To examine neighbourhood food environments, adolescent nutrition and weight status.

Cross-sectional, observational study.

Minneapolis/St. Paul metropolitan region, Minnesota, USA.

A total of 349 adolescents were recruited to the study. Participants completed 24 h dietary recalls and had their weight and height measured. They also reported demographic information and other diet-related behaviours. Geographic Information Systems were used to examine the availability and proximity of food outlets, particularly those captured within the 800, 1600 and/or 3000 m network buffers around participants’ homes and schools.

Adjusting for gender, age and socio-economic status, adolescents’ sugar-sweetened beverage intake was associated with residential proximity to restaurants (including fast food), convenience stores, grocery stores and other retail facilities within the 800 and/or 1600 m residential buffers (P ≤ 0·01). BMI Z-score and percentage body fat were positively associated with the presence of a convenience store within a 1600 m buffer. Other individual-level factors, such as energy, fruit and vegetable intake, as well as convenience store and fast food purchasing, were not significantly associated with features of the residential neighbourhood food environment in adjusted models. In addition, school neighbourhood environments yielded few associations with adolescent outcomes.

Many factors are likely to have an important role in influencing adolescent dietary intake and weight status. Interventions aimed at increasing neighbourhood access to healthy foods, as well as other approaches, are needed.

Current nutrition environment instruments are typically designed to measure a small number of healthy foods based on national trends. They lack the depth to accurately measure the unique dietary choices of subpopulations, such as Texas consumers whose food preferences are influenced by Hispanic/Latino culture. Thus the purposes of the present study were to: (i) develop a comprehensive observational tool to measure the availability of healthy foods from retail stores in Texas; and (ii) conduct a pilot test to examine the tool’s reliability, as well as differences in the availability of healthy foods in stores between high- and low-income neighbourhoods.

Grocery and convenience stores were assessed for availability of healthy foods. Reliability was calculated using percentage agreement, and differences in availability were examined using 2 (store type) × 2 (neighbourhood income) ANOVA.

One high-income and one low-income neighbourhood in Austin, Texas.

A sample of thirty-eight stores comprising twenty-five convenience stores and thirteen grocery stores.

The low-income neighbourhood had 324 % more convenience stores and 56 % fewer grocery stores than the high-income neighbourhood. High inter-rater (mean = 0·95) and test–retest reliability (mean = 0·92) and a significant interaction (P = 0·028) between store type and neighbourhood income were found.

The TxNEA-S tool includes 106 healthy food items, such as fruits, vegetables, dairy, proteins and grains. The tool is reliable and face validity is affirmed by the Texas Department of Health. Grocery stores have more healthy foods than convenience stores, and high-income grocery stores offer more healthy foods than low-income grocery stores.

Through a literature review, we investigated the geographic information systems (GIS) methods used to define the food environment and the types of spatial measurements they generate.

Review study.

Searches were conducted in health science databases, including Medline/Pubmed, PsycINFO, Francis and GeoBase. We included studies using GIS-based measures of the food environment published up to 1 June 2008.

Twenty-nine papers were included. Two different spatial approaches were identified. The density approach quantifies the availability of food outlets using the buffer method, kernel density estimation or spatial clustering. The proximity approach assesses the distance to food outlets by measuring distances or travel times. GIS network analysis tools enable the modelling of travel time between referent addresses (home) and food outlets for a given transportation network and mode, and the assumption of travel routing behaviours. Numerous studies combined both approaches to compare food outlet spatial accessibility between different types of neighbourhoods or to investigate relationships between characteristics of the food environment and individual food behaviour.

GIS methods provide new approaches for assessing the food environment by modelling spatial accessibility to food outlets. On the basis of the available literature, it appears that only some GIS methods have been used, while other GIS methods combining availability and proximity, such as spatial interaction models, have not yet been applied to this field. Future research would also benefit from a combination of GIS methods with survey approaches to describe both spatial and social food outlet accessibility as important determinants of individual food behaviours.

The news media are an important source of dietary information. Understanding news content, particularly the portrayal of risks and benefits of certain foods, is relevant for effective public health communication. Fish consumption may reduce risk for CVD and aid neonatal development, but recent work shows public confusion about the benefits of fish, challenged by the evidence of mercury and other contaminants in fish. We present an analysis of the messages about fish in US news media over 15 years, identifying trends in coverage and highlighting implications of current messaging.

