate compounds that counteract the muscle wasting phenotype. andreas friedberger , alexandra grimm , wolfgang kemmler , klaus engelke , (( ) institute of medical physics, friedrich-alexander-universität erlangen-nürnberg, erlangen, germany; ( ) department of internal medicine; ( ) friedrich-alexander-universität erlangen-nürnberg and university hospital erlangen, erlangen, germany) background: sarcopenia is characterized by a progressive loss of skeletal muscle mass, which is infiltrated by adipose tissue. dual energy x-ray absorptiometry can only differentiate overall lean and fat mass. a local muscle analysis requires d imaging like magnetic resonance imaging (mri). usually, t weighted images are used for a visual grading of the amount of intermuscular adipose tissue (imat). however, a quantitative analysis requires segmentation of the fascia lata (fl, deep fascia of the thigh). objectives: our aim was to develop a highly reproducible d segmentation method in oder to quantify imat and the fat fraction of the thigh muscles using a combination of t weighted turbo spin echo (t wtse) and corresponding pt turbo spin echo (tse) dixon fat fraction (ff) images. methods: mri scans were acquired on a t scanner (magnetom skyrafit siemens) at the midthigh (length cm, slices, voxel size t w . x . x . mm³, dixon . x . x . mm³). since the fl is difficult to detect in the ff images, the t wtse images were used for segmentation. this process involved several steps, starting with a fuzzy c-mean clustering followed by several filtering steps to enhance d surface like structures representing the fl. finally, a level set algorithm was applied to obtain a closed d surface. if necessary, results were corrected manually. segmented masks were transferred from the t w to the ff images by rigid registration. imat was then segmented using a threshold determined from the histogram of the ff values within the intra-fascia region. sarcopenic ( ± y) and healthy ( ± y) male subjects were analyzed by three operators once (interoperator reproducibility) and three times by one operator (intraoperator reproducibility). results: inter-and intra-operator variability results of imat are shown in the table as mean / root mean square of the standard deviation (rms-sd) in units of the measured variable / coefficient of variation (rms-cv) in %. overall precision was excellent with errors below . %. conclusion: a semi-automatic d segmentation for the fascia of the thigh was developed. the operator impact on imat was almost negligible. background: sarcopenia a muscle disease that causes muscle mass loss and weakness. the calf circumference is a good screening test for sarcopenia in older adults in primary care. the most commonly used cutoff point is cm, but it is derived from north american studies and it may not be adequate for screening different populations that have lower height, weight and bmi. objectives: the objective of this study was to determine the ideal cutoff point for calf circumference for sarcopenia in community-dwelling older people in northeastern brazil. methods: this was a cross-sectional study of community-dwelling older people with a mean age of ± years ( % women). data on sociodemographics, anthropometrics, grip strength, gait speed, and skeletal muscle mass (bioimpedance) were collected. sarcopenia was assessed based on the diagnostic criteria suggested by european working group on sarcopenia in older people (ewgsop ). the area under the roc curve (auc) was calculated for different calf circumferences to identify the best cutoff point to determine sarcopenia among the participants. results: the prevalence of sarcopenia was %. the most appropriate calf circumference cutoff point was cm, with an auc of . , % sensitivity and % specificity. conclusion: it was found that the most appropriate calf circumference cutoff point to diagnose sarcopenia in older northeastern brazilians was cm. this is a more accurate cutoff point and will reduce the number of false positives and optimize health services in brazil. background: osteosarcopenia is a new geriatric syndrome defined as the presence of both sarcopenia and osteopenia or osteoporosis. this musculoskeletal disorder is related to higher prevalence of disabilities, falls and fractures and higher risk of mortality among community-dwelling older adults. therefore, the early diagnosis of this condition must be considered in order to reduce costs and negative impact on function. objectives: to explore the use of the infrared spectroscopy as a potential screening tool for osteosarcopenic older women (>= years old). methods: sarcopenia was identified by observing the presence of both reduction of muscle strength (grip strength) and mass (appendicular skeletal muscle mass) as suggested by the revised algorithm of the european working group on sarcopenia in older people ( ). reduction on bone mineral density was identified through bone densitometry and a t-score of <- , was adopted to classify the older women as osteopenic/osteoporotic. infrared spectroscopy through attenuated total reflection-fourier transform infrared spectroscopy (atr-ftir) was used to collect the sample information and to perform a multivariate analysis model. vibrational spectrum was obtained from serum. six samples of each group (osteosarcopenic and non-osteosarcopenic) were used to test the model and thirteen ostesarcopenic samples and fifteen non-osteosarcopenic samples were used for training. results: the most suitable model was the ga-svm with an accuracy of . %, % of sensibility and . % of specificity to differ osteopenic to non-osteopenic women. the more important selected variables found in the model were at the spectral regions: ~ cm- for carbs, ~ to cm- for nuclei acids and ~ to cm- for proteins. conclusion: infrared spectroscopy may be a promisor future method to early and easily diagnosis osteosarocopenia and prevent the harms this health condition may cause to the elderly population and minimizing costs to treat them. background: the modified european working group on sarcopenia in older people (ewgsop- ) algorithm to identify older people with sarcopenia contains three steps after initial clinical suspicion. the chair stand test, also known as the fivetimes sit-to-stand test ( sts), is one of two tests that can be used to assess muscle strength. the sts is also a component of the short physical performance battery (sppb), which is used as a measure of severity in the ewgsop- algorithm. objectives: the objective of this study was to determine whether the sts could be used to assess both muscle strength and physical performance in the ewgsop- algorithm to detect sarcopenia. methods: one hundred and ten older people aged . ± . years participated in the study. all participants were evaluated using the sppb score, as well as the timed-upand-go (tug). the ewgsop- algorithm specifies cut-off points of ≤ points on the sppb, ≤ . m/s for gait speed, and ≥ s for the tug. each participant was classified for tug and gait speed using the ewgsop- cut-offs, with stepwise discriminant function analysis used to predict the classification of participants. the remaining participants were used for cross-validation. prediction of sppb classification used the sts score in combination with predicted balance and sppb gait scores from stepwise linear regression. the total sppb score obtained using this method was used to predict sppb classification for the ewgsop- cut-off for sppb. results: the sts scores were able to predict tug and gait speed classification with % and % accuracy, respectively for the learning set of participants. the predicted sppb score had a classification accuracy of %, with % sensitivity and % specificity. when the remaining participants were evaluated, the sppb classification was correctly predicted for participants ( %), with % sensitivity and % specificity. conclusion: the sts can be used to accurately predict sppb classification in the ewgsop- algorithm to detect sarcopenia, meaning that the sts test could be used as a standalone test in an initial screening for sarcopenia. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital , san josé, costa rica) background: obesity is a disease characterized by increased adiposity with negative impact on patient health. aging process is associated with a progressive loss in muscle function, that may lead to functional decline and frailty. there are only few studies that have compared the prevalence of sarcopenia and dynapenia in obesity. objectives: the aims of this study were to determine the prevalence of sarcopenic and dynapenic obesity in elderly using the european working group on sarcopenia in older people criteria. methods: we conducted a cross-sectional study that included elderly patients with obesity from the obesity clinic since january to june . sarcopenia was defined according to the european working group on sarcopenia in older people (ewgsop ) criteria, and obesity with body mass index (bmi) > kg/m . handgrip strength was assess using a hydraulic dynamometer (jamar). bioimpedance analysis (bia) was performed. results: we evaluated persons, but only had bia data ( %). a total of older ( . ± years), % were women. mean body mass index, waist circumference, weight and calf circumference were . ± . kg/m , . ± . cm, . ± . kg and . ± . cm respectively. all patients had elevated body fat (mean %) and % had abdominal obesity. patients showed higher frequency of hypertension ( %), diabetes ( %), dyslipidemia ( %). sedentary was present in % and falls in %. mean handgrip strength and muscle mass for men and women were . ± . kg; . ± . kg and . ± . kg; . ± . kg respectively. there were ( . %) individuals fulfilling criteria for sarcopenic obesity, all women. but, dynapenic obesity was present in . % men and % women. conclusion: although the loss of muscle mass is associated with the decline in strength during aging, the decline in strength is more prevalent than the loss in muscle mass in our obeses. a large difference in prevalence of the two conditions was observed, sarcopenia obesity . % and dynapenic obesity %, respectively. barrientos-calvo (nutritional support department and geriatric department, geriatric national hospital, san josé, costa rica) background: sarcopenia is a geriatric syndrome characterized by progressive and generalized loss of skeletal muscle mass, strength, and function. several operative definitions for sarcopenia have been proposed over the past two decades. objectives: the aim of this study was to determine the prevalence of sarcopenia in costa rican longevity and health aging study (creles) using the ewgsop and ewgsop criteria. methods: to carry out the analysis, all the available cases of the creles study database in which belong to the cohort that follows in the period - were used. we analyzed community-dwelling older adults. low muscle mass was assessed using calf circumference < cm and low strength if < kg in men or < kg in women (ewgsop) vs < kg in men or < kg in women (ewgsop ). results: according to the ewgsop . % of the participants had sarcopenia, while according to the ewgsop sarcopenia was present in , % of participants. there was an increasing trend of sarcopenia by age group, it was more prevalent in women. mean handgrip strength was , kg in men and , kg in women with sarcopenia. mean calf circumference was , cm. sarcopenia was positively associated with age (or= . ; ci: . - . ), incomplete primary education (or , ; ic , ) , perceived as unhealthy (or , ; ic , - , ), antecedent of ischemic vascular event (or , ; ic , - , ), arthritis (or , ; ic , - , ), and falls ( r , ; ic , - , ). conclusion: the overall prevalence sarcopenia were significantly lower in ewgsop . prevalence of sarcopenia varies widely depending on the grip strength cut-off points applied. based on a -hour dietary recall, and poorer nutritional status as determined using must compared to their non-sarcopenia counterparts (all p<= . ). conclusion: the high prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition highlights the importance to devise targeted exercise and nutrition interventions to improve muscle health, physical performance and nutritional status. these interventions are essential to reduce the risk of progression to frailty and disability in this population group. v i n c e n z o m a l a f a r i n a , l e t i z i a s u e s c u n p u e r t a , a r a n t z a z u b i a i n u g a r t e , i ñ a k i a r t a z a a r t a b e , virtudes niño martín ( ( ) s o p h i e g u y o n n e t , c a t h e r i n e t a k e d a , philipe de souto barreto , yves rolland , sandrine andrieu , bruno vellas and the inspire study group ( ( ) background: the new geroscience field should not only be focusing on preventing age-related diseases, but should investigate the optimal maintenance of intrinsic capacity (ic): mobility, cognition, psychological, vitality and sensorial (hearing and vision) capacities as defined by the w.h.o. a better understanding about how to measure biological aging is an indispensable step that may lead to the definition of the best putative markers of aging capable of predicting healthspan. objectives: the main objective of inspire bioresource research platform for healthy aging is to build a comprehensive research platform gathering biological, clinical (including imaging) and digital resources that will be explored to identify robust (set of) markers of aging, age-related diseases and ic evolution. methods: the inspire platform will gather