 Good morning everybody. I should say good afternoon now. It's 12 noon. My name is Mark Ramis and I'm one of the Associate Scientific Directors for the Canadian Longitudinal Study on Aging. And I'm going to welcome you now to our December webinar. The presenter will be Dr. Paul Loprinzi and we'll just give people another two minutes to log on and sometimes the software that we use can be very finicky. And in a couple of minutes we'll begin. I will introduce Dr. Loprinzi and then he will give his talk and of course we'll have time for some questions afterwards. So let's just wait a couple of more minutes for last minute joiners and then we'll get the webinar underway. Okay, let's begin. I'm sure some other individuals will be joining us shortly. So I will introduce Dr. Loprinzi, our speaker today. He's an Assistant Professor of Health and Exercise Science at the University of Mississippi. His research focuses on examining the effects of physical activity on various health outcomes and determining psychosocial and bio-behavioral determinants of physical activity. Dr. Loprinzi is also Director of Research Engagement at the Jackson Heart Study, Vanguard Center of Oxford. And that is the largest single-site prospective epidemiologic investigation of cardiovascular disease among African Americans that's ever been undertaken. His background is in Exercise Science and Behavioral Epidemiology. He holds a PhD in Exercise and Sports Science from Oregon State University and he has over 175 first authored or co-authored peer-reviewed publications to his credit. Today Dr. Loprinzi is going to be talking about factors that influence physical activity and the effects of physical activity on cardiovascular disease risk factors and health outcomes among middle-age and older adults. Dr. Loprinzi is going to be the first in a series of international speakers from the United States and from the UK. So he will present for approximately the next 40 to 45 minutes and then we will entertain your questions. Now if we intentionally mute participants because if everyone's talk features were enabled, there would be a great deal of feedback and we wouldn't be able to hear the speaker present. So if you have a question, please look at the bottom left of your screens and you'll see the chat feature. Just type your questions in at any time during the presentation. And when the presentation is complete, I will read the questions allowed to everyone and our speaker will be able to answer. So without further ado, I'll stop talking and I will pass the baton to Dr. Loprinzi. Paul, please go ahead. Thank you, Mark, for this opportunity. It's an absolute pleasure to give this presentation and talk about some of our previous work as well as current ongoing work surrounding the topic of physical activity epidemiology, looking at some of the health outcomes associated with physical activity and determinants of physical activity behavior. Look forward to everybody's comments and questions at the very end of my presentation and of course if we don't have time to answer them all, I'm happy to correspond via email so feel free to send me an email and we can continue the dialogue at a later time. As Mark mentioned, the title of my presentation is Factors that Influence Physical Activity and the Effects of Physical Activity on CVD Risk Factors and Health Outcomes Among Middle-Age and Older Adults. So here's an outline for my talk today. I'm going to talk about a variety of different things centered around the topic of physical activity epidemiology. The first half of my presentation will specifically focus on a particular chronic disease that being smoke-induced COPD. And then the later half of my presentation will focus on middle-age and older adults with a variety of different chronic diseases. And so I'll first start out talking about the potential limitations that COPD patients have in engaging in higher-intensity physical activity. And then this will underscore the importance of this particular population to engage in light-intensity physical activity. So then subsequently, I'll talk about some of our emerging work that addresses the potential beneficial effects of light-intensity physical activity on a variety of different health outcomes in this specific population. And then I'll go into some of our other work that looks at not only the direct effects of physical activity on CVD biomarkers among smoking-induced COPD, but also the potential additive interaction effects of physical activity in a healthy diet on a variety of different cardiovascular disease biomarkers among smokers. And then I'll finish my talk among the COPD patient by addressing an emergent study that we recently published that addresses the potential for physical activity to help to facilitate smoking cessation. Now, as I mentioned, I'll go into a different population, middle-age and older adult population, talk about unique daily movement patterns that we've been talking about in the literature and how they relate to CVD risk factors. Then I'll talk about the beneficial effects of longer bouts of physical activity as well as shorter bouts of physical activity. And then lastly, I'll conclude with a paper that we published that looks at behavioral and cognitive determinants of physical activity that can be utilized to help to promote physical activity among chronically diseased populations. So as I mentioned, the first half of my talk today will focus on individuals with COPD. We know COPD affects about 5% of U.S. adults, causes over 2 million deaths annually. There's a genetic component to COPD, but one of the primary modifiable factors of COPD is smoking. We know smoking itself increases the risk of lung cancer, but they can also increase the risk of endotypes of cancers, as well as increasing the risk of cardiovascular disease. One way in this may occur is the inflammatory markers that are activated in the lung from smoking they translocate into the circulatory system, can activate plaque tissues, induce vascular information, and then ultimately induce vascular related events. So because of this translocation effect of these inflammatory markers into the circulatory system, it's important that we can identify modifiable behaviors to attenuate these pro-inflammatory effects associated with smoking. So today I'll be talking about the potential effects that physical activity can have in attenuating