We conducted a descriptive text analysis and coded for manifest content: locality of focus, story frame, reference to studies, inclusion of government guidelines and portrayal of uncertainty. We identified chronological patterns and analysed the data for statistically significant relationships between media source and content.

News stories were selected from five daily newspapers and five television networks (1993–2007).

We analysed 310 health-related news stories on fish.

Risk messages outweighed benefit messages four to one, and health benefits only became prominent after 2002. No difference existed in coverage topic by news source. Fish consumption has increasingly become a national issue.

With the bulk of messages about fish consumption focused on risk, the benefits may be lost to consumers. This gap creates a need for public health to work with news media to more effectively communicate benefits and risks around fish consumption and health and to consider options for communicating tailored information where it can be more readily utilised.

Although breakfast is important for obesity prevention and dietary quality, breakfast skipping is a common behaviour. Knowledge of changes in breakfast habits may provide potential behaviour targets for intervention programmes. The present study describes the actual data on trends in breakfast habits and composition.

A total of 7800 3 d dietary records of 1081 participants aged 2–18 years collected between 1986 and 2007 in the DONALD (Dortmund Nutritional and Anthropometric Longitudinally Designed) Study were analysed using mixed linear models.

Breakfast was eaten at 78 % of all record days; regular breakfast (breakfast was eaten on all three recorded weekdays) was eaten in 75 % of records. During the study period, the number of records with regular breakfast decreased significantly in 6–12- and 13–18-year-olds (P = 0·0084 and 0·0350, respectively). Of all breakfast meals, 62 % were bread meals and 21 % were ready-to-eat cereal (RTEC) meals. RTEC meals nearly doubled from the youngest to the oldest age group (P < 0·0001). During the study period, the percentage of bread meals decreased, whereas the percentage of RTEC meals increased (P < 0·0001). A higher percentage of RTEC meals than the bread meals was in accordance with the food-based guidelines (36 % v. 20 %, P < 0·0001), i.e. a breakfast including grain, dairy and fruit/vegetables.

In the DONALD Study sample, a negative age and time trend in breakfast consumption was verified. Interventions regarding breakfast habits should be aimed at adolescents and should focus on fruit/vegetables.

To investigate average sodium excretion in 24 h urine as a marker for salt intake in the Slovene population.

Salt intake was determined by measuring sodium excretion in 24 h urine collected from a representative sample of geographically diverse Slovene adults.

Slovenia.

A random sample of 600 adults aged 25–65 years was generated from census data. The effective sample yield was 143 people, 42·7 % men and 57·3 % women.

Urinary sodium excretion was significantly higher in men (220·9 (sd 86·0) mmol Na/d) than in women (169·8 (sd 73·8) mmol Na/d); t test = 14·5, P < 0·001. Average salt intake was 11·3 (sd 4·9) g/d, higher in men than in women (13·0 (sd 5·1) v. 9·9 (sd 4·3) g/d, respectively). Average intakes of salt among regions were not significantly different. Salt intake increases slightly with increasing age, but there was no significant correlation between age and salt intake. Salt intake was increased with BMI (r = 0·384, P < 0·001).

Salt intake in Slovene adults, especially in men, exceeds the WHO recommended population nutrient intake goal of 5 g by more than twofold. A national programme for reducing salt intake in Slovenia needs to be implemented through systematic efforts including public education and involving the health-care sector and the food industry.

To examine the prevalence and likelihood of taking folic acid or vitamin supplements among adults with CHD or stroke v. adults without these conditions.

A cross-sectional Behavioural Risk Factor Surveillance System survey was conducted in twelve states of the United States and Puerto Rico in 2006. Self-reported data from participants were collected.

The United States.

US non-institutionalised adults (n 41 792), aged ≥45 years.

Of all participants, 5445 had CHD and 2076 had stroke. Significantly higher percentages of women than men reported taking folic acid or vitamin supplements. After adjustment for potential confounders, women with CHD had a significantly lower adjusted prevalence (AP) and adjusted OR (AOR) than women without CHD for taking folic acid less than one time per d (AP = 3·9 % v. 5·5 %; AOR = 0·56; 95 % CI 0·39, 0·81), for taking folic acid one to four times per d (AP = 50·0 % v. 57·5 %; AOR = 0·68; 95 % CI 0·60, 0·79), and for taking vitamin supplements (AP = 60·9 % v. 69·9 %; AOR = 0·66; 95 % CI 0·57, 0·76). Men with CHD had a significantly higher AP (50·4 % v. 46·2 %) and AOR (1·17; 95 % CI 1·02, 1·33) of taking folic acid one to four times per d than men without CHD. In both sexes, adults with stroke were as likely as those without to take these supplements.