clinical data and biospecimens from subjects in the occitania region of different ages (from years or over -no upper limit for age) and functional capacity levels (from robust to frail to disabled) over years (inspire human translational research cohort). data are collected annually. between two annual visits, ic domains are monitored (with or without the help of a caregiver) each -month. once ic declines are confirmed, participants have a thorough clinical assessment and blood sampling to investigate the response of markers of aging at the time declines are detected. biospecimens includes blood, urine, saliva, and dental plaque that are collected from all subjects at baseline and then, annually. nasopharyngeal swabs and cutaneous surface samples are collected from all subjects at time-points (baseline visit and follow-up visits at m , m , m , m and m ). feces, hair bulb and skin biopsy are collected optionally at the baseline visit. results: recruitment started in october for a two years period. the identification of markers of aging will take advantage of three complimentary approaches to look for the best markers of aging: without a priori approach (transcriptomics, proteomics, lipidomics); semi a priori approach (metabolism, inflammation, cell cycle, mitochondrial network…); and targeted approach (pre-identified targets). the inspire platform will also aim to develop an integrative approach to promote novel new technologies for the assessment and monitoring of functional capacities. *acknowledgments: the inspire plateform is supported by grants from the occitania region and the european regional development fund (erdf), and co-funding by the apoc, the ctad, and the edenis, korian, pfizer, and pierre fabre groups. the promotion of this study is supported by the university hospital center of toulouse. background: energy balance is usually regulated by silent information regulator related enzyme (sirt ) and adenosine monophosphate-activated protein kinase (ampk). caloric restriction (cr) can postpone the pathological process of aging-related diseases and has a neuroprotective effect on nervous system degenerative diseases, but the mechanism is complex and not yet fully elucidated, although some of the cr effects may be mediated by sirt and ampk. objectives: to evaluate the beneficial effects of a cr diet on learning and memory ability. methods: six-week-old male c /bl mice were fed ad libitum for week before the experiment began. animals were weight-matched and randomly divided into three different groups: normal control group (nc group, n = ), high-energy group (he group, n = ), and cr group (n = ). the energy of nc diet, he diet and cr diet caloric ratio was : . : . . the total experimental duration was months. results: cr improved spatial learning and memory ability and decreased body weight and serum glucose. nissle staining showed the cell density was significantly decreased in the he group and increased in the cr group. cr decreased the expression of insulin signal pathway-related proteins such as igf- , ir, irs- , pi k, akt/pkb, and p-creb. more sirt -immunoreactive cells and fewer mtor-and s k immunoreactive cells were observed in the hippocampal in the cr group than in the nc group. cr decreased hippocampal mtor and s k protein activation and mrna expression. the expression of beclin , lc and cat b was increased and p was decreased in the cr group. the number of gfap-positive and iba- -positive cells in the cr group was significantly reduced compared to the nc group. conclusion: cr may prevent age-related learning and memory impairment via suppression of pi k/akt pathway and activation sirt / ampk/ mtor pathway in brain. background: head-down ( °) bed rest (hdbr) is a wellaccepted model to understand the pathophysiology of disuseinduced sarcopenia. human centrifugation as a measure to counteract muscle wasting during spaceflight is discussed. previous studies have observed decreases in maximal voluntary contraction force of the knee and hip-extensors of up to % following weeks of hdbr. muscle force is regulated by the recruitment of motor units (mus) and the modulation of mu firing rate. objectives: the aim of this study was to assess whether long-duration hdbr alters motor unit properties as one cause for disuse induced sarcopenia and whether human centrifugation can attenuate this decrement. methods: twelve healthy participants ( . ± . yr; ± cm & . ± . kg) were confined to -days ° hdbr in the frame of the first campaign of the agbresa bedrest study. eight received mins of artificial gravity (ag) daily via human centrifugation whereas four belonged to a control group. estimations of mu number (munix) and size (musix) in the abductor digiti minimi (adm) and tibialis anterior (ta) muscles were made using the motor unit number index method from on day preceding bed rest (bdc ) and on days (hdt ) and (hdt ). mean compound muscle action potential (cmap), munix and musix as a percent change from bdc were compared using repeated-measures anova, where muscle and time were ascribed as within-group factors and intervention a between-group factor. significance was denoted by p< . . results: both cmap and munix were unaltered over time in both muscles, irrespective of the intervention. although musix was also indifferent over time for both muscles, a significant muscle*time interaction was observed, indicating that the changes over time differed between the two muscles. conclusion: the preliminary data from the ongoing study indicate that neurodegeneration due to bedrest might affect muscles differently. there does not seem to be an effect of ag on mu number. analyses have to be repeated when the study is completed with a larger number of participants. additional histological and biochemical data will give further insight in the pathophysiology. living. soumaya msaad , geoffroy cormier , guy carrault (( ) univ rennes, inserm, ltsi -umr , f- rennes, france; ( ) neotec vision , rennes , france) background: several models have been proposed for elderly frailty detection. there is a consensus on two of them: the fried model, and the rockwood model. however, daily monitoring of the elderly is impossible with these models, whereas it is very important to detect any change as soon as possible to prevent dependency, since frailty is reversible only if early detected. objectives: the objective of this study is to propose a non-intrusive and low-cost method that anticipates frailty using depth images. crucial hypotheses are that regularity of daily activities is important for the elderly and that any prolonged change is considered as an indicator of frailty. methods: the proposed method consists in three steps: ) extraction of parameters from depth images: lying and sitting time percentage during the day, walking speed, and number of falls, visits, and exits. ) classification of the daily state using logistic regression and the extracted parameters. the daily state is considered as normal if the daily routine is maintained and abnormal if it is broken. ) computation of the weekly percentage of maintaining routine based on the classification of the nature of the day. results: tracking frailty is a difficult task that requires recording data over several months. as real data has not been collected yet, the feasibility of our approach was assessed on simulated data. in the latter, we reproduced variations of the parameters we would have extracted from real images of a patient after investigating his or her daily life. the classification of the days (normal/abnormal) led to an accuracy of % (training dataset: days, test dataset: days). a patient is considered frail when the weekly percentage of maintaining routine decreases steadily. conclusion: the preliminary results prove that in addition to being non-intrusive, a depth-imaging based approach can be a promising tool for frailty detection. anna franke , ellen freiberger , robert kob simon moskowitz , david w. russ , , leatha a clark , , , nathan p. wages , , dustin r. grooms , , brian c. clark , , ( ( ) background: one putative mechanism explaining mobility limitations (mls) in older adults (oas) is a reduction in the central nervous system's (cns) ability to rapidly drive muscle force/torque production. rapid movements can be mathematically expressed as the time derivative of force/ torque, also termed 'yank' (y). muscles are ultimately responsible for generating y, but cns input (ni) to the muscles clearly influences y. the time derivative of the voluntary electromyogram during maximal efforts is associated with gait speed (gs) and chair rise time (crt). however, since the electromyogram is influenced by non-physiological factors (e.g., subcutaneous adipose tissue acting as a low pass filter), it is difficult to fully ascribe this finding to cns deficits. theoretically, normalizing y to the time derivative of electrically evoked force/torque controls for musculoskeletal factors contributing to y (ymsk), which yields a value representing the cns's ability to rapidly produce force/torque (yni=y/ymsk). objectives: to better understand the role of the cns in mls in oas we ) compared leg extensor yni between young and oas, and ) examined the association between leg extensor yni and measures of mobility. methods: twenty-one young and fifty-nine oas ( . +/- . and . +/- . yrs) were instructed to "kick out as fast and hard as possible" against a fixed lever arm attached to a torque motor, and we quantified y between onset and -msec. next, we quantified ymsk from a supramaximal electrically evoked torque-time recording (potentiated -hz doublet) and calculated yni as described. on a separate visit six-minute walk ( mw) gs, stair climb power (scp), and x crt were measured. results: oas had higher yni vs. young adults reflecting a % reduction in central neural activation during rapid torque development ( . +/- . vs. . +/- . ; p< . ). significant associations were observed between yni and mwgs (r= . ), scp (r= . ), and x crt (r=- . ). conclusion: oas have a slower rate of volitional neural activation during rapid leg extensor torque production relative to young adults. in addition, yni explained ~ - % of the variability in measures of mobility, thereby supporting the notion that age-related reductions in the ability of the cns to rapidly activate muscles contribute to mls. background: opa mutations cause dominant optic atrophy (doa), an incurable retinopathy with variable severity and which mechanisms are still unknown. more than % of patients will endure a doa plus syndrome with ataxia, deafness or parkinsonism. the hypothesis of an oxidative stress has been proposed to explain the variability of these symptoms. objectives: that's why our goal is to improve understanding of the physiopathological mechanisms involved in this disease by developing mathematical models of the production of reactive oxygen species (ros) by the mitochondrial respiratory chain. methods: we monitored the levels of mitochondrial respiration, reactive oxygen species (ros), anti-oxidant defenses and cell death by biochemical and in situ approaches using in vitro and in vivo models of opa related disorders and model the complex i functioning with a detailed stochastic background: the sarc-f is a -question screening tool for sarcopenia. we present results for reliability and validity of the german version of the sarc-f. objectives: translation, adaptation and validation of the german version of the sarc-f for community-dwelling older adults in germany. methods: design: cross-sectional. setting and participants: community-dwelling outpatients with a mean age of . ± . years were included in the study, ( . %) of them were female. ( . %) had a positive sarc-f score of >= points. according to the definition for sarcopenia from the european working group on sarcopenia in older people (ewgsop ), eight patients ( . %) were identified as sarcopenic and ( . %) as probable sarcopenic. methods: translation and cultural adaption was composed of seven different steps that were in general based on the guidelines put forward by the world health organization. validation include test-retest and the inter-rater reliability (intra-class correlation coefficient) as well as internal consistency (cronbach's alpha). further, sensitivity, specificity, positive predictive value, and negative predictive value of the sarc-f were calculated. receiver operating characteristics (roc) analysis was performed to calculate the area under the curve. results: the translated and culturally adopted version of the sarc-f for the german language has shown excellent interrater reliability and good test-retest reliability. the internal consistency is acceptable. sensitivity ( %) and specificity ( %) for sarcopenia is low. for detecting patients with probable sarcopenia, the sarc-f in the german version has shown % sensitivity and % specificity. conclusion: due to a low sensitivity for detecting sarcopenia but an acceptable sensitivity for identifying probable sarcopenia, the german version of the sarc-f is a suitable tool for case finding of probable sarcopenia. background: skeletal muscle is a vital component of the locomotor system necessary for physical function. however, there is increasing evidence that skeletal muscle acts as a secretory organ in itself, communicating with other organ systems. acute sarcopenia is an emerging condition affecting adults following hospitalisation, which should be considered akin to organ insufficiency