these pro-inflammatory markers in the circulatory system, which will clearly have cardiovascular disease implications. The first thing I would like to talk about is a paper that myself and my colleagues from Bellarmine University, including Drs. Cain, Siggler, Brown, and Dr. Jerry Walker, we've recently published in the journal Physiology and Behavior entitled Freeliving Physical Activity Characteristics, Activity-Related Air Trapping and Breathlessness, and Utilization of Trains Theoretical Constructs in COPD Pilot Study. So in this study we had individuals with moderate to severe COPD, confirmed from pulmonary function testing in our lab, come into our lab for a graded exercise test. These moderate and severe COPD patients, which included ten of them, were all older individuals, mean age of 70 years. They completed a graded exercise test on the treadmill that included three different stages. Two miles per hour, 2.5 miles per hour, and three miles per hour. Each stage lasted five minutes in duration. And as you can see here, this is the indirect calorimetry data across these three different stages. So there was a progressive increase in energy expenditure across the three stages, which is what we would expect. At the end of each of the five-minute stages, we asked individuals to point to a scale, specifically the MVP scale, the multidimensional Disneya Profile Scale, to provide some indication of their air hunger or their air breathlessness, or whether they perceived that they were smothering for air or how much air they could get into their lungs. And then also, right after that assessment, we had them complete the inspiratory capacity measurements while walking on the treadmill at the end of each stage as a proxy for air trapping or this indication of this air being left into the lung capacity. Here are the results from these findings here. The first line right here, this is the data from the MVP scale or their air hunger breathlessness. As you can see at baseline, individuals had a air hunger breathlessness score of zero, so no problems getting air into the lungs. They did not feel like they were smothering, so no issues at the baseline level. But then as you can see, as they progressed to the different intensity levels, their air hunger breathlessness drastically increased. And then similarly, this line right here represents the air trapping or the inspiratory capacity measurement. At baseline, they consumed about 1.65 liters. And then initially, that very first stage, after the first stage, you can see a drastic reduction in inspiratory capacity, and that maintained across the three different stages. So collectively, these findings provide some evidence that as COPD patients, they engage in modern higher intensity levels of physical activity. They perceive that they can't get enough air into their lungs, as demonstrated here by the air hunger breathlessness. And they trapped more air in their lungs at sort of a relatively low intensity level. So ultimately, these findings to us underscore the importance of engaging in light intensity physical activity among this population. So I just talked about the potential exercise induced hyperinflation or air trapping, as well as this enhanced perception of smothering. They can't get enough air into their lungs among the COPD population, which again, underscores the importance of engaging in light intensity physical activity. So then the next thing I'm going to talk about addresses some of our recent findings that delineates the relationship between light intensity physical activity and a variety of different CVD biomarkers among smoke and induced COPD. And again, we feel that this is particularly important based on what I mentioned previously, and that smokers tend to have elevated levels of these pro-inflammatory markers in the circulatory system. So identifying behaviors that can tend to affect is critical. The title of this study that we recently published in the American Journal of Health Promotion is the association between physical activity and inflammatory markers among U.S. adults with chronic obstructive pulmonary disease published by my co-authors, Dr. Jerry Walker and Dr. Haya Lee. In this study, we utilized a representative sample of Americans with evidence of COPD coming from the National Health and Nutrition Examination Survey cycles 2003 to 2006. This was to examine the association between accelerometer to determine physical activity and white blood cells and neutrophils among this representative sample of COPD patients. We specifically focused on white blood cells and neutrophils because in addition to evidence suggesting that these parameters may increase the risk of cardiovascular disease, they're also associated with other chronic diseases including diabetes, cancer, cancer mortality, and all-cause mortality. In the literature, we know that physical activity has an anti-inflammatory effect. However, the effect is less clear among those with COPD. Fewer studies have looked at the relationship between physical activity and inflammatory markers among this specific population. So again, we utilized data from the National Health and Nutrition Examination Survey. 238 current or former smokers with COPD constituted the analytical sample. COPD was determined via self-reportive physician diagnosis of chronic bronchitis or emphysema. Smoking status, again, was self-reported, but we did biochemically verify the acotin levels. We did inflammatory markers included, as I mentioned before, white blood cells and neutrophils. And physical activity was objectively determined using accelerometry data where participants wore a waist-mounted Actograph 7164 accelerometer on their hip and they wore it for up to seven days. Only individuals with at least four days of at least 10 hours per day of monitoring data were included in the analysis to ensure habitual representation of their daily movement patterns. And we utilized established accelerometer-determined intensity-related activity count cut points to differentiate between light intensity physical activity and moderate to vigorous physical activity with the combination of these two intensity levels equaling total physical activity. We employed a multi-variable linear regression model controlling for a variety of different potential confounding variables including several demographic parameters, a chronic disease index variable indicating