Body image perception, smoking, alcohol use, indoor tanning, and disordered eating in young and middle-aged adults: findings from a large population-based Swedish study.

BACKGROUND: Body image concerns may give rise to a multitude of risk behaviors, such as unhealthy weight control practices, disordered eating behaviors (e.g., compensatory purging or preoccupation with food), smoking, excessive alcohol intake, or sunbed use. However, the distribution of these risk behaviors across adulthood has rarely been studied. METHODS: The aim of this study was to explore health risk behaviors as correlates of body image perception in a randomly selected study population of 30,245 individuals aged 30-66 in Stockholm, Sweden, utilizing data from the Stockholm Public Health Cohort. Bivariate correlations were explored and a hierarchic binary logistic regression analysis was performed. RESULTS: The prevalence of body image discrepancy was higher among smokers and respondents displaying disordered eating behaviors. In contrast, alcohol and sunbed use were inversely correlated to body image discrepancy. Body mass index was the substantially strongest explanatory factor behind the observed variance in body image discrepancy, followed by loss-of-control eating. Notably, no major gender differences in body image perception were detected. Some unexpected patterns of association between variables other than body image perception, such as those between smoking, alcohol use, and sunbed use, were seen. CONCLUSIONS: Overall, the patterns differ substantially from what has previously been found in adolescent and young adult samples, indicating that the synergy and aggregation of risk behaviors observed among younger individuals may not apply to adults aged 30-66.

Pupils' use of school outdoor play settings across seasons and its relation to sun exposure and physical activity.

BACKGROUND: Long outdoor stay may cause hazardous exposure to ultraviolet radiation (UVR) from the sun even at high latitudes as in Sweden (Spring to Autumn). On the other hand, long outdoor stay is a strong predictor of primary school children´s free mobility involving moderate to vigorous physical activity (MVPA). UV-protective outdoor environments enable long outdoor stay. We investigated the concurrent impact of different school outdoor play settings upon pupils´ sun exposure and levels of physical activity across different ages, genders, and seasons. METHOD: During 1 week each in September, March, and May, UVR exposure and MVPA were measured in pupils aged 7-11 years. Erythemally effective UVR exposure was measured by polysulphone film dosimeters and MVPA by accelerometers. Schoolyard play was recorded on maps, and used areas defined as four play settings (fixed play equipment, paved surfaces, sport fields, and green settings), categorized by season and gender. RESULTS: During the academic year, sport fields yielded the highest UVR exposures and generated most time in MVPA. In March, time outdoors and minutes in MVPA dropped and UVR exposures were suberythemal at all play settings. In May, green settings and fixed play equipment close to greenery promoted MVPA and protected from solar overexposure during long outdoor stays. CONCLUSION: More outdoor activities in early spring are recommended. In May, greenery attractive for play could protect against overexposure to UVR and stimulate both girls and boys to vigorous play.

Solar Ultraviolet Radiation Exposure Proxy-estimated by Sky View Fish-eye Photography-Potentials and Limitations from an Exploratory Correlation Study.

Potentials and limitations of sky view fish-eye photography and calculation of the percentage of free sky (sky view factor, SVF) as a proxy to estimate solar ultraviolet radiation (UVR) exposure in shade settings are investigated using controlled situations. SVF and measured solar UVR exposure correlated at high mid-latitude (56.65°N) near autumnal equinox in September. The correlation was enhanced by splitting the sky view images into a south- and a north-half and weighting the south-half higher to account for the direct sun. Sky view images from eight different settings with SVF-values 98.3% - 14.9% were compared to exposure measurements by polysulphone film dosimeter badges in the horizontal zenith-, vertical-south-, east-, west- and north-directions and their combinations. The sky view images were un-split and un-weighted or split and the semi-skies given south/north weights (3.0/1.0) or a higher weight ratio (3.5/0.5). Of all tested combinations split sky view SVFs weighted 3.0/1.0 and compared to horizontal (zenith-oriented) dosimeters yielded the highest correlation (R2  = 0.96). The weight ratio (3.5/0.5) yielded the 2nd highest correlation (R2  = 0.90) both compared to measured horizontal exposure and compared to the horizontal exposure averaged with the vertical-south-oriented exposure. SVF from sky view fish-eye photography may estimate solar UVR exposure in shade settings.

Levels of physical activity during physical education lessons in Sweden.