elsewhere. however, acute sarcopenia remains poorly characterised to date. objectives: • to characterise changes in muscle quantity, strength, physical performance, and patient-reported physical function in hospitalised older adults at one week and three months. • to determine what biological and clinical factors are predictive of changes to enable further research towards targeted interventions. methods: planned recruitment will include hospitalised patients aged years and older; elective colorectal surgery patients, emergency surgery patients, and general medical patients with acute bacterial infections. patients will be recruited to the elective cohort in pre-operative assessment clinic with repeat measures within hours of surgery, at one week, and at three months. emergency surgery patients will be recruited pre-or post-operatively with repeat measures at one week, and at three months. medical patients will be recruited within hours of admission, with repeat measures at one week, and at three months. muscle quantity will be measured by bilateral anterior thigh thickness using ultrasound and bioelectrical impedance. muscle function will be measured by handgrip strength and short physical performance battery. serum and plasma samples will be obtained prior to admission in the elective cohort, within hours of surgery in both surgical cohorts, and within hours of admission in the medical cohort. background: sarcopenia is common in old age and is associated with various diseases. as human life expectancy is projected to increase, this will pose a challenge for the global healthcare industry. since sarcopenia is highly heritable, study of its genetic underpinning can help its etiology. in the past decade genome wide association studies (gwas) have allowed the identification of new genetic markers for various conditions. identification of new genetic markers through gwas requires functional validation using cellular models in order to both prioritize and validate the potential loci/genes. objectives: demonstrate that a locus identified in gwas may affect muscle health, which is approximated by lean mass and hand grip strength. methods: gwas results are screened using a two-step scoring system which utilizes publicly available databases such as genecards, ensembl and coxpresdb to assess the relevance of a certain locus. relevant genes are then knocked out using crispr-cas in c c mouse myotube cells which are induced to differentiate. after cell harvest rt-qpcr and western blot are performed to assess mrna and protein expression, respectively. knocked out cells are also examined against wild type cells for morphological phenotype. results: slc a is a promising candidate based on: (a) muscle gwas results, (b) the expression of the gene in smooth and striated muscle tissue, (c) the lack of co-expression with other genes that have an effect on muscle; (d) mouse phenotypes associated with a mutation in the mouse ortholog slc a , (e) cell epigenetic data and (f) the topologically associated domain (tad) at chr. : , , - , , . rt-qpcr of wild type c c cells showed a fast increase in the expression of slc a 's mrna which remains constant during the entire differentiation process. conclusion: preliminary results indicate that slc a might be a promising candidate to investigate for involvement in muscle health. there is a fast and stable increase of the gene's expression during myotube formation. positive results may suggest that slc a is of importance to muscle health. to farther assess slc a role, wild type cells will be compared to knocked-out cells. this might lead to a new genetic marker for muscle health, thus extending personalized medicine in the field of sarcopenia and muscle health. jesse zanker , terri blackwell , sheena patel , kate d u c h o w n y , , s h a r o n b r e n n a n -o l s e n , s t e v e n r . cummings , , william j. evans , , eric s. orwoll , david scott , , sara vogrin , gustavo duque , peggy m. cawthon , ( ( ) background: muscle mass, strength and physical performance are independent risk factors for disability and mobility disability in older adults. it is not known how measures of body composition (muscle, lean and fat mass), strength and physical performance are interrelated or how empirical groupings of these measures relate to disability and mobility disability. objectives: to determine the relationship between measures of body composition, strength and physical performance in older men and to examine how empirical groupings of these measures relate to adverse mobility and disability outcomes. methods: muscle mass was assessed by d -creatine dilution (d cr muscle mass) in men ( . + . years) enrolled in the osteoporotic fractures in men (mros) study. participants completed anthropomorphic measures, walk speed ( m), grip strength (kg), chair stands (s), and dual x-ray absorptiometry (dxa) appendicular lean mass (alm) (adjusted for weight, body mass index or height ) and body fat percentage. factor analysis was conducted to reduce variables into smaller components. men self-reported limitations in mobility (walking - blocks, climbing steps, or carrying pounds); activities of daily living (adls); and instrumental adls at initial and follow-up visits. negative binomial models adjusted for participant characteristics were used to determine the relative risk of factors with mobility and disability outcomes. results: factor analysis reduced variables into four factors: factor , body composition, with strong loading by alm, body fat percentage, weight and muscle mass; factor , body size and lean mass, with strong loading by height, weight and alm; factor , muscle mass, strength and performance, with strong loading by walk speed, chair stands, grip strength, and muscle mass; and factor , lean mass and weight, with strong loading by alm and weight. only factor was associated with prevalent disability and background: urinary incontinence(ui) is a prevalent and costly condition that affects ~ % of older communitydwelling women.one of the contributors of ui is decreased pelvic muscle strength. objectives: to determine the effect of additional oral glutamine supplementation to kegel-exercise on pelvic floor strength and clinical parameters of ui in females. methods: it is a randomized, double-blind study. females with ui were included. digital test and a vaginal manometer were used for measuring the strength of the pelvic floor muscles. hours pad weight test was examined. participants were randomized into groups as oral glutamine gr/day and placebo. it was asked to use the supplementation and kegel-exercises to all participants for months. basic and th month measurements were compared by paired sample t -test and wilcoxon tests in each group. the progression between measurements at basic and th months was compared between the groups by using mann-whitney-u test. (clinical trials protocol id: / background: it is important to identify if middle-aged people are at risk for sarcopenia. a screening-tool identifying predictors of pre-sarcopenia early in the lifespan may inform prevention focused interventions. objectives: develop and validate a practical screening-tool to identify middle-aged adults at risk for pre-sarcopenia using data from the dunedin multidisciplinary health and development study (dmhds). methods: the dmhds is an ongoing longitudinal birth cohort study from the greater dunedin (nz) metropolitan area. the primary outcome of the screening-tool was low appendicular lean muscle index (almi) in middle-aged adults, at age . low almi was classified using prado's age-specific median cut-scores. the models were developed in % (n= ) of the cohort and cross-validated in the remaining % (n= ). possible predictors at age , were examined for associations with low almi, using univariate logistic regression. significant predictors were selected in a multivariate logistic regression to derive sex-specific prediction models. each individual in the cohort was allocated a risk-score and classified as low, medium and high risk, based on the quartile risk score. overall performance of the final models was estimated with nagelkerke r score, discrimination of the models with the area under the roc curve and calibration of the final models with hosmer-lemeshow tests. results: % of the development set and % of the validation set were female. the final models for both sexes included body mass index (b=- . , p= . ; b=- . , p= . ), vo max (b=- . , p= . , b=- . , p= . ) and grip strength (b=- . , p= . , b=- . , p= . ). the final model for females also included creatinine (b=- . , p= . ). nagelkerke's r showed that . % and . %, of the variance in low almi, is explained by the variables in the screening-tool for males and females, respectively. the area under the roc curve demonstrated good discrimination ( . ). sensitivity in the lowest quartile was . %, specificity in the highest quartile was . %. the hosmer-lemeshow p-values were respectively . and . , showing goodness of fit. conclusion: this screening-tool was able to predict the sex-specific risk of pre-sarcopenia in a large birth cohort of early middle-aged adults. clinical utility and application of this screening-tool require further investigation. background: aging-associated changes in body composition include a decrease in skeletal muscle mass, which may predispose women to physical limitations and disabilities. in women, these changes may already be accelerated during menopause, when ovarian estradiol (e ) production ceases. e , the main female sex hormone, is known to have beneficial effects on female skeletal muscle mass. objectives: the aim of this study was to investigate the effects of menopausal transition on lean body mass, lower limb muscle mass, muscle area and muscle fiber cross-sectional area in middle-aged women. methods: middle-aged women (n= ) were followed from perimenopause to postmenopause. menopausal state was defined based on repeated follicle-stimulating hormone (fsh) measurements and menstrual bleeding diaries. serum hormone levels (e and fsh; immulite ), lean body mass (lbm), right leg lean mass (dxa, n= ), and thigh muscle cross-sectional area (computed tomography (ct), n= ) were measured in peri-and postmenopause. muscle biopsies for immunohistochemistry were obtained from participants at peri-and postmenopausal phases, and muscle fiber crosssectional areas were measured. the level of physical activity (pa) from the previous months was assessed with a questionnaire (met-hours/day, n= ). statistical differences were analyzed with paired t-test and wilcoxon signed rank test. gee-modeling was used to analyze the effects of covariates during follow-up. results: the average followup time was . years (range . - . years) and there was a significant difference in e and fsh levels during the transition (p< . for both). lbm decreased . % (p= . ) and leg lean mass . % (p= . ) during the menopausal transition. no changes were found in the cross-sectional area of thigh muscles or muscle fibers. the level of pa declined during the transition (p= . ). when individual menopausal transition time and pa were controlled, only systemic e levels were positively associated with lbm (b= . , p= . ). conclusion: despite the relatively short follow-up time, significant declines were observed in lbm and leg lean mass during the menopausal transition. the decrease in lbm was associated with lower systemic e level. therefore, it seems that although pa might slow the decrease in muscle mass, estradiol loss is one key factor in whole body muscle loss during menopausal transition. hiroyuki shimada , takehiko doi , sangyoon lee , kota tsutsumimoto , seongryu bae , sho nakakubo , keitaro makino , hidenori arai (( ) department of preventive gerontology, center for gerontology and social science, national center for geriatrics and gerontology, aichi, japan;( ) national center for geriatrics and gerontology, aichi, japan)background: in , the european working group on sarcopenia in older people met again (ewgsop ) to update the original definition of sarcopenia. ewgsop uses detection of low muscle quantity and quality to confirm the sarcopenia diagnosis, and identifies poor physical performance as indicative of severe sarcopenia. however, it is not clear that the relationships between the revised definition of the sarcopenia and disability incidence in japanese older adults. objectives: to examine the associations between sarcopenia for ewgsop criteria and disability incidence among community-dwelling older japanese individuals. methods: a total of older adults participated in the study ( women; average age, . ± . years) form a japanese national cohort study called the ncgg-sgs. skeletal muscle mass was assessed using a bioimpedance analysis device and handgrip strength and walking speed were measured as physical performance. we used the cut-points of the asian working group for sarcopenia to determine the low muscle mass and low physical performances. the participants were divided into non-sarcopenia, sarcopenia, and severe sarcopenia groups. the incidence of disability was determined using data collected by the japanese longterm care insurance system over months. results: the prevalence rates of sarcopenia and severe sarcopenia were . % and . %, respectively. the participants with sarcopenia, included sarcopenia and sever sarcopenia, showed higher risk of disability incidence than those with non-sarcopenia (hazard ratio [hr]: . , % confidence interval [ % ci]: . - . ). in