Substantial variations in the prevalence and likelihood of taking folic acid or vitamin supplements exist by gender and by CHD status, but not by stroke status.

To assess coffee consumption in the Sami and Norwegian populations and to investigate the impact of unfiltered boiled coffee consumption on serum cholesterol concentrations.

A cross-sectional study. Information was collected by self-administrated questionnaires and total serum cholesterol was analysed. Participants were divided into three ethnic groups: Sami I (Sami used as home language in the last three generations), Sami II (at least one Sami identity marker) and Norwegian.

In an area with Sami, Kven/Finnish and Norwegian populations, the SAMINOR study, 2003–2004.

A total of 5647 men and 6347 women aged 36–79 years.

More than 90 % of the study populations were coffee drinkers. Only 22 % were unfiltered coffee consumers. Sami I had the highest proportion of participants who consumed nine or more cups of unfiltered coffee per day, although the number of participants was limited. Total coffee consumption was associated with increased total cholesterol for men (P < 0·01) and women (P < 0·0001). For those who drank only unfiltered coffee, a significant association was found only in Norwegian men, adjusted for physical activity in leisure time, BMI and smoking habits (P < 0·001). From the lowest (less than five cups) to the highest (nine or more cups) unfiltered coffee consumption category, the mean total cholesterol levels increased by 0·29 mmol/l in Norwegian men.

Unfiltered coffee consumption was lower in the present study compared to previous reports. In general, total coffee consumption was positively associated with total cholesterol levels. However, for unfiltered coffee consumption, an association was found only in Norwegian men.

Some versions of restaurant menu labelling legislation do not require energy information to be posted on menus for drive-through lanes. The present study was designed to quantify the number of customers who purchase fast food through drive-in windows as a means of informing legislative labelling efforts.

This was an observational study.

The study took place at two McDonald’s and Burger King restaurants, and single Dairy Queen, Kentucky Fried Chicken, Taco Bell and Wendy’s restaurants.

The number of customers entering the chain restaurants and purchasing food via the drive-through lane were recorded. A total of 3549 patrons were observed.

The percentage of customers who made their purchases at drive-throughs was fifty-seven. The overall average (57 %) is likely a conservative estimate because some fast-food restaurants have late-night hours when only the drive-throughs are open.

Since nearly six in ten customers purchase food via the drive-through lanes, menu labelling legislation should mandate the inclusion of menu labels on drive-through menu boards to maximise the impact of this public health intervention.

To describe dietary habits and extent of overweight and obesity among Cree youth.

Dietary intake and habits were assessed by a 24 h recall and FFQ as part of a cross-sectional survey.

Three Cree communities in northern Québec, Canada.

A total of 125 youth aged 9–18 years.

Overall 67·6 % of the study population was either at risk of overweight or overweight. Over 98 % had a usual saturated fat intake over 10 % of energy while 65 % had a lower consumption of fruit/vegetables and 95 % had a lower consumption of milk and milk products than recommended by Canada’s Food Guide. The majority (96·8 %) consumed high-fat foods (>40 % of total energy as fat), which accounted for 39 % of total energy intake (EI). Similarly, 92·8 % consumed high-sugar food and beverages (>25 % of total energy as sugar), which accounted for 12·8 % of total EI. Furthermore, 95 % of the youth had a Healthy Eating Index (HEI) below the recommended score of 80 or above. Certain measures of diet quality (traditional food (TF) consumption, HEI and vegetables and fruit consumption) were significantly correlated with adiposity measures.

A high prevalence of low-diet quality was found with a high degree of sugar and fat intake and a low consumption of vegetables/fruit and milk/milk alternates and any weekly TF. Dietary interventions are sorely needed.

The aim of the present study was to explore the existence of clusters in multiple lifestyle behaviours, including physical activity (PA), sedentariness and food habits, in young adolescents. The present study also investigated whether the identified groups could be characterised by gender and components of health-related physical fitness, especially weight status and cardiorespiratory fitness (CRF).