AIM: The aim of this study was to measure the percentage of sedentary light and moderate-to-vigorous physical activity (%MVPA) provided by physical education (PE) lessons for Swedish second, fifth and eighth grade students, aged eight, 11 and 14. METHODS: We observed 39 PE lessons and divided them into seven lesson categories: ball play, ball games, dance, fitness, playing games, orienteering and gymnastics. Physical activity (PA) during PE was estimated using accelerometers and the height and weight of the children were measured. RESULTS: We studied 149 children: 63 in the second grade, 66 in the fifth grade and 19 in the eighth grade. On average, 25% of the PE lessons were spent in MVPA and the mean %MVPA varied with the lesson content, with fitness, orienteering and playing games being the most intense. The highest %MVPA was in the fitness category, providing 33% (8-62%) for girls and 37% (7-72%) for boys. With the exception of the second grade, no significant gender differences in %MVPA were seen. CONCLUSION: The content of Swedish PE lessons affected the %MVPA in all age groups. In some content, individuals reached two-thirds of their daily PA recommendations, highlighting the potential that PE contributes to public health goals.

Accelerometer-measured physical activity among adolescents in a multicultural area characterized by low socioeconomic status.

PURPOSE: The aim of this cross-sectional study was to describe and analyze accelerometer-measured sedentary time and physical activity (PA) among adolescents in a multicultural area characterized by low socioeconomic status (SES). METHOD: Seventh-graders (n=114 (girls n=66), mean age: 12.8±0.5 y) were recruited from three schools in a multicultural area of the city of Gothenburg, Sweden. Sedentary time and PA were measured with ActiGraph™ accelerometers. RESULT: Of total wear-time, 70 (±6)% was sedentary, with girls being more sedentary than boys. Girls had less light PA (LPA) and moderate-to-vigorous PA (MVPA) than boys. Similar patterns were shown during in-school and out-of-school hours. During wear-time, 53% had a mean of ≥60 min of MVPA per day, but only 6% of the girls and 24% of the boys were sufficiently physically active every day. Girls had more sedentary bouts of ≥10 min and fewer MVPA bouts of ≥5 min per day than boys. Those who participated in organized sports spent a mean of 15 more minutes of MVPA per day compared to those who did not. No association was observed between body mass index (BMI) and sedentary time and PA. CONCLUSION: Only a few adolescents from a Swedish multicultural area characterized by low SES met the PA recommendations every day, and girls were more sedentary and less physically active than boys. Adolescents involved in organized sports had more of MVPA per day than their non-involved peers. Sedentary time and PA were not related to BMI.

Compulsory School In- and Outdoors-Implications for School Children's Physical Activity and Health during One Academic Year.

Regulated school days entail less free-living physical activity (PA) and outdoor stay, which may jeopardize the opportunities for cohesive moderate-to-vigorous physical activity (MVPA) and, by extension, children's health. The role of outdoor stay during school time for pupils' free-living PA vs. physical education (PE) and indoor stay was studied during one academic year in 196 pupils aged 7-14 years at four schools in mid-southern Sweden during five consecutive days each in September, March, and May. Actigraph GT3X+ Activity monitors were used. Predictors for PA during school stay were expressed as mean daily accelerometer counts and were measured per season, day, grade, gender, weather, and time outdoors. Overall, free-living PA outdoors generated the highest mean accelerometer counts for moderate and vigorous PA. Outdoor PA and PE, representing 23.7% of the total school time contributed to 50.4% of total mean accelerometer counts, and were the greatest contributors to moderate and vigorous PA. Age and weather impacted PA, with less PA in inclement weather and among older pupils. More time outdoors, at all seasons, would favorably increase school children's chances of reaching recommended levels of PA.

Suberythemal Sun Exposures at Swedish Schools Depend on Sky Views of the Outdoor Environments - Possible Implications for Pupils' Health.

More scheduled outdoor stay is increasingly advocated for school children. This study measured 2(nd) , 5(th) and 8(th) graders' erythemal UV-exposure in September, March and May at four Swedish schools. We related those exposures, as fractions of total available ambient radiation, to the schools outdoor environments differing in amount of shade, vegetation, and peripheral city-scape quantified as percentage of free sky view calculated from fish-eye photographs. Exposures correlated with the sky views (with exceptions in May) and were suberythemal. The exposures were also below the threshold limit of the International Commission on Non-Ionizing Radiation Protection (ICNIRP) for hazard evaluation of UVR but were potentially enough for adequate vitamin D formation according to a cited model calculation - as illustrated in the results and discussed. The school environments, typical in southern and middle Sweden, offer enough shade to protect children from overexposure during seasons with potentially harmful solar UV radiation. Pupils' outdoor stay may be extended during September and March. In May extended outdoor stay of the youngest pupils requires a more UVR-protective environment.