the number of chronic diseases that they had, ethylial dysfunction as measured by homocysteine levels, mobility function, medication use and how long they wore the accelerometer each day. Overall we found that some interesting findings specifically found an inverse association between all the intensity levels and the different inflammatory markers that we evaluated. Specifically we found that a 60-minute increase in light intensity physical activity was associated with a 6% decrease in neutrophils and a 2% decrease in white blood cells. And similarly we found that a 50% increase in moderate to vigorous physical activity was associated with a 1.6% decrease in white blood cells and a 2% decrease in neutrophils. So as I mentioned before we know smoking and COPD not only increases inflammation in the lung but systemically as well with this increased systemic inflammation, increase in the risk of cardiovascular disease and the types of chronic diseases. So this underscores the importance of in this particular population as well as other populations that would promote behaviors that can have an anti-inflammatory effect in the systemic circulatory system. The present findings suggest that among those with smoking-induced COPD physical activity may help to slow the progression of cardiovascular and other metabolic disorders by attenuating systemic inflammation. Of course we do want to interpret these findings in the context of the limitations of the study which include primarily the cross-sectional study design. So light intensity physical activity appears to be a palatable alternative to higher intensity physical activity levels among COPD patients for a variety of different reasons. One of which I already talked about in our pilot study showing that modern higher intensity levels of physical activity among COPD patients may induce air-trapping or exercise-induced hyperinflation. Also we know that higher intensity physical activity may have a pro-inflammatory response which may be counterproductive among COPD patients who already have an inflammatory response from the condition. And then also, light intensity physical activity may be a preferred intensity level compared to higher intensity levels among this specific population because the majority of COPD patients have one or more chronic diseases that may limit their ability to engage in higher intensity levels of physical activity. So these findings again as I mentioned provide some suggestive evidence that physical activity and in particular light intensity physical activity may have cardiovascular disease implications in this population of COPD patients. So far I've talked about the limitations of engaging in higher intensity physical activity among COPD patients. We provided some evidence of air-trapping in this population. Just talked about the beneficial associations of light intensity physical activity on pro-inflammatory markers among COPD patients. This next study that I'm going to talk about takes one step further and looks at the potential additive associations of physical activity and diet markers among smoking because we know that not only does physical activity have an anti-inflammatory effect when engaged habitually as opposed to acutely, we also know that dietary behavior also has an anti-inflammatory effect. So this study published by myself and Dr. Jerry Walker from Bellarmine University was published this year in 2015 in the Journal of Diabetes and Metabolic Disorders entitled Combined Association of Physical Activity and Diet with C-reactive protein among smokers. Again, we utilized that representative sample of smokers including over 800 adult smokers and again physical activity was objectively measured in this study via seven days of accelerometry data. The outcome measure of interest in this study was C-reactive protein with the two primary independent variables being physical activity behavior and dietary behavior. We ultimately dichotomized these two behaviors into meeting physical activity guidelines, so at least 150 minutes per week of accelerometer determined to vigorous physical activity compared to those less than 150 minutes per week and then with regard to the dietary behavior based on self-reported dietary data we calculated the healthy eating index and those who were in the top 40th percentile for the HEI or the healthy eating index we considered them to consume a healthy diet. So this is one of the tables from that study. We computed three different models and unadjusted, newly adjusted and a fully adjusted model. I'm going to go to that third column, the Model 3 there and focus on those findings which controlled for a variety of different confounding variables so that a negative 0.19 value that is the CRP level when compared to those who engaged in one of those dichotomized healthy behaviors versus those who did not engage in any of those two healthy behaviors. You can see it was not statistically significant but those who engaged in both healthy behaviors so were sufficiently active and need a healthy diet and after adjustment for a variety of different confounding variables they had a 0.34 lower CRP level expressed in milligrams per deciliter and you can see that was statistically significant. So even though it was somewhat of a marginal association these findings provide some evidence that concurrent engagement in both health behaviors may have a greater anti-inflammatory effect than engaging in fewer health behaviors which underscore the importance of concurrent adoption of both of these behaviors, healthy diet and physical activity. So I talked about the limitations of engaging in higher intensity physical activity among COPD patients, the beneficial effects of light intensity physical activity and attenuating these pro-inflammatory markers in the circulatory system and also just address the potential additive associations of physical activity and healthy diet on C-reactive protein in particular among smokers. This next study I want to talk about that was recently published in the Journal of Preventative Medicine addressing the potential implications for physical activity to help to facilitate smoking cessation among smokers. This study is entitled Exercise Facilitates Smoking Cessation Indirectly the Improvements in Smoking Specific Self-Efficacy, a prospective cohort study among a national sample of young smokers co-authored by my