analysis between non-sarcopenia and sarcopenia or severe sarcopenia, although the association between disability incidence and severe sarcopenia remained significant (hr: . , % ci: . - . ), there was no significant association in sarcopenia (hr: . , % ci: . - . ). conclusion: severe sarcopenia combined low muscle mass and low physical performance could have a higher risk of disability than healthy older adults or older adults with low muscle mass alone. further studies are needed to determine whether sarcopenia without poor physical performance is associated with disability incidence.background: sarcopenia is one of the biological hallmarks of frailty that has been associated with adverse events in older adults undergoing cardiac surgery. dual x-ray absorptiometry (dxa) is a recommended modality to measure muscle mass, however, dxa may be less accurate in acute cardiac patients due to the confounding effects of peripheral edema and fluid shifts. objectives: the study aims to determine if sarcopenia as measured by a combination of dxa and timed chair rises is associated with mortality in older adults referred for cardiac surgery. methods: a convenience sample of hospitalized older adults being evaluated for cardiac surgery was prospectively enrolled at the jewish general hospital. after a questionnaire and physical performance battery, patients underwent a dxa scan (ge lunar) to measure their appendicular muscle mass (amm). patients were categorized as sarcopenic based on the european working group guidelines if they had low amm defined as < kg/m in men or < kg/m in women and low muscle strength defined as chair rises > seconds. multivariable logistic regression was used to test the ageand sex-adjusted association between sarcopenia and allcause mortality. results: the cohort consisted of patients with a mean age of . ± . years and % females. the interventions were isolated coronary bypass in %, valve surgery in %, and decision not to proceed with surgery in %. the mean amm was . ± . kg in men and . ± . kg in women. the prevalence of sarcopenia was % (n= ), similar in men and women. sarcopenia was not associated with -year mortality (or . , % ci . - . ) and, in a separate model, neither was low amm (or . , % ci . - . ). slow chair rise time was associated with higher -year mortality (or . , % ci . - . ). when patients with heart failure and reduced ejection fraction were excluded, sarcopenia appeared to be more prognostic (or . , % ci . - . ) although it did not reach statistical significance. conclusion: lower-extremity muscle strength, but not dxa-based measures of muscle mass or sarcopenia, is predictive of survival in hospitalized older adults referred for cardiac surgery. background: the "blue zone" are limited areas with a high prevalence of centenarians, with rather homogeneous characteristics, life styles and environment." this blue zone, located in the nicoya peninsula, is in the province of guanacaste. even though costa rica has this blue zone, there are no studies that characterize the prevalence sarcopenia in the centenarians of the region. objectives: the aim of this study was to determine the prevalence of sarcopenia on centenarians from nicoya, costa rica, using the ewgsop criteria. methods: this is a cross-sectional study using a population base of community-dwelling centenarians from guanacaste. antropometric measures, weight, height and strength were assessed. to assess the nutritional state, the mini nutritional assessment (mna) was used and activities of daily living (adl) scores. low muscle mass was assessed by calf circumference < cm and low strength if < kg in men or < kg in women. results: the mean age of the patients were . ± . years. from this group, ( . %) were men and ( . %) were women. patients showed comorbilities: hypertension ( . %), diabetes ( . %), copd ( . %), cancer ( %), osteoarthritis ( %) and depression ( %). mean body mass index, weight, brachial and calf circumference were . ± . kg/m , . ± . kg, . ± . cm and . ± . cm. mean handgrip strength was . ± . kg. the mean score for the mna test was . ± . and adl score . ± . . with respect to sarcopenia prevalence, a total number of ( . %) subjects were detected, ( . %) men and ( . %) women fulfilled the criteria. according to the nutritional status, patients with sarcopenia had malnourishment, were on nutritional risk and had a good nutritional state. from the sarcopenic centenarians, at least % of the subjects had dependency with adl. conclusion: we had high prevalence sarcopenia in centenarians from the "blue zone". there are few studies in centenarians, but using the ewgsop criteria, it is the first in latin america. background: sarcopenia is a geriatric syndrome characterized by low muscle mass and low muscle function and/or reduced physical performance. malnutrition is a major risk factor for sarcopenia. there is limited data on the prevalence of sarcopenia in community-dwelling older people who are at risk of malnutrition in singapore. objectives: the objectives were (i) to determine the prevalence of sarcopenia and its components i.e. low handgrip strength, low appendicular skeletal muscle mass index (asmi) and low gait speed based on the asian working group for sarcopenia consensus (chen et al., ) , (ii) to describe the characteristics and dietary intake of older adults with sarcopenia to those without sarcopenia. methods: a total of community-dwelling older adults (>= years) who were at risk of malnutrition (malnutrition universal screening tool; must score >= ) took part in this study. sarcopenia was diagnosed by low muscle mass (asmi using bioelectrical impedance analysis) plus low muscle strength (handgrip strength) and/or low physical performance ( -meter usual gait speed). anthropometric measurements, dietary intake, and short physical performance battery (sppb) were also collected. results: over % of participants had a charlson comorbidity score of . the overall prevalence of sarcopenia was %; . % had low asmi, . % had low handgrip strength and . % had low gait speed. participants with sarcopenia were significantly older, shorter, and with lower body weight and bmi, mid-upper arm circumference, calf circumference and bone mass compared to those without sarcopenia (all p< . ). they also had lower physical functions as measured using handgrip strength and endurance, leg strength, and sppb score than those without sarcopenia (all p<= . ). additionally, older adults with sarcopenia had lower total energy intake and energy-adjusted protein intake background: the prevalence of sarcopenia varies according to the diagnostic criteria used, however it is an important geriatric syndrome related to a worse functional state in the elderly. very older adults are often excluded from clinical trials. objectives: the aim of this observational prospective study is to describe the prevalence of sarcopenia in community very older adults with high comorbidity. methods: we included patients who enter the geriatric day hospital of the hospital of navarra, spain, aged more than y, underwent bioelectrical impendance analisys (bia), measurement of hand grip strength (hgs), gait speed (gs), short physical performance battery (sppb), mini-nutritional assessment (mna-sf), barthel index and cumulative illness rating scale-geriatric (cirs-g). sarcopenia were defined according to ewgsop ( ). the study begining in and it is actually ongoing. we registered variables at baseline, and at the time , and months. all-cause mortality were registered. results: we present the preliminary results of baseline value. we icluded patients ( . % men, . ± . y). sarcopenia were present in participts, vithout sex differences. sarcopenic vs no-sarcopenic patiets were older ( . ± . vs . ± . y) (p< . ) and they presented worse nutritional status (bmi . ± . vs . ± . kg/m ) (p< . ), mna-sf ( %ci - ) vs ( - ) (p< . ). sarcopenic patients presented lower barthel index ( , %ci - vs , - ) (p= . ), but we have no observed differnces nor in the sppb , %ci - in sacropenic, vs , - in no-sarcopenic participats (p= . ), neither in comorbididy index (cirs-g , - vs , - respectivelly) (p= . ). sarcopenia is significantly associated with higher mortality (hr . , %ci . - . ) (p= . ). at the present time the mean follow-up is . ± . months. at months in patients ( %) the sarcopenia reverted, and we have observed new sarcopenic cases ( %) (incident sarcopenia). conclusion: sarcopenia is highly prevalent in very older adults with high comorbidity. sarcopenia is associated with malnutrition and with higher mortality. background: disability is a multifactorial trait that contributes substantially to decline of health/wellbeing and increases steeply with age after midlife. progress in genomewide sequencing has created the potential for discovering genes influencing various health-related traits. the vast majority of such studies focus on the genetic bases of different traits assuming that they have independent mechanisms. as conceptualized by geroscience age/aging are major risk factors of geriatric traits of distinct etiologies. accordingly, the same mechanisms can predispose not to just one, but to a large fraction of geriatric conditions. objectives: identify the common genetic architecture of various traits by discovering the genetic architecture of complex multifactorial trait such as disability. methods: genome-wide association study of disability in a sample of , subjects from five studies with , disabled individuals from the women's health initiative (whi) genomics and randomized trials network, whi memory study, cardiovascular health study, framingham heart study, and health and retirement study. disability was defined as having at least one of four basic activities of daily living impairments (bathing, dressing, getting out of bed, and walking). results: we identified promising disability-associated single nucleotide polymorphisms (snps) in loci at p< - . four of them attained suggestive level of significance, p< - . in contrast, polygenic risk scores (prs) aggregating effects of minor alleles of independent snps that were adversely or beneficially associated with disability showed highly significant associations in meta-analysis, p= . × - and p= . × - , respectively, and were replicated in each study. the analysis of genetic pathways, related diseases, and biological functions supported the connections of genes for the identified snps with disabling and age-related conditions primarily through oxidative/nitrosative stress, inflammatory response, and ciliary signaling. we identified musculoskeletal system development, maintenance, and regeneration as important components of gene functions. conclusion: the discovery of adverse and beneficial prs for a multifactorial trait of distinct etiologies such as late life disability supports the concept of geroscience. the beneficial and adverse gene sets may be differently implicated in the development of musculoskeletal-related disability with the beneficial set characterized, e.g., by regulation of chondrocyte proliferation and bone formation, and the adverse set by inflammation and bone loss. key: cord- -wjx xki authors: da silveira, matheus pelinski; da silva fagundes, kimberly kamila; bizuti, matheus ribeiro; starck, Édina; rossi, renata calciolari; de resende e silva, débora tavares title: physical exercise as a tool to help the immune system against covid- : an integrative review of the current literature date: - - journal: clin exp med doi: . /s - - - sha: doc_id: cord_uid: wjx xki acute viral respiratory infections are the main infectious disease in the world. in , a new disease caused by severe acute respiratory syndrome coronavirus (sars-cov- ), coronavirus disease (covid- ), became a global pandemic. the immune response to the virus depends on factors such as genetics, age and physical state, and its main input receptor is the angiotensin-converting enzyme . the practice of physical exercises acts as a modulator of the immune system. during and after physical exercise, pro- and anti-inflammatory cytokines are released, lymphocyte circulation increases, as well as cell recruitment. such practice has an effect on the lower incidence, intensity of symptoms and mortality in viral infections observed in people who practice physical activity regularly, and its correct execution must be considered to avoid damage. the initial response is given mainly by type i interferons (ifn-i), which drive the action macrophages and lymphocytes, followed by lymphocyte action. a suppression of the ifn-i response has been noted in covid- . severe conditions have been associated with storms of pro-inflammatory cytokines and lymphopenia, as well as circulatory changes and virus dispersion to other organs. the practice of physical activities strengthens the immune system, suggesting a benefit in the response to viral communicable diseases. thus, regular practice of adequate intensity is suggested as an auxiliary tool in strengthening and preparing the immune system for covid- . further studies are needed to associate physical exercise with sars-cov- infection. acute respiratory infections (aris) are caused by respiratory viruses and bacteria, being the most infectious disease in humans [ , ] . these can be caused by more than different viruses, with rhinovirus being the most common etiological agent [ ] [ ] [ ] . in december , a new coronavirus outbreak was reported in china, being called the severe acute respiratory syndrome coronavirus (sars-cov- ), spreading