A cross-sectional survey. Leisure-time PA, sedentary behaviour and food consumption were assessed by a questionnaire. Overweight prevalence was estimated using BMI (kg/m2) calculated from self-reported height and weight. CRF was measured using a 20 m shuttle-run test.

The study was conducted in four middle schools in Flanders, Belgium.

The sample size was 317 seventh grade students aged 11–12 years.

Four reliable and meaningful lifestyle clusters could be identified, labelled as ‘Sporty media-oriented mixed eaters’ (boys: n 34; girls: n 16), ‘Academic healthy eaters’ (boys: n 30; girls: n 58), ‘Inactive healthy eaters’ (boys: n 38; girls: n 57) and ‘Inactive media-oriented unhealthy eaters’ (boys: n 35; girls: n 49). The lifestyle clusters could not be characterised by adolescents’ weight status. Among boys, the ‘Sporty media-oriented mixed eaters’ group performed significantly better on the shuttle-run test than those in clusters with the lowest levels of PA (clusters 3 and 4).

Our results showed that healthy and risk-related behaviours may coexist in some groups of young adolescents. Isolated unhealthy behaviours, such as high levels of screen-based media use or high consumption of energy-dense food items, are not necessarily related with negative health outcomes, on the condition that these risk-related behaviours co-occur with more health-enhancing behaviours such as PA.

To modify the self-administered, short version of the International Physical Activity Questionnaire (IPAQ) for adults to be used in the elderly (aged 65 years and above), and to validate this modified IPAQ for the elderly (IPAQ-E).

A direct validity study using accelerometer-measured physical activity (PA) as the criterion measure, and an indirect criterion validity study using high-sensitivity C-reactive protein (hs-CRP) as a biological marker of activity.

Organisations for retired persons in Sweden.

The direct validity study consisted of fifty-four participants and the indirect criterion validity study consisted of 359 participants. All participants were retired persons (66–91 years) living independently.

All self-reported activity domains (sitting, walking, moderate and vigorous) were positively correlated with the corresponding variable objectively assessed by an accelerometer (ρ = 0·277–0·471), but a systematic error was observed. The specificity of IPAQ-E to identify low-active participants was 85 %, and the sensitivity to identify the more active participants was 81 %. A main effect of IPAQ-E category (Low, Moderate or High) was observed for hs-CRP (P = 0·041).

We found this modified version of IPAQ, the IPAQ-E, to be well accepted by our sample of socially active elderly. It provided acceptable estimates of PA, well in line with other questionnaires, even though it had a systematic error. The IPAQ-E was able to identify an expected response of a biomarker (hs-CRP) to PA. We recommend the use of the IPAQ-E to classify participants aged 65 years and above into PA categories, to rank individuals or to identify individuals meeting certain PA criteria.

To assess the nutritional quality of prepared foods available to primary-school children.

Prepared foods available in a public and private school were sampled daily for 4 weeks (a total of forty-five samples) and chemically analysed for protein, fat, carbohydrate, iron, salt and sodium. The results were compared to the nutritional standards for children aged 7–10 years.

Alfenas, south-eastern Brazil.

The concentration of protein, lipid, iron and sodium and the energy values of the foods at the private school were significantly higher than those at the public school. No differences were seen in the carbohydrate and salt values. The range of macronutrients was more balanced at the public school in relation to fat and protein. Foods at the private school were, in general, energy-dense. At both the public and private school, they provided the minimum energy and iron. Salt content was over twice the maximum amount, and that for sodium was over three times the amount, in both the public and private school.

Overall, foods prepared at the public school were better nutritional quality than those at the private school and those offered in public schools in some developed countries. This finding can probably be explained by the fact that a nutritionist, as required by law, was responsible for planning the menus at the public school. However, corrective action is needed to adjust for the wide variability in energy and nutrient content during weekdays and in the sodium content of prepared foods available in both the public and private school.

To characterize the relationship between serum carotenoids, retinol and anaemia among pre-school children.

A cross-sectional study was conducted in two groups: anaemic and non-anaemic. Serum levels of retinol, α-carotene, β-carotene, β-cryptoxanthin, lycopene, lutein and zeaxanthin were measured in the study subjects.