colleagues from Bellarmine University, Dr. Christy Wolfe and Dr. Jerry Walker. In this study we used a nationally representative sample of older adolescents and younger adult smokers, all smokers at baseline, over a thousand smokers were in the sample at baseline and these participants were followed over a two-year period to determine if they continued to smoke in the different follow-up assessments. So in this study we employed a Hayes Mediational Analysis Model to examine whether smoking-specific self-efficacy played any mediation role on the relationship between baseline exercise and two-year smoking status. As you can see here we found no direct association between baseline exercise and two-year follow-up smoking status. However, we did find an indirect effect in that smoking-specific self-efficacy mediated the relationship between self-reported baseline exercise and self-reported two-year smoking status. And it was somewhat of a large effect in that smoking-specific self-efficacy mediated about 84% of the total effect of exercise on smoking status. So this provides some evidence that smokers who begin exercising and start to become more active this may augment their smoking-specific self-efficacy or their confidence that they can ultimately quit smoking, which may help to facilitate smoking cessation down the road in the future. We don't know the exact mechanism that explains the relationship between baseline exercise and smoking-specific self-efficacy. We have a few studies right now that's trying to explore this relationship. One potential explanation may be the augmentational global self-efficacy associated with exercise. So exercise itself enhances exercise-specific self-efficacy or an individual's confidence that they can overcome exercise-related barriers. But there's also some work that we're exploring right now to see if exercise itself can increase overall global self-efficacy and how that in turn may increase self-efficacy in other behavioral domains such as smoking. So that's one potential explanation we're excited to explore. And then the potential explanation for the relationship between baseline exercise and smoking-specific self-efficacy is via enhancement in a variety of different cognitive related parameters, specifically executive function which we've talked about in the literature. In this study entitled development of the conceptual model for smoking cessation physical activity, neuro-cognition, and executive function published with my co-authors from Bellarmine University, Pacific University, and Oregon State University. In this paper here we present a conceptual model here and I'm just going to focus on pathway B as well as pathway C plus A. Pathway B here that we talked about in this study identifies the potential for physical activity to attenuate the neuro-cognitive decline associated with smoking. But in reference to what I was just talking about in that previous paper in this paper we talked about the potential for executive function to mediate the relationship between physical activity and smoking itself as well as psychological parameters related to smoking such as smoking-specific self-efficacy. We often define executive function as an individual's ability to engage in a goal-directed purposeful behavior or the inhibition of a goal inconsistent behavior. So based on this definition and based on the fact that we know that physical activity plays a pretty strong role in increasing executive function, in individuals with higher executive function are more likely to adopt health-enhancing behaviors. It's plausible to suggest that physical activity may play a role in facilitating smoking cessation among smokers via this augmentation of executive function. Of course, this is conceptual. At this point we do plan to explore this in detail in some of our future work to assess the utility of this particular model and facilitating smoking cessation among smokers via engagement physical activity. So just to recap on the studies that I've talked about so far with regard to smoking induced DOPD, we know that smokers who in particular have DOPD may have limitations in engaging in higher intensity physical activity via several different factors, one of which I talked about is air trapping or this perception that they can't get enough air in their lungs and they've been smothered by air. So again, as I mentioned this to us underscores the importance of promoting light intensity physical activity. We know light intensity physical activity has beneficial associations with a variety of different cardiovascular disease biomarkers among smokers. There appears to be an additive association between physical activity and healthy diet on some of these CBD biomarkers and we also have some exciting evidence to suggest that physical activity itself may not only have implications in directly influencing cardiovascular disease via these cardiovascular biomarkers but perhaps indirectly via the facilitation of smoking cessation itself. So the next half of my presentation is going to focus on other populations, not specifically those with smoked induced DOPD. I'm going to first continue this discussion of the beneficial associations of light intensity physical activity on CBD biomarkers but among the broader older adult population. So this paper that we recently published this year in 2015 in the American Journal of Health Promotion is entitled evidence to support including lifestyle light intensity recommendations into physical activity guidelines for older adults. And this represented a sample of older adult Americans at least 65 years of age, again utilizing data from the National Health and Nutrition Examination Survey. Again, they were an accelerometer for at least four out of seven days for at least 10 hours per day. And we looked at the associations of both light intensity physical activity as well as monitor vigorous physical activity with a lot of these same biomarkers, cardiovascular disease biomarkers that I've already talked about so far. So we separated moderate and light intensity physical activity and then also looked at them independent of each other. I'm going to first talk about the results from monitor vigorous physical activity. Similar to the previous study that I talked about, we dichotomized participants into leading guidelines versus not leading guidelines, so 150 minutes a week versus less than 150 minutes