rapidly and infecting more than million people, being declared a health emergency international public service on january , [ , ] . the main mode of transmission is contact with droplets containing viral particles eliminated through the cough or sneeze of an infected person, and the incubation period usually varies from to days. approximately % of the cases are asymptomatic or with mild symptoms, and the others can be severe or critical and can lead to death [ ] . the development of coronavirus disease (covid- ) is dependent on the interaction between sars-cov- and the host's immune system, the immune response being influenced by genetics (hla genes), age, sex, nutritional status and status physical [ ] . the immune response includes two stages, innate immunity and adaptive immunity. the first one comprises physical and chemical barriers and the action of cells such as macrophages, dendritic cells (dcs), natural killer cells (nks), neutrophils and molecules such as cytokines, interleukins (ils), nitric oxide (no) and superoxide anion (o -). the second one has as mechanism of action the t lymphocytes (tcd + and tcd +) and b lymphocytes and their products, such as antibodies and cytokines. furthermore, the adaptive immune response can be subdivided into cellular immunity (mediate by cells as macrophages and lymphocytes) and humoral immunity (mediates by cells as macrophages and lymphocytes) and humoral immunity (mediated by antibodies) [ , ] . the regular practice of physical exercises promotes improvements in quality of life and can act in the immune response, reducing the risk of developing systemic inflammatory processes and stimulating cellular immunity [ ] . therefore, the present article aims to perform an integrative review of the literature relating the role of physical exercise on the immune system in the fight against covid- . for this purpose, the bibliographic study included knowledge about respiratory infections, influences of physical exercise on the immune system and proposed the comprehension of the most recent information about the immunopathogenesis of sars-cov- infection, also comprising its relationship with the host's physical and health conditions. physical activity is considered one of the main components of healthy living. in addition to the functions related to the prevention of excess body weight, systemic inflammation and chronic non-communicable diseases, a potential benefit of physical exercise in reducing communicable diseases, including viral pathologies, is suggested [ ] . the practice of physical exercise, both in its acute form and in its chronic form, significantly alters the immune system [ , ] . studies indicate that the modulation of the immune response related to exercise depends on factors such as regularity, intensity, duration and type of effort applied [ , ] . moderate-intensity physical exercises stimulate cellular immunity, while prolonged or high-intensity practices without appropriate rest can trigger decreased cellular immunity, increasing the propensity for infectious diseases [ , ] . according to the international society for exercise and immunology (isei), the immunological decrease occurs after the practice of prolonged physical exercise, that is, after min of moderate-to high-intensity physical activity [ ] . cellular changes due to physical activity are illustrated in fig. . cytokines are classified as anti-inflammatory and proinflammatory according to their functions. among the antiinflammatory cytokines, we highlight il- and transforming growth factor-beta (tgf-β), responsible for inhibiting the production of pro-inflammatory cytokines [ ] . among the pro-inflammatory cytokines, we highlight il- , il- , il- , il- , interferon-gamma (ifn-γ) and tumor necrosis factor-alpha (tnf-α) [ ] . cytokine production can be modified due to hormonal or oxidative stress and physical exercise. the muscle contraction has the effect of increasing the release of antinflammatory and pro-inflammatory cytokines at levels that vary according to the volume of contractile mass involved, duration and intensity of exercise [ ] . during the practice of physical exercise, the activation of the muscle fiber is responsible for increasing the release of calcium (ca +) and, therefore, promoting the synthesis of proinflammatory cytokines, namely tnf-α and il- β, which act in the regulation of selectins, which, in turn, attract neutrophils to the site [ ] . the neutrophilia induced by physical activity is due to the release of neutrophils from the bone marrow due to the influence of cortisol [ ] . after aerobic physical exercise (approximately h), there is a significant reduction in neutrophil chemotaxis, however, without compromising bactericidal activity. the reduction in neutrophil chemotaxis is reversed within h after physical activity, during which the opportunistic activity of infectious microorganisms can occur [ ] . physical activity is also responsible for increasing the concentration of circulating leukocytes [ ] . this is due to shearing of immune cells in blood vessels, especially secondary lymphoid tissues such as liver, spleen and lung [ ] . the leukocyte concentration remains high with a peak of - min after constant physical activity, which may persist for up to h after [ ] . the practice of aerobic physical exercise in an exacerbated manner is responsible for decreasing the expression of tolllike receptors (tlrs) in macrophages, considerably reducing the presentation of antigens to t lymphocytes, thus causing the suppression of the inflammatory t helper type (th ) response. thus, the failure to develop an inflammatory activity precludes possible tissue damage resulting from inflammatory mediators and, consequently, the risk of chronic inflammatory processes. however, the susceptibility to infections due to intracellular microorganisms increases [ ] . during physical activity, blood flow increases in order to supply the metabolic demands of the human body. the recruitment of nk cells occurs through cellular stress promoted by exercise and a consequent decrease in adhesion molecules induced by catecholamines [ ] . however, physical activity lasting more than three hours causes the concentration of nk cells to return to the pre-exercise state or even lower than this. this is because the nk cells migrate to the muscle injury site [ ] . during moderate physical exercise, the concentration of lymphocytes increases in the vascular bed and, after strenuous exercise, decreases to levels below the pre-exercise period [ , ] . the cd +:cd + ratio decreases as tcd + cells increase [ ] . tcd + cells decrease due to the increase in nk cells [ , ] . after physical activity, the lymphocyte concentration decreases due to the apoptosis mechanism [ ] . thus, the increase in lymphocyte concentrations favors the th mediated immune response, preventing infections by intracellular microorganisms [ ] (fig. ). sars-cov- is constituted by single-strand positivesense rna and belongs to the genus betacoronavirus, lineage b and subgenus sarbecovirus. viral genome studies have identified similarity of sars-cov- with bat coronaviruses, as well as coronaviruses responsible for two previous pandemics: the severe acute respiratory syndrome-related coronavirus (sars-cov) and the middle eastern respiratory syndrome coronavirus (mers-cov) [ , ] . similar to sars-cov, the novel coronavirus uses a structural glycoprotein to infect cells: the envelope spike protein (s), using the angiotensin-converting enzyme- (ace ) as entry receptor [ , ] . ace consists of a cell membrane protein abundantly expressed in the organism, which is present in cardiac, pulmonary, renal, intestinal and vascular cells, and the binding of sars-cov- with this enzyme has a strong affinity, which may explain the high transmissibility of the virus [ , , ] . due to mainly respiratory symptoms, it is believed that the target cells of sars-cov- are in lower airways [ ] , as is the case of type pneumocytes or alveolar cells, the main site of expression of ace receptors [ ] . the result of the interaction between the s receptor binding domain (rbd) and ace is the fusion of the viral and host membranes, which proceeds for viral replication and dissemination and may reach the other cells with ace expression in the organism [ ] . with the purpose of containing the infection, the innate and adaptive immune system is activated by mechanisms that are not yet completely elucidated. in spite of this, it is known that effective immunological actions are essential to control viral replication and dissemination, cellular inflammation and tissue injury, and many studies have reported that the immune response of the host influences the severity of covid- [ , [ ] [ ] [ ] . to initiate the antiviral response, cells of the innate immune system need to recognize the infection, a process performed through pattern-recognition receptors (prrs) such as tlr, nod-like receptor (nlr), c-type lectinlike receptor (clr), rig-i-like receptor (rlr) and freemolecule receptors in the cytoplasm, which detect pathogen-associated molecular patterns (pamps). once viral nucleic acids are recognized as pamps, prrs activate molecular pathways of inflammatory response, stimulating chemotaxis, maturation of immune cells, phagocytosis and expression of inflammatory factors [ ] . viral recognition by tlr , tlr and rig-i receptors leads to activation of the nuclear factor-κb (nf-κb) and irf signaling cascade, with nuclear transcription and expression of type i interferons (ifns-i) and pro-inflammatory cytokines, creating the first line of defense against viral infections. the ifns-i (ifn-α and ifn-β) are the most important antiviral cytokines, and they act as immunomodulators influencing the activities of macrophages and lymphocytes, performing actions such as protection of non-infected cells, containment of viral replication and effective activation of the adaptive immune system [ , , ] . a suppression or delay of ifns-i response-due to viral evasion mechanisms-results in impairment of early infection control, hyperinflammatory infiltrate of neutrophils, macrophages and monocytes into the lungs, production of cytokines by these cells and lung tissue damage. this process, described in sars-cov and mers-cov, has been suggested as a possible strategy to trigger or collaborate to the pathology of covid- [ , ] . macrophages and dcs act as apcs for lymphocytes via mhc and produce a microenvironment of signaling cytokines, activating the adaptive immune system. t lymphocytes perform important functions against viral microorganisms, since tcd + can cause direct cytotoxicity against infected cells and tcd + stimulate b lymphocytes to produce neutralizing antibodies. in turn, t helper lymphocytes (th)-predominantly th -contribute to the organization of the adaptive response and release cytokines that are able to recruit monocytes and neutrophils and to promote other cascades of pro-inflammatory molecules, amplifying the immune response [ , ] (fig. ). the complement system can also be activated and has an important role in coronavirus infections, because it helps the innate immune system to identify antigens. however, its activation can contribute to the disease due to its potent capacity to stimulate neutrophils and to recruit inflammatory cells, which can trigger tissue damage [ ] . studies suggest that in mild cases, pulmonary tissue macrophages are capable of containing sars-cov- and innate and adaptive immune responses are efficiently activated against viral replication. however, severe cases of covid- are associated with an imbalance in antiviral immunity, characterized by two main situations: a pro-inflammatory cytokine storm and a lymphopenia state [ , ] . the degree of lymphopenia and cytokine storm was related to the severity of covid- [ ] , and similar situations had already been reported in other respiratory viral infections, including influenza, sars-cov and mers-cov. activation of the complement system and abnormalities in coagulation were also observed in severe patients with markers such as c-reactive protein (crp), dimero-d and fibrin degradation products, which are usually elevated in advanced stages of the disease [ , ] . the mechanism of cytokine storm and lymphopenia associated with circulatory alterations and viral dissemination to several organs was proposed as being responsible for viral sepsis. among the complications of this condition are acute respiratory distress syndrome (ards), septic shock, multiple organ failure (mof) and death [ , ] . in patients with severe covid- , increased levels of cytokines were observed, including il- β, il- , il- , il- , il- , il- , interferon-gamma (ifn-γ), tumor necrosis factor alpha (tnf-α), granulocyte-colony stimulating factor (g-csf), gamma-induced protein (ip ), monocyte chemoattractant protein (mcp ), macrophage inflammatory protein alpha (mip -α) and other molecules, characterizing the cytokine storm [ , ] . additionally, elevations of il- β, ifn-γ, ip and mcp in infections by the novel coronavirus were associated with the th response; however, an increase in interleukins of the t helper type (th ) profile, such as il- , il- , il , which suppress the inflammation, was also associated with a greater severity of covid- , which may demonstrate an imbalance in immune regulation and an attempt to minimize tissue inflammatory damage [ , ] . the cytokine storm generates an immunological system attack against the organism, which