Six rural communes of Dinh Hoa, a rural and mountainous district in Thai Nguyen Province, in the northern mountainous region of Vietnam.

A total of 682 pre-school children, aged 12–72 months, were recruited.

Geometric mean serum concentrations of carotenoids (μmol/l) were 0·056 for α-carotene, 0·161 for β-carotene, 0·145 for β-cryptoxanthin, 0·078 for lycopene, 0·388 for lutein and 0·075 for zeaxanthin. The mean levels of Hb and serum retinol were 108·8 g/l and 1·02 μmol/l, respectively. The prevalence of anaemia and vitamin A deficiency was 53·7 % and 7·8 %, respectively. After adjusting for sex and stunting, serum retinol concentrations (μmol/l; OR = 2·06, 95 % CI 1·10, 3·86, P = 0·024) and total provitamin A carotenoids (μmol/l; OR = 1·52, 95 % CI 1·01, 2·28, P = 0·046) were independently associated with anaemia, but non-provitamin A carotenoids (μmol/l; OR = 0·93, 95 % CI 0·63, 1·37, P = 0·710) were not associated with anaemia.

Among pre-school children in the northern mountainous region of Vietnam, the prevalences of vitamin A deficiency and anaemia are high, and serum retinol and provitamin A carotenoids are independently associated with anaemia. Further studies are needed to determine if increased consumption of provitamin A carotenoids will reduce anaemia among pre-school children.

To systematically analyse determinants of overweight prevalence and incidence in children and adolescents, as a basis of treatment and prevention.

Cross-sectional and longitudinal data of the Kiel Obesity Prevention Study (KOPS).

Schools in Kiel, Germany.

Cross-sectional data from 6249 students aged 5–16 years and 4-year longitudinal data from 1087 children aged 5–11 years. Weight status of students was assessed and familial factors (weight status of parents and siblings, smoking habits), social factors (socio-economic status, nationality, single parenting), birth weight as well as lifestyle variables (physical activity, media time, nutrition) were considered as independent variables in multivariate logistic regression analyses to predict the likelihood of the student being overweight.

The cross-sectional data revealed the prevalence of overweight as 18·3 % in boys and 19·2 % in girls. In both sexes determinants of overweight prevalence were overweight and obese parents, overweight siblings, parental smoking, single parenthood and non-German nationality. High birth weight and low physical activity additionally increased the risk in boys. High media time and low parental education were significant determinants in girls. Effect of media time was mediated by maternal weight status in boys as well as by socio-economic status and age in girls. From the longitudinal data, the 4-year cumulative incidence of overweight was 10·0 % in boys and 8·2 % in girls. Parental obesity, parental smoking and low physical activity were determinants of overweight incidence in boys, whereas paternal obesity increased the risk in girls.

Treatment and prevention should address family and social determinants with a focus on physical activity and media use.

A front-of-pack nutrition logo on products with relatively favourable product compositions might help consumers to make more healthful choices. Studies investigating actual nutrition label use in point-of-purchase settings are scarce. The present study investigates the use of the ‘Choices’ nutrition logo in Dutch supermarkets.

Adults were asked to complete a validated questionnaire about motivation for food choice and their purchased products were scored for the Choices logo after they had done their shopping.

Nine supermarkets in The Netherlands.

A total of 404 respondents participated.

Of the respondents, 62 % reported familiarity with the logo. The motivations for food choice that were positively associated with actually purchasing products with the logo were attention to ‘weight control’ and ‘product information’. The food choice motive ‘hedonism’ was negatively associated with purchasing products with the logo.

This is the first study to investigate actual use of the Choices logo. In order to stimulate consumers to purchase more products with a favourable product composition, extra attention should be paid to hedonistic aspects such as the tastefulness and the image of healthy products.

The aim of the present work was to calculate the current cost of the Mediterranean diet in Greece and to evaluate the role of diet cost in the development of cardiovascular events after a 5-year follow-up.

Cross-sectional. Cost of diet was measured in €/week based on common Greek dietary choices, while baseline dietary habits were assessed through a semi-quantitative FFQ (Greek-EPIC). The Mediterranean Diet Score (MedDietScore) was applied to assess overall adherence to this pattern using scores of eleven food variables and alcohol, according to the principles of the Mediterranean diet.

Five-year follow-up of the ATTICA study, a nutrition and health survey of a representative, free-living sample of the Greek population resident in the province of Attica, where Athens is a major metropolis.