a week of accelerometer determined monitor vigorous physical activity utilizing the established MVPA cut point of 2-0, 2-0 accounts per minute. All the bolded values here indicate a significant association between the dichotomy of MVPA and the outcome variable shown right here. So as you can see here, those who met physical activity guidelines had lower body mass index, had lower waist circumference, lower tricep skin fold, sub-scapular skin fold, and lower white blood cells, lower neutrophils, so on and so forth. Lower levels of insulin, insulin resistance measured from the homo technique and then lower levels of glycosylated hemoglobin A1C down here. So these are findings that you would expect higher engagement in MVPA or leading guidelines associated with better outcomes specifically CVD biomarkers. More interestingly, however, we also found a lot of beneficial associations with light intensity physical activity. So we dichotomized individuals into engaging in over 300 minutes a week of light intensity physical activity versus less than 300 minutes a week of light intensity physical activity and we utilized the accelerometer cut point of 750 counts per minute to differentiate sensory behavior from this lifestyle light intensity physical activity. Similar to moderate to vigorous physical activity, we saw a lot of beneficial associations of light intensity physical activity with these cardiovascular disease biomarkers and this held true even after statistically controlling for moderate to vigorous physical activity. Both of them are these findings similar to the findings that I talked about in the smoking induced COPD population. These findings among older adults at least 65 years of age underscore the importance of engaging in light intensity physical activity which is of paramount interest because this older adult population may have a disinclination to want to engage in moderate to vigorous physical activity because of a variety of reasons. Some of the reasons that I talked about before with the COPD population or the perceived worry of getting injured these are very exciting findings. The next study that I'm going to talk about looks at daily movement patterns and their association with cardiovascular disease biomarkers. This paper published with Dr. Hill Lee and Bradley Cardinal is entitled daily movement patterns in biological markers among adults in the United States published last year 2014 in the journal prevented medicine. We also utilized accelerometer data to objectively measure these unique daily movement patterns. We ultimately classified individuals into four unique or distinct groups that can range across this continuum of the most active group here to the least active group there. So let's start with the most active group. We defined individuals as engaging in 150 minutes a week of non-to vigorous physical activity and then we also looked at the balance of their light intensity to sedentary behavior ratio. So about 18% of Americans middle aged and older adults engage in 150 minutes a week of non-to vigorous physical activity so they engage in that structure of exercise but importantly they engaged in more light intensity physical activity than they did sedentary behavior. So they were structured exercises but you could also consider them engaging in an active lifestyle approach so they essentially walked more than they spent time shitting during the day. The next group not as a favorable group with regard to daily movement patterns are those who engage in that structure of exercise for example so they engaged in 150 minutes a week of MVPA but they had a negative light intensity to sedentary behavior ratio so you can view them as structured exercises but then they sat more during the day than they spent sort of walking out of light intensity. The third group even less of a favorable group which only consisted of 9% of Americans middle aged and older adults these were people who did not engage in a sufficient dose of MVPA so less than 150 minutes a week but they had a positive light intensity physical activity to sedentary behavior balance so they walked around in a light intensity more so than they sat during the day but again didn't reach that threshold for structured exercise. And then the last group which comprised the majority of Americans almost 50% of Americans were those who were not sufficiently active with regard to participation in MVPA and also had a negative light intensity to sedentary behavior balance or stated another way they sat more during the day for example than they spent walking during the day. Not a light intensity physical activity. So these are the four unique distinct groups that we identified. You can see most of Americans fit into this less than favorable group and then we looked at the association between these different groups with regard to the same cardiovascular disease biomarkers that I've talked about previously. The reference group here is the least active group and as you can see here and as expected the most favorable group those who engaged in that structured exercise and employed an active lifestyle approach they had more favorable levels of almost all of the biomarkers. There's also favorable associations in the other group who engaged in structured exercise but then sat more during the day than they spent walking at a light intensity. And very few associations emerged with this group of those who did not engage in structured exercise at a sufficient dose but had a positive light intensity physical activity to sedentary behavior balance. Notably however there were a few biomarkers that were more favorable in this group compared to the reference group. Which provides some suggestive evidence that even if you don't engage in a sufficient dose of MVPA engaging an active lifestyle approach may have important implications on cardiovascular disease. So again an active lifestyle approach walking a little bit more standing walking more so than you spent sitting throughout the day. So I talked about in this last half of the presentation among the broader adult population the beneficial associations of light intensity physical activity just talked about the importance of considering MVPA light intensity physical activity and sedentary behavior or the ratio or the balance of these different intensity levels on cardiovascular disease. And the next thing that I want to talk about