can cause substantial lesions in organs such as the lung, heart, brain, kidneys, spleen, liver and lymph nodes. the increase of neutrophils, macrophages and monocytes in association with a dysfunction of the ifn-i response has been reported as the main cause of lethality in sars-cov and mers-cov pneumonia, and a similar conclusion has been suggested for sars-cov- [ , , ] . in the lungs, alveolar macrophages and epithelial cells are the most responsible for the production of cytokines and chemokines. during infection by the novel coronavirus, excessive secretion of these molecules by the immune cells mediates a massive pulmonary infiltrate of neutrophils, monocytes and macrophages, which results in alveolar damage due to wall thickening and formation of hyaline membranes. in addition, the accumulation of neutrophils in the lungs increases the production of reactive oxygen species (ros) and pro-inflammatory molecules, predisposing to injury [ ] . therefore, high levels of pro-inflammatory cytokines are associated with respiratory insufficiency, ards and may lead to shock, mof and death in the covid- [ , ] . in comparison, pulmonary disease caused by sars-cov also presents with formation of hyaline membranes, desquamation of alveolar space pneumocytes and interstitial infiltration with lymphocytes and mononuclear cells. in the serum of patients who develop sars, there are high levels of cytokines and pro-inflammatory chemokines [ ] . additionally, it has been observed that during viral infections, pro-inflammatory cytokines can stimulate an increase in the levels of ace protein, the receptor for sars-cov- . a larger quantity of this protein may accelerate the entry of the novel coronavirus into the host cells and contribute to its dissemination in the organism, negatively influencing the antiviral response [ ] . in critically ill patients, a state of immune suppression is also described, with a significant and sustained decrease in the absolute number of tcd + and tcd + lymphocytes, possible reduction of b lymphocytes, nk cells, monocytes, eosinophils and basophils [ , ] . the study conducted by liu et al. [ ] did not observe significant changes in the total counts of b lymphocytes, nk cells and monocytes; however, there was a considerable reduction in the lymphocyte count in peripheral blood of patients with severe covid- at the beginning of the disease, especially cytotoxic tcd + cells [ ] . activation markers for tcd + and tcd + lymphocytes showed excessive stimulation and exhaustion markers for tcd + lymphocytes were elevated in the disease, suggesting lymphocyte dysfunction [ , ] . additionally, an increase in the number of neutrophils and a greater neutrophil-to-cd + t cell ratio (n r) was associated with severe covid- and proposed as the most significant predictor of poor prognosis [ , ] . cell death induced by interaction between fas and fas ligand by activation of the tnf-related apoptosis inducing ligand axis and by direct infection of t lymphocytes by sars-cov- may be responsible for the origin of lymphopenia in covid- [ ] . the cytokine storm can also influence the lymphopenia, since in the study of liu et al. [ ] , the peaks in cytokine levels il- , il- , il- , tnf-α and ifn-γ coincided with the lowest t lymphocyte counts, about - days after the onset of severe covid- ; therefore, the restoration of t cell numbers was associated with reductions in circulating cytokines [ ] . the fact that t cells are important regulators of the activation of the immune system during a viral infection may explain how lymphopenia is related to the worsening of inflammatory responses [ ] . in consequence of lymphopenia and lymphocyte dysfunction, the adaptive immune response is ineffective and the infection is not adequately controlled, further increasing the stimulation of cytokines and cellular infiltrations [ ] . it was observed that patients with sars-cov- infection present increased risk of venous thromboembolism (vte) and disseminated intravascular coagulation (dic). coagulopathy associated with covid- , as it may be named, is characterized by hypercoagulability and thrombosis and is associated with worse prognosis in infection. among the altered coagulation parameters in patients with severe covid- are exacerbated coagulation activation, coagulation factor consumption, prolongation of prothrombin time (pt) and activated partial thromboplastin time (appt), moderate to severe thrombocytopenia, increased d-dimer and reduction of fibrinogen [ ] . through a retrospective analysis of patients with coronavirus pneumonia, high levels of the d-dimer and fibrin degradation product have been identified, in addition to prolonged pt, as well as appt in patients who had deceased. tang et al. [ ] considered the d-dimer as an important coagulopathy marker in cases of sars-cov- infection. the same findings were found in the studies by han et al. [ ] who see the use of hemostasis tests as tools to be used in early diagnosis and in monitoring disease progression [ ] . blood coagulation is the fastest mechanism in the confinement and inactivation of infections, being the first and the last defense line of the innate immune system to take place in tissues and blood circulation. the sore promotes the activation of the endothelial cells and the dysfunction of the endothelium, thus generating a pro-thrombotic state [ ] . in cases hyperactivation of the immune system, the coagulation may become intravascular and disseminated, therefore causing multiple organ failure. after all, the amount of vascular endothelial lesions of organs and tissues is, due to their activation intent, inversely proportional to the amount of existing coagulation factors [ ] . thereupon, the first clinical studies carried out in patients with pneumonia caused by the coronavirus confirmed the occurrence of organ dysfunction and coagulopathy as possible causes of the negative outcomes of the disease [ ] . the activation of the immune system, in response to the infection, leads the production of cytokines and tissue factor expression. the cytokines, in large amounts, harm the gas exchange and lead not only to inflammation but fibrinolysis, thus increasing d-dimer concentration [ ] . the tissue factor is related to an increase in thrombin generation and fibrin deposition, leading to hypercoagulability and civd and, thus, a worse prognosis [ , ] . as a contributor to the coagulation process, there is the presence of polymorphonuclear leukocytes (pmn) that are activated during the inflammatory process, releasing extracellular neutrophil traps (nets) which contain proteases that generate the inactivation of endogenous anticoagulants and the propagation of a procoagulant state. the interaction of activated platelets with pmn can form vaso-occlusive thrombotic complexes [ ] . some authors also elucidate the virus's relationship with the eca functional receptor, present in the arterial and venous endothelial cells of most human organs and part of both axes of the renin-angiotensin system, the vasoconstrictor eca/ang/at r and the vasodilator eca /ang-( - )/mas [ , ] . dalan et al. [ ] cite that both aging and metabolic disorders positively regulate the eca/ang/at r axis, leading to inflammatory, oxidative, vasoconstrictor and fibrotic effects. therefore, the eca / ang-( - )/mas axis is negatively regulated, resulting in a decrease in the anti-inflammatory and anti-fibrotic effects [ ] . the connection of sars-cov- to the eca receiver affects the balance between eca/ang/at r and eca /ang-( - )/mas, making the effects of the eca/ ang/at r axis even more prominent [ ] . the different immune responses of the host to the sars-cov- infection may explain the reason why men and women, young and old, infected by the virus can suffer a different severity of the disease [ ] . therefore, a considerably higher mortality rate was observed in patients with advanced chronological age [ ] . immune aging is related to an increase in individuals' susceptibility to infections, due to the decline in immune function, which can occur at any stage of the immune response. such changes can be seen, especially when associated with emotional stress [ ] . immune senescence is associated with the suppression of the activation and presentation of antigens by macrophages, which consequently prevent the migration of dendritic cells and the activation made by toll receptors with less effect [ , ] . ewers et al. [ ] mention the decline and proliferation of t cells, in addition to the increased production of pro-inflammatory cytokines il- , il- and tnf-α in the elderly. another point is the imbalance between th and th cytokines, generating an increase in the susceptibility of these individuals as infections by viruses and extracellular bacteria [ ] . in view of this, aging is associated with a constitutive pro-inflammatory environment due to persistent and low-grade immune activation, which can lead to increased tissue damage caused by infections [ ] . also, there should be taken into account the positive regulation of the ace-ang-ii-at axis that leads to proinflammatory and pro-fibrotic effects. although not very detailed, it is still suggested the occurrence of a greater number of eca receptors associated with aging, which would increase this imbalance. after all, it is through this receptor that sars-cov- infects humans and thus contributes to the development of covid- in older people [ ] . the precarious metabolic health is considered the main risk factor for the development of severe forms of covid- . this may occur in t dm, obesity and ms, possibly due to immune dysfunction in synergism with pathophysiological complications of these comorbidities [ ] . increased ace expression is a protective adaptive mechanism in t dm; however, it may facilitate the viral entry and spread of sars-cov- in the body [ ] . adipose tissue also exhibits high expression of ace , so the population with obesity may present greater vulnerability to covid- [ ] . it was observed that the expression of ace in the adipose tissue of obese patients allows viral entry in adipocytes and makes this tissue a reservoir for the viral dissemination of sars-cov- , since it is viscerally distributed [ , ] . in addition, obesity is an important factor for the development of t dm-especially when associated with low levels of physical activity and poor physical conditioning-and as mentioned, both diseases are related to higher expression of ace , increasing the risk of advanced infection by sars-cov- [ ] . metabolic disorders lead to immune activation of tissues such as the adipose, increasing the concentration of lowgrade chronic inflammation plasma markers, called metabolic inflammation or meta-inflammation [ ] . in this sense, the release of pro-inflammatory adipokines such as leptin, tnf-α, il- and il- b is observed, with a reduction in antiinflammatory action through the suppression of adiponectins [ , ] . the presented relationship is directly proportional to the presence of adipose tissue, the same that can be regulated through the practice of physical activity [ ] . the pro-inflammatory state found in metabolic syndrome and t dm may increase the probability of an unbalanced inflammatory response in covid- , like the cytokine storm described in patients with severe disease [ ] . similarly, as obesity is a state of low-grade chronic inflammation, it shows a potential for immune amplification of pathogens, as the regulatory elements of the immune response are absent or dysfunctional and this may contribute to the cytokine storm, which is already in greater concentration in obese individuals and which sustains and activates multiple cytokine pathways for a long time after the viral insult [ , ] . damage to blood vessels caused by chronic diseases, such as t dm, associated with hypercoagulability present in covid- may intensify the risk of infection complications [ ] . obesity can also aggravate endothelial dysfunction present in covid- due to inflammation triggered by perivascular and vascular adipose tissue, combined with changes in the synthesis of endogenous vasoactive agents, leading to platelet hyperactivation, leukocyte adhesion and other modifications related to endothelial inflammation, prothrombosis and proatherogenesis [ ] . hypercoagulability is directly proportional to the severity of overweight in obese patients. among the pathophysiological mechanisms are the action of adipocytokinins, with leptin and adiponectin, overactivity of coagulation factors, reduction of fibrinolytic function and, once again, increased inflammation (tnf and il- ). other contributors include elevated oxidative stress, lipid and glucose tolerance disorders, ms and venous stasis. thus, it is considered a synergic effect of obesity and ms on the state of hypercoagulability in covid- , aggravating the risk of vte and dic even more [ ] . there is also a greater amount of macrophages in the adipose tissue of obese individuals due to areas of microhypoxia, which lead to the nuclear factor-κb (nf-κb) pathway activation, thus increasing the expression of genes involved in inflammation [ ] . this condition is the result of the attraction of monocytes in the circulation made by chemokines; when they infiltrate the adipose tissue, they transform into macrophages, which, in turn, release tnf-α and il- which induce the tissue's resistance to insulin [ ] . insulin resistance is also related to the host's immune response, as it can inhibit the resolution of t