From 2001 to 2002, 1514 men and 1528 women (aged >18 years) without known CVD were enrolled. In 2006, the 5-year follow-up was performed.

The weekly cost of participants’ diets varied from 5·35 to 83·57 €/week in men (mean 25·45 (sd 6·80) €/week) and from 10·89 to 55·49 €/week in women (mean 25·63 (sd 6·30) €/week). Diet cost was correlated marginally to MedDietScore (r = 0·060, P = 0·05) as well as being associated with history of hypercholesterolaemia (mean (sd), yes v. no: 24·90 (5·73) v. 25·82 (6·95) €/week, P = 0·027), physical activity (mean (sd), yes v. no: 26·42 (6·90) v. 24·82 (6·20) €/week, P < 0·001) and current smoking (mean (sd), yes v. no: 24·99 (6·40) v. 25·98 (6·70) €/week, P = 0·017). No significant association was found between diet cost and 5-year incidence of CVD (hazard ratio = 1·021, 95 % CI 0·965, 1·081). However, adherence to the traditional Mediterranean diet was inversely associated with the development of CVD (relative risk per 1-unit increase in MedDietScore = 0·92, 95 % CI 0·89, 0·94) after adjustment for various potential confounders including diet cost.

Quality but not cost of the diet is associated with the development of CVD.

To explore whether initiatives to promote fruit and vegetables in primary schools are associated with changes in children’s diet.

Cross-sectional dietary survey. Main outcome measures were intakes of fruit, vegetables and key nutrients; and a score for initiatives promoting fruit and vegetables in school.

One hundred and twenty-nine English primary schools.

Year 2 children (aged 6–7 years, n 2530).

In schools running a gardening club, children ate more vegetables, 120 (95 % CI 111, 129) g/d, compared with those that did not, 99·3 (95 % CI 89·9, 109) g/d; and where parents were actively involved in school initiatives to promote fruit and vegetables, children’s intake of vegetables was higher, 117 (95 % CI 107, 128) g/d, compared with those where parents were not involved, 105 (95 % CI 96·2, 114) g/d. In schools that achieved a high total score (derived from five key types of initiatives to promote fruit and vegetables in school) children ate more vegetables, 123 (95 % CI 114, 132) g/d, compared with those that did not, 97·7 (95 % CI 88·7, 107) g/d.

Gardening, parental involvement and other activities promoting fruit and vegetables to children in school may be associated with increased intake of vegetables but not fruit. These effects were independent of deprivation status and ethnicity.

Convincing evidence exists for a beneficial effect of physical activity (PA) on health and well-being for elderly women. Nevertheless, many women in Germany are insufficiently physically active. Activity promotion programmes should target women in particular need. Thus, we examined subject-related determinants of PA for postmenopausal women in Germany.

Associations of sociodemographic, anthropometric, lifestyle and health-related factors with activity since the age of 50 years were assessed with multiple linear and logistic regression models, regarding overall leisure-time PA (LPA) in metabolic equivalent hours per week, engagement in sports (ever v. never), cycling (yes v. no) and walking (≥3·5 v. <3·5 h/week).

All controls from a population-based case–control study carried out in 2002–2005 in Germany (MARIE study).

A total of 6569 postmenopausal women.

We found significant associations of overall LPA, sports, cycling and walking in postmenopausal years with several characteristics, among others: obese v. normal BMI (adjusted OR: ORsports = 0·73; ORcycling = 0·60; ORwalking = 0·63), tall v. short (ORsports = 1·49), worker v. medium employee (ORsports = 0·47), working full time v. unemployed/retired (ORsports = 0·80; ORwalking = 0·56), current v. non-smoker (ORsports = 0·62; ORcycling = 0·62; ORwalking = 0·82), non-German nationality (ORsports = 0·58; ORcycling = 0·41). Parity seemed more relevant than marital status for sports or cycling activity. Further, CVD, hypertension and diabetes were significantly associated with lower activity (ORsports = 0·77, 0·79 and 0·80; ORcycling = 0·80, 0·75 and 0·85, respectively).

Our results suggest potential target groups for promoting sports, cycling or walking activity. Postmenopausal women with chronic diseases may need to be stronger encouraged by their physicians to engage in adequate PA for the management of their diseases.