also addresses an important behavioral pattern. Looking at the difference between shorter bouts of physical activity versus longer bouts of physical activity and implications it has on health outcomes. So this study recently published this year a few months ago in Mayo Clinic Proceedings entitled Accumulated Short Bouts of Physical Activity are associated with reduced premature all-cause mortality implications for physician promotion of physical activity and revision of current U.S. government physical activity guidelines. So again utilizing a representative sample of Americans from M. Haynes from the 2003 to 2006 cycle with these participants followed through 2011 to assess mortality status. We looked at the independent associations of doubted, large vigorous physical activity and non-doubted large vigorous physical activity as shown here in this table. We looked at these parameters in a Cox proportional hazard model and you can see here both non-doubted and doubted MVPA were significantly associated with reduced risk of all-cause mortality. So a 10 minute a day increase in non-doubted physical activity was associated with a 27% reduced risk of all-cause mortality. A 10 minute a day increase in reduced risk of MVPA, reduced risk of all-cause mortality, excuse me. We defined doubted MVPA as physical activity, specifically moderate to vigorous physical activity that lasted at least 10 minutes in duration. Non-doubted MVPA we defined as moderate to vigorous physical activity that did not last at least 10 minutes in duration. So a 5 minute quick bout of MVPA walked into the car for example really quickly so any MVPA that did not last at least 10 minutes in duration. So these findings underscore the importance of engaging in sort of that structured exercise that doubted MVPA but also underscore the importance of that active lifestyle approach so you can still have beneficial effects if you engage in non-doubted MVPA according to these findings. Now the next today I want to talk about specifically focuses on adults who are at a high risk for developing a cardiovascular disease event in the next 10 years. In this sample here we again using a representative sample from NHANES we utilized the recently developed pooled cohort equations from the American College of Cardiology and the American Heart Association. We delimited our analysis to individuals who did not have any experience or any exposure or diagnosis of any cardiovascular related disease or cerebral vascular related disease. So these were individuals at baseline who never had a cardiovascular disease related outcome. And then we further delimited the sample to those who had a high risk for developing a cardiovascular disease event within the next 10 years so we utilized the ASCVD cut point of 7.5% again those who had a from the pooled cohort equation algorithm, those who had a 7.5% score were included in the sample. So these were again all individuals who were free of cardiovascular disease but were at risk for developing a cardiovascular disease event within the next 10 years. And we looked at the association between physical activity and mortality among this at risk or high risk population. Table one here essentially just looks at the study characteristics among those who are alive at follow up versus those who are deceased at follow up. 309 individuals were alive at follow up and then over the 8 year follow up period 68 high risk individuals died. Those alive at follow up you could see at baseline they engaged in more monitor vigorous physical activity and also had a lower ASCVD score. Now in our weighted tox proportional hazard model as you can see here for every 10 minute a day increase in monitor vigorous physical activity among these at risk or high risk individuals they had a 42% reduced risk of all cause mortality. Underscoring the importance of engaging in physical activity not only among the broader middle age and older adult population but especially among the middle age and older adult population who is at high risk for developing cardiovascular disease within the next 10 years. So so far I've talked about a lot of our studies that among COPD patients as well as among the middle age and older broader adult population that looks at the beneficial associations of physical activity on health outcomes specifically light intensity physical activity on CVD biomarkers as well as all cause mortality being another outcome of interest in some of our work. I'm going to finish up here with a study that looks at the determinants of physical activity behavior in chronically diseased individuals to give us a sense of particular ways in which we can help to promote physical activity among these vulnerable populations because we know physical activity itself can have a beneficial effect so identification of factors that influence physical activity is a great public health interest. This paper recently published in support of care and cancer. It is entitled theory based predictors of follow up exercise behavior after a supervised exercise intervention in older breast cancer survivors. So these were all breast cancer survivors but they did have a variety of other types of comorbidities. This sample included 69 breast cancer survivors. They went through a 12 month randomized control trial and we looked at the efficacy of different modalities of exercise on different outcomes. But this specific study here that I'll be talking about focused on them right at that end period of the intervention. So after the 12 month intervention we had them complete a questionnaire that assessed a variety of different behavioral and psychological constructs vetted within the trans theoretical model and then we were interested in seeing if individuals who were more of these processes of change, which I'll talk about in a second, would be more likely to maintain physical activity as they transition from a supervised exercise environment or intervention to a home based sort of environment. So as I alluded to, we utilized the major tenets of the trans theoretical model so we evaluated their exercise specific self efficacy and other confidence that they could engage in exercise in the presence of other exercise related barriers we assessed decisional balance or the weighting of pros and cons for physical activity. We looked at processes of change, which included behavioral based processes of change and