cell-mediated inflammation [ ] . the adipose tissue is not the only one affected by the deposition of fats, because of that, bone marrow and thymus also present significant changes to the immune system of obese individuals and those with ms [ ] . thus, there is a marked deregulation of immune responses, which leads to a lower presence of circulating t cells, reducing the response to pathogens [ , , ] . despite the lack of accurate data on how physical activity improves the immune response against the new coronavirus, there is evidence of lower rates of ari incidence, duration and intensity of symptoms and risk of mortality from infectious respiratory diseases in individuals who exercise at high levels appropriate. furthermore, different studies suggest that regular physical exercise is directly related to decreased mortality from pneumonia and influenza, improvements in cardiorespiratory function, vaccine response, metabolism of glucose, lipids and insulin [ , ] . increased immune surveillance against infections has been proposed as a mechanism responsible for improving the immune response related to physical exercise. moderateintensity physical activity is responsible for providing an increase in the anti-pathogenic activity of macrophages, at the same time as elevations in the circulation of immune cells, immunoglobulins and anti-inflammatory cytokines occur, thereby reducing the burden of pathogen on organs such as the lung and the risk of lung damage due to the influx of inflammatory cells [ ] . during regular physical exercise practices, inflammatory responses and stress hormones are decreased; in contrast, lymphocytes, nk cells, immature b cells and monocytes are at high levels. thus, there is an improvement in immunovigilance, as well as a reduction in the systemic inflammatory process, factors that corroborate that regular physical activity helps to improve the immune system, while helping to prevent respiratory diseases and thus protect against infections such as covid- [ ] . dynamic exercises that generate cardiorespiratory overload promote the mobilization and redistribution of effector lymphocytes, mediated by catecholamines. this action primarily stimulates subtypes of lymphocytes capable of migrating from reservoirs-such as blood vessels, spleen and bone marrow-to lymphoid tissues and organs-such as the upper respiratory tract, lungs and intestines, aiming at recognizing and fighting pathogens and, thus, increasing immune surveillance and improving the antiviral response [ ] . similarly, regular exercise practices at moderate levels favor the function of the human body's immune surveillance against pathogens, as they stimulate an exchange of white blood cells between the circulatory system and tissues, a fact that reduces morbidity and mortality from acute respiratory disease and infections viral. they are also capable of promoting protection against infections triggered by intracellular microorganisms, as viral agents, given that the predominant immune response is mediated by th cells [ ] . regular exercise of moderate intensity has already been associated with a reduction in respiratory infections compared to sedentariness. however, exhaustive physical practices before or during an infectious condition, such as influenza or covid- , can trigger severe illness due to changes in the immune system [ , ] . this occurs due to the production of th anti-inflammatory cytokines in order to reduce muscle tissue damage, but in strenuous activities this effect can reach immunosuppression levels, thus providing the opportunity for infections [ , ] . therefore, attention should be paid to the importance of developing physical training at appropriate levels of execution. to the detriment of the world demographic change and the habits arising from the technological revolution, the population is aging more, becoming more obese and, consequently, less active when it comes to physical exercise. in this way, the immune system undergoes negative changes; that is, there is a functional impairment of innate immunity and adaptive immunity called immunosenescence, which results in greater susceptibility to infectious diseases and systemic inflammatory processes, decreased response to antibodies and, therefore, compromised immunological surveillance [ ] . therefore, for the elderly population, physical activity is even more essential, as these individuals generally have greater comorbidities and, in relation to the new coronavirus, are more vulnerable to contracting the disease [ ] . damiot et al. [ ] suggested that individuals who have remained active throughout their lives have less pronounced immunosenescence characteristics, which may be a possible protective factor against the development of complications caused by covid- . in this sense, beneficial effects of regular physical exercise have been reported in the elderly population, including reduction in oxidative stress, improvement in immune competence and reduction in cellular changes related to immunosenescence [ , ] . elderly individuals who maintain continued physical activity have levels of tcd + and tcd + lymphocytes similar to younger individuals, in addition to not having harmful defects in the recruitment of lymphocytes during the infectious process [ ] . according to the study by ferrer et al. [ ] with elderly volunteers, through physical activity there is a decrease in the current levels of il- , as well as an increase in the expression of il- in active individuals [ ] . a low presence of circulating pro-inflammatory cytokines is observed in contrast to the increase in anti-inflammatory cytokines. thus, there are positive changes in the immune system of these individuals, including enhancements in host response and vaccine immunoprotection [ ] . similarly, while prolonged maintenance or worsening of obesity and ms perpetuates deregulation of immune responses, promoting greater risks of the individual developing diseases and increasing their vulnerability to infection by the novel coronavirus [ , , ]. an association between physical activity and reduction of inflammatory markers in obese and overweight patients is suggested [ ] . luzi and radaelli [ ] add the lack of physical activity as an important factor among obese patients, as it impairs the immune response against microbial agents, from the activation of macrophages to the inhibition of pro-inflammatory cytokines. on the other hand, both metabolic health and immune health benefit from the practice of physical activity, which reduces the risk of infectious complications. thus, regular physical exercise appears as a preventive measure in the defense of the host against viral infection [ ] . muscle contraction is responsible for the transient increase in circulating levels of il- cytokine, in proportion to the duration of physical activity and the amount of muscle mass recruited. the elevation of this interleukin seems to be followed by increases in antinflammatory cytokines, such as il- , released by cells of innate immunity and responsible for promoting an antinflammatory environment, inhibiting inflammatory mediators to limit tissue damage. this effect may be beneficial in cases of chronic inflammation, such as obesity, t dm and ms, and may reduce the risk of a pathogenic inflammatory response such as the cytokine storm present in severe covid- [ , ] . in addition, il- is associated with enhanced insulin sensibility and glycemic metabolism [ ] . physical practice is able to reduce the excessive concentration of pro-inflammatory adipocin leptin and improve sensitivity to leptin and insulin [ , ] . in patients with t dm and new coronavirus infection, good glycemic control has been associated with better prognosis in covid- [ ] . thus, physical exercise is shown to be an immunomodulatory and non-pharmacological intervention, achieving positive immunomodulation through exercises of light to moderate intensity [ ] . through exercise, there is an improvement in the response to infection in obese individuals, due to immune and cellular restoration [ ] . although covid- is not primarily a metabolic disease, there is a need to maintain metabolic control of glucose, lipid levels and blood pressure in order to prevent metabolic and cardiovascular complications, as well as to reduce the local inflammatory response and block the virus entering the cells [ ] . as seen, innate immunity has an important role in the pathogenesis of covid- and ards, due to inflammatory cascades, recruitment of neutrophils, macrophages and dc cells and increased production of ross. in turn, by the modulation mechanism of chemokine production, physical training and therapeutic exercises can attenuate alveolar neutrophilia in the face of lung injury [ ] . furthermore, the expression of the extracellular superoxide dismutase enzyme (ecsod), an important antioxidant in the body and highly present in the lungs, is enhanced by resistance physical activity and was associated with inhibition of endothelial activation and inflammatory adhesion, with potential benefit to reduce oxidative stress and tissue damage in covid- [ ] . the amplification of the antioxidant defense generated by routine physical activity also contributes to immunological surveillance [ ] . moreover, womack, nagelkirk and coughlin [ ] point out that through the intensity of physical exercise, a change in the potential for coagulation, platelet aggregation and fibrinolysis can be seen. as an example, there is long-term training through aerobic exercises where a decrease in the clotting potential is observed in healthy individuals. thus, it is suggested that the practice of physical exercises contributes to reducing the risk of ischemic events depending on their intensity and duration [ ] and may contribute to attenuating coagulation disorders associated with sars-cov- infection. the anti-inflammatory, antioxidant and endothelial activation inhibitor benefits may also be linked to the reduction in hypercoagulability related to covid- . this is because, as previously mentioned, the exacerbated activation of the immune system increases the expression of the tissue factor and, consequently, the predisposition to the formation of thrombi; in addition, metabolic disorders, oxidant stress and changes in senescence positively stimulate the vasoconstrictor axis eca/ang/at r, contributing to endothelial imbalances [ , , [ ] [ ] [ ] [ ] [ ] ] . therefore, the immunometabolic improvements promoted by physical exercise may help in the control of coagulation disorders in the covid- (fig. ) . finally, in view of the quarantine status adopted in several countries as a measure to prevent and control the spread of sars-cov- during the covid- pandemic, social isolation and restrictions on the movement of people reduced the practice of physical activity, predisposing the population to adopt sedentary behavior [ ] . social distancing is a sine qua non in reducing the speed of contagion of covid- and associated deaths. however, due to these measures, sports clubs, gyms and fitness spaces have suspended their activities in order to reduce agglomerations; thus, difficulties regarding physical exercise were imposed [ ] . therefore, despite being one of the main strategies against covid- , social isolation has been related to behavioral and physiological changes, including the increased prevalence of sedentarism and eating disorders (food compulsion, hyperphagia), resulting in negative consequences for metabolic health, such as weight gain, growth of fat tissue, hyperglycemia and insulin resistance and loss of muscle tissue [ ] . since this condition can harm the body's defenses and contribute significantly to the reduction in individuals' physical condition, functional and health loss, the adoption of healthy habits and an exercise routine can help in maintaining health [ , ] . it is significant to consider that contexts like this increase the susceptibility to stressful events and elevations of glucocorticoids (cortisol), with consequent inhibition of the functions of nk cells and tcd + lymphocytes in the antiviral response. however, good physical conditioning was associated with lower risks of reactivation of latent viral infections in situations of isolation and confinement, indicating a favored immune system compared to individuals with less physical fitness [ ] . physical activity is considered a non-medication practice for the prevention and treatment of diseases of psychological, physical and/or metabolic origin [ ] . regular physical exercise should be encouraged during social isolation as a preventive measure for health, given that exercise is essential during the period of fight against the spread of coronavirus [ ] . the american college of sports medicine (acsm) recommends that the practice of moderate physical exercise should be maintained during the quarantine period, since it helps in the immune reinforcement against sars-cov- . the who recommends that asymptomatic and healthy individuals should exercise at least min per week for adults and min per week for children and adolescents. these times can be distributed during the days of the week and according to the person's routine [ ] . it is important to emphasize that physical activity should be interrupted and a health professional should be consulted in case symptoms such as fever, dyspnea at rest and dry cough are manifested, because these symptoms can be related to covid- [ , ] . in social isolation, the home environment has become