Physical activity decreased by a quarter in the 11- to 12-year-old Swedish boys between 2000 and 2013 but was stable in girls: a smartphone effect?

AIM: This study explored physical activity, body mass index (BMI) and overweight and obesity from 2000 to 2013 using a convenience sample of second- and fifth-grade Swedish schoolchildren aged 8-9 years and 11-12 years, respectively. METHODS: We examined cross-sectional cohorts of 126 second-grade children in 2000, 84 in 2006 and 44 in 2013 and 105 fifth-grade children in 2000 and 38 in 2013. No fifth graders were available in 2006. Physical activity data were collected based on pedometer readings over four consecutive weekdays, and height and weight were measured. Identical instruments and procedures were used in all three years. RESULTS: There was an increase in physical activity in second-grade girls from 2000 to 2006 (p < 0.01), which then stabilised between 2006 and 2013, but second-grade boys and fifth-grade girls were stable throughout the study period. Fifth-grade boys decreased significantly (24%) from 16 670 to 12 704 steps per day (p < 0.01) from 2000 to 2013. Mean BMI scores remained stable over time. CONCLUSION: Time trends in physical activity differed between boys and girls. Second-grade boys and fifth-grade girls were stable throughout, whereas second-grade girls increased from 2000 to 2006 before stabilising. Fifth-grade boys showed a significant 24% reduction from 2000 to 2013. Changes in recess and leisure time habits, such as smartphone use, may have influenced the result.

Upgrading Preschool Environment in a Swedish Municipality: Evaluation of an Implementation Process.

Redesigning outdoor preschool environment may favorably affect multiple factors relevant to health and reach many children. Cross-sectional studies in various landscapes at different latitudes have explored the characteristics of preschool outdoor environment considering the play potential triggering combined physical activity and sun-protective behavior due to space, vegetation, and topography. Criteria were pinpointed to upgrade preschool outdoor environment for multiple health outcomes to be applied in local government in charge of public preschools. Purposeful land use policies and administrative management of outdoor land use may serve to monitor the quality of preschool outdoor environments (upgrading and planning). This study evaluates the process of implementing routines for upgrading outdoor preschool environments in a medium-sized municipality, Sweden, 2008-2011, using qualitative and quantitative analysis. Recorded written material (logs and protocols) related to the project was processed using thematic analysis. Quantitative data (m(2) flat/multileveled, overgrown/naked surface, and fraction of free visible sky) were analyzed to assess the impact of implementation (surface, topography, greenery integrated in play). The preschool outdoor environments were upgraded accordingly. The quality of implementation was assessed using the theory of policy streams approach. Though long-term impact remains to be confirmed the process seems to have changed work routines in the interior management for purposeful upgrading of preschool outdoor environments. The aptitude and applicability of inexpensive methods for assessing, selecting, and upgrading preschool land at various latitudes, climates, and outdoor play policies (including gender aspects and staff policies) should be further discussed, as well as the compilation of data for monitoring and evaluation.

A repeated measurement study investigating the impact of school outdoor environment upon physical activity across ages and seasons in Swedish second, fifth and eighth graders.

BACKGROUND: School children are confined to and exposed to outdoor environment that happens to be at their disposal during compulsory school time. The health-promoting potential of outdoor environment, and the use of it, is therefore important. We have studied the impact of school outdoor environment in terms of playground features, space, topography and vegetation upon the patterns of moderate to vigorous physical activity (MVPA) across ages and seasons in Swedish pupils at compulsory school. METHODS: Four schools in the Middle and Southern parts of Sweden, with outdoor environments differing in playground features, space, topography and vegetation were analyzed during one school year. A sample of 196 children was drawn from eligible pupils in grades 2, 5 and 8, aged 7-14 years. PA was monitored with time-stamped Actigraph accelerometers GT3X+, measuring different intensity levels during outdoor time. Maps were used to mark places where the children stayed and what they did during outdoor time. RESULTS: Mean MVPA during outdoor stay was 39 minutes for the entire school year, time in MVPA correlated positively with outdoor time, as did MVPA with used outdoor play area (p < 0.001). Outdoor MVPA declined with age, boys accumulated more MVPA than girls at all ages (p < 