cognitive based processes of change. As you can see here from this model these breast cancer survivors at base of transition from the supervised intervention to the home based intervention, those who had higher levels of self efficacy were 10% more likely to be sufficiently active six months later on their own exercise and on their own. Similarly, breast cancer survivors at that point of transition from the supervised to sort of engaging in exercise on their own, those who utilized more of these behavioral processes of change were more likely to be sufficiently active six months later. So collectively, these findings underscore the importance of among these chronically disease individuals when they are preparing to engage in exercise on their own that we teach them these behavioral process of change, which I'll talk about in the subsequent slide that can help to facilitate future physical activity behavior as well as maintain this behavior over time. And I'm not going to talk about it today, but we also have some other work demonstrating that the utilization of these behavioral processes of change play an important role in influencing self efficacy, which as we showed as I showed here plays an important role in long-term physical activity behavior. So with regard to these behavioral processes of change, there's five main behavioral processes of change which include self liberation, helping relationships, counter conditioning, reinforcement management, and stimulus control. Now these are all the skills or the strategies that we want to teach these individuals to increase their likelihood of initiating and maintaining physical activity. With regard to self liberation or making a commitment, this can often be done via a contingency-based contract that they can use to help to facilitate their physical activity behavior. With regard to helping relationships, we find that it's very critical that these chronically disease individuals who are in need of physical activity enlist social support. Social support, as we all know, demonstrated to be a strong predictor of physical activity across a variety of different populations. So this can be done via several different approaches, but the common four-step approach would be having the individual identify the problem, which in this case might be physical and activity, identify another reference individual who can provide that support, have the courage to ask them for support, and then lastly, reward that supportive individual so they'll continue to facilitate social support or exercise-related support. Counter-conditioning is another behavioral-based strategy that we recommend to facilitate physical activity or using substitutes or substituting less than desirable behavior with a more desirable behavior. So we're all familiar in the smoking literature, using some type of chewing gum. So substituting less than desirable behavior with smoking with a more desirable behavior. In the exercise domain, it could be, for example, instead of after dinner watching TV, I'll take a quick brisk walk before engaging in sort of leisure activities that might be more sedentary based in the evening. Another behavioral-prositive change is reinforcement management or utilizing rewards. So after these, we find individuals who utilize rewards after they accomplish some of the short-term goals are more likely to adhere to the physical activity program compared to those who don't. A sensible recommendation would be to utilize rewards that facilitate the behavior in the future. So, for example, allowing yourself to, after you accomplish a short-term goal, buy yourself a pair of walking shoes or sign up for a trail race or something like that. And then the last behavioral-prositive change that appears to be associated with physical activity stimulus control are managing your environment, utilizing cues or prompts to facilitate physical activity behavior. So, for example, scheduling physical activity into your calendar. So back to the outline here. So just to recap, I talked about the limitations of higher-intensity physical activity among chronic disease individuals could be a result of a variety of different factors, one of which we talked about today was exercise-induced air trapping. So this underscores the importance of engaging in light-intensity physical activity. We talked about the beneficial effects that light-intensity physical activity has, the potential additive effects of light-intensity physical activity and diet on these cardiovascular disease biomarkers. The exciting merging work suggesting that physical activity itself may help to facilitate smoking cessation. The underlying mechanism to this needs to be explored and we're looking forward to some of our future work on this topic. And then we talked about the unique contributions of molecular physical activity, light-intensity physical activity and sedentary behavior and their associations with cardiovascular disease biomarkers. And then lastly, I just talked about ways in which we can promote physical activity among chronically disease individuals which include the utilization, in particular, of behavioral-based strategies. So my last slide is here to conclude. As I sort of just mentioned, now last slide is that older adults with chronic disease may be intolerant to higher intensity physical activity levels. I'm just going to importance of light-intensity physical activity based on what I've talked about today. There's some suggestive evidence from our studies as well as other excellent research out there demonstrating that light-intensity physical activity may not only help to improve cardiovascular disease risk factors, as well as prolonged survival. It may even help to facilitate the adoption of other health behaviors. And then lastly, given the beneficial effects of physical activity on health, it's important that we identify evidence-based strategies to promote physical activity in one particular way, maybe the utilization of these behavioral processes of change. So thank you for your attention. Again, it's a pleasure to give this talk and share some of our recent work. I'm happy to answer any questions that you may have. And again, as I mentioned at the beginning of this presentation, I'm happy to correspond via email if you have questions that you'd like to address in that form. Thank you. Great. Thank you very much, Paul. Fantastic, fantastic