the ideal and necessary place for physical activity. activities that are satisfactory and that allow better exploring the home space should be sought. activities of daily living such as organization of spaces, cleaning and maintenance also help in coping with covid- . in environments with children, playing and exercising with them is a great way to promote energy expenditure, thus leaving the beginning of sedentary rest. meditation, stretching and relaxation are allies in combating a sedentary lifestyle. it is important to avoid long rest periods, which should be intercalated with active practices [ ] . the acsm has published guidelines for moderate-intensity activities that can be practiced during the pandemic period, including aerobic exercises and strength training, indoors, like at home, or outdoors, when permitted by fig. benefits of regular moderate-intensity physical activity on factors that influence the response against to covid- . source: the authors ( ) government authorities. options for aerobic activities to be performed at home include walk briskly around the house, up-and downstairs, dancing and jumping rope. when possible, walking or running outdoors, cycling, gardening work and family games are interesting alternatives, as long as infection prevention measures are maintained [ ] . among the strength activities, acsm indicates downloading a strength workout app that does not require any equipment and suggests exercises such as squat, sit-ups, push-ups, lunges and yoga practice, which can also help in anxious states [ ] . oliveira neto et al. [ ] suggest resistance exercises based on acsm recommendations to be performed at home, including exercises involving the muscles of the lower body, upper body and limbs, and lower limbs, which can be adapted for beginners in physical practice or experienced people. activities that make use of the individual's own body weight, associated with resistance training as well as the use of elastic bands, provide excellent health results, results similar to those achieved by traditional gyms. thus, objects such as backpacks, books, market bags and water bottles can be used as an auxiliary tool in resistance physical activity. exercises such as squats, jumping jacks and going up and down steps can be effective in physical training [ ] . as for the intensity and volume of physical exercise practices, these must be moderate, as they exceed both the volume and the intensity, effects such as momentary immunosuppression are achieved, thus providing greater vulnerability as to the contagion of the novel coronavirus. if individuals want to practice high-intensity exercises, a reduction in exercise volume should be adopted as a preventive measure, in order to avoid strenuous exercises [ ] . in addition, technological tools can contribute to the better performance of these activities in the home environment, as video calls with a physical education professional facilitate the orientation of the exercises to be performed, providing support that has, as a consequence, better results and greater safety in the execution of the exercises. regardless of whether or not you are in the risk group for covid- , regular exercise, according to the acsm, should be regularly performed, given that it aims to improve the immune system, reduce stress perceived and decrease anxiety disorders [ ] . there are still gaps in the knowledge regarding the pathogenic mechanisms involved in sars-cov- infection. however, there is consensus in the scientific literature about the important involvement of the immune system in the susceptibility, progression and outcome of covid- . the imbalance in innate and adaptive immune responses, characterized mainly by changes such as cytokine storm and lymphopenia, in addition to the disorders in coagulation-and host-related conditions, including obesity, metabolic syndrome and aging (immunosenescence), is among the factors notoriously associated with a worse prognosis of infection. the benefits of exercise-regular and at appropriate intensity levels-for the immune system in respiratory infections such as covid- include increased immunovigilance and improved immune competence, which help in the control of pathogens, a fact that becomes more important considering the immunosenescence and susceptibility of the elderly population to severe infection. other favorable effects in relation to host factors, such as prevention or reduction of overweight, increased physical and cardiopulmonary conditioning, attenuation of the systemic pro-inflammatory and pro-thrombotic states, decrease in oxidative stress, improvements in glycemic, insulinic and lipidic metabolisms, besides the enhancement of the vaccination response, also indicate how adequately physical activity can help the organism's immune response against covid- . in the covid- pandemic situation, adopting mitigation practices is an essential strategy to reduce the risks related to the novel coronavirus infection. these interventions include the use of personal protective equipment (ppe), adherence to hygiene procedures and social isolation measures, as well as actions that lead to a healthier lifestyle, minimize stress factors and strengthen the immune system, such as regular physical activity. however, remaining active at appropriate levels seems to be a challenge in a context of confinement and social isolation, which emphasizes the importance of developing training with recommendations adapted to the new routine of the population. fortunately, there are viable alternatives for performing physical exercises in restricted environments, enabling the population to enjoy the advantages of physical training for health in the context of ovid- . finally, future studies that deepen the relationship between physical activity and infection by sars-cov- , including the influences of exercise on metabolic and immunological disorders present in covid- , will certainly be relevant in view of the probable benefits already mentioned and considering the impacts of infection by the novel coronavirus in the global context. faced with the possibility of new pandemics by previously unknown microorganisms, without totally effective prevention measures, vaccines or specific treatments of proven efficacy, the host organism's capacity against infections becomes the most important line of defense, thus emphasizing the importance of investing in lifestyle habits that promote health and well-being, such as the practice of physical activity. the persistence of acute respiratory infections as a public health problem respiratory viral infections in immunocompromised patients the common cold scientific group on viral respiratory diseases & world health organization. viral respiratory diseases: report of a who scientific group technical report series/world health organization) coronavirus disease (covid- ) pandemic longitudinal characteristics of lymphocyte responses and cytokine profiles in the peripheral blood of sars-cov- infected patients immune responses in covid- and potential vaccines: lessons learned from sars and mers epidemic molecular immune pathogenesis and diagnosis of covid- the immunological case for staying active during the covid- pandemic neuroendocrine regulation of il- and tnf-alpha/il- balance the compelling link between physical activity and the body's defense system physical activity for immunity protection: inoculating populations with healthy living medicine in preparation for the next pandemic exercise and the immune system: regulation integration and adaption adaptative mechanisms of the immune system in response to physical training the immunological case for staying active during the covid- pandemic position statement part two: maintaining immune health neuroendocrine regulation of il- and tnf-alpha/il- balance inflammatory cytokines in nonpathological states efeito do exercício no sistema imune: resposta, adaptação e sinalização celular oxidant production and immune response after stretch injury in skeletal muscle effects of running on chronic diseases and cardiovascular and all-cause mortality transient decrease of neutrophil chemotaxis following aerobic exercise moderate to vigorous physical activity and risk of upper-respiratory tract infection smoking, leisure-time exercise and frequency of self-reported common cold among the general population in northeastern china: a cross-sectional study exercise and toll-like receptors heart rate and plasma catecholamines during h of everyday life in trained and untrained men leukocytes, cytokines, growth factors and hormones in human skeletal muscle and blood after uphill or downhill running: leukocytes, cytokines and hormones in response to physical exercise effect of acute physical exercise on lymphocyte subpopulations in trained and untrained subjects biphasic changes in leukocytes induced by strenuous exercise human natural killer cell subsets and acute exercise: a brief review effect of exercise intensity on exercise-induced lymphocyte apoptosis genomic characterisation and epidemiology of novel coronavirus: implications for virus origins and receptor binding increasing host cellular receptor-angiotensin-converting enzyme (ace ) expression by coronavirus may facilitate -ncov infection clinical features of patients infected with novel coronavirus in wuhan multiple classes of antiviral agents exhibit in vitro activity against human rhinovirus type c covid- : immunopathology and its implications for therapy sars-cov- and viral sepsis: observations and hypotheses coronavirus infections and immune responses the anti-inflammatory effects of exercise: mechanisms and implications for the prevention and treatment of disease extracellular superoxide dismutase, a molecular transducer of health benefits of exercise infecções respiratórias virais comuns obesity and outcomes in covid- : when an epidemic and pandemic collide abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia prominent changes in blood coagulation of patients with sars-cov- infection covid- -related severe hypercoagulability in patients admitted to intensive care unit for acute respiratory failure hyperinflammation and derangement of renin-angiotensin-aldosterone system in covid- : a novel hypothesis for clinically suspected hypercoagulopathy and microvascular immunothrombosis blood coagulation: a powerful bactericidal mechanism of human innate immunity recommendations on antithrombotic treatment during the covid- pandemic position statement of the working group on cardiovascular thrombosis of the spanish society of cardiology tissue distribution of ace protein, the functional receptor for sars coronavirus a first step in understanding sars pathogenesis inappropriate activity of local renin-angiotensin-aldosterone system during high salt intake: impact on the cardiorenal axis the ace- in covid- : foe or friend? angiotensin-converting enzyme (ace ) is a key modulator of the renin angiotensin system in health and disease expression of the sars-cov- cell receptor gene ace in a wide variety of human tissues covid- and chronological aging: senolytics and other anti-aging drugs for the treatment or prevention of corona virus infection? aging (albany ny) aging of the innate immune system a metabolic handbook for the covid- pandemic is adipose tissue a reservoir for viral spread, immune activation and cytokine amplification in covid- impact of obesity and metabolic syndrome on immunity the impact of obesity on the immune response to infection obesity, inflammation and metabolic complications obesity and inflammatory adipokines: practical implications for exercise prescription parallels in immunometabolic adipose tissue dysfunction with ageing and obesity obesity-a risk factor for increased covid- prevalence, severity and lethality (review) the role of adipose tissue immune cells in obesity and low-grade inflammation coronavirus disease- : a tocsin to our aging, unfit, corpulent, and immunodeficient society physically active lifestyle as an approach to confronting covid- . arq bras cardiol immunological implications of physical inactivity among older adults during the covid- pandemic regular practice of moderate physical activity by older adults ameliorates their anti-inflammatory status influenza and obesity: its odd relationship and the lessons for covid- pandemic rbone-brazilian journal of obesity, nutrition and weight loss impact of obesity on influenza a virus pathogenesis, immune response, and evolution endocrine and metabolic link to coronavirus infection exercise-induced changes in coagulation and fibrinolysis in healthy populations and patients with cardiovascular disease exercise in the time of covid- praticar exercícios físicos é fundamental para a saúde física e mental durante a pandemia da covid- . braz j health rev page_docum ents/eim_rx% for % hea lth_% sta ying% act ive% dur ing% cor onavi rus% pan demic traininginhome-home-based training during covid- (sars-cov ) pandemic: physical exercise and behavior-based approach authors' contributions dtrs had the idea for the article. es, kksf e mrb performed the literature search, data analysis and translation. mps drafted and revised the work.funding not applicable. conflict of interest the authors declare that they have no conflict of interest.human and animal rights statement and informed consent this article does not contain any studies with human participants or animals performed by any of the authors, and informed consent is not a standard required.