presentation. Very informative and enjoyable. I've got a couple of questions, but before I ask, one of my colleagues from the University of Waterloo, Laura Gengorio, has a couple of questions. What do you think are the key knowledge gaps related to exercise in older adults? Key knowledge gaps specifically in the older adult population. We have some fun. I think most people think that it's common knowledge that physical activity itself can have beneficial effects, and I would agree to that to a certain extent. We have some other work that I didn't present today demonstrating that across a variety of different age populations, individuals aren't as knowledgeable actually as far as the health enhancing effects of physical activity. So I think one particular knowledge gap is increasing their awareness of the beneficial effects of physical activity itself. Not only at the higher intensity levels, monitor vigorous physical activity, but I think another knowledge gap, especially in the older adult population, is their knowledge and awareness of not only the beneficial effects of exercise, but of this light intensity physical activity, which appears to be emerging in the literature as a beneficial intensity level. Great. And Laura has a follow-up. How does resistance training fit into all of this? That's a great question. Thank you, Laura. Most of my work and interest focuses on ambulatory based movement. We do actually have some work right now in review demonstrating that on the middle age and older adult populations, which I think is common with a lot of other literature showing beneficial effects, obviously, of muscle strengthening activities, essentially just the contraction of the muscle itself can help to regulate glycemic levels, which can have implications on diabetes and other chronic diseases, which ultimately influences survival. We have some other work that I find to be very interesting. It's in review right now that looks at the additive effects of aerobic-based physical activity and resistance training or muscular strengthening activities on a variety of different outcomes. So we've looked at multimorbidity as an outcome. And similar to what I mentioned today with regard to the additive associations of physical activity and dietary behavior, we find additive associations of physical activity and resistance training on several different outcomes. And so I think both are important, but especially among older adults, perhaps who may have limitations with amateur-based movement, I think a sensible strategy most certainly would be engagement in resistance training initially. Great. And she's asking for clarification. Oh, sorry. Go ahead. She's asking for clarification. What are the gaps that we need to fill with future research? So the next best, I guess the next important research question might be what? Yeah. I think, you know, there's been, we have a paper I didn't talk about today that look at the dose response effects of monitor vigorous physical activity on CVD biomarkers and all-cause mortality that was published in preventative medicine. So I think a lot of work is starting to look at sort of the optimal dose of NVPA on these different health outcomes. I think what we need to start to look at, especially based on this emerging work that light intensity physical activity can have beneficial effects would be to look at sort of the optimal dose of light intensity physical activity on a variety of different health outcomes among the older adult population. Great. Thanks. A question from me. Some of your slides you were talking about behavior and it brought back a systematic review I had done for the Agency for Healthcare Research and Quality about health risk appraisals in the elderly. And I'm wondering what your, if you've done any work or what your feelings might be on the effect of health risk appraisals to modify risk factor behavior. Yeah. I'm not as well versed in that area. But I do think that can be very important identifying the individual level risks that these participants may have and then helping them overcome some of the barriers that they may have so they can engage in safe forms of physical activity. I think that's of critical importance. Right. And also you were talking about the importance of social participation. And one form of social participation is religious activity. Have you looked at any of that in your work, the impact of religious participation for example on whether it encourages physical activity or anything like that? I haven't specifically but it's a very fascinating area that filled the religiosity and physical activities. I find that quite fascinating. But we haven't specifically looked at that. We've had some discussions about possibly looking at that with some of our, with one of my PhD students in the future. But nothing at this point yet. The whole dynamic of sort of group physical activity I find to be quite fascinating. I think obviously it can help to facilitate physical activity. But we also want to be mindful that sometimes it can be counterproductive via for example the social loathing phenomenon. But it's something of interest but we haven't explored yet. Great. So are there any other questions? So Laura is saying thank you for answering her queries. Are there any other questions from anyone from the audience? So we'll give people maybe a few seconds to type. Okay. Well, we've got another thank you. You're welcome. So I think we're not going to get any more questions. So Paul once again I thought it was a really great presentation. Very informative. And thank you so much for taking the time to present to us today. My pleasure. Thanks for the opportunity. Great. Thank you. And so for those of you in attendance we thank you very much for joining us for this final webinar of 2015. And our first webinar in 2016 will be held on January 21st from 12 to one eastern time. Diana Koo from the United Kingdom is going to present a talk called aging is a lifelong and socially patterned process. Insights from a life course approach using a maturing British birth cohort study. And of course, Professor Koo is one of the seminal authors in the area of life course epidemiology. So promises to be another great presentation. And the bar has been set very high by Paul's presentation. So thank you very much again, Paul, for presenting today. And I wish everyone a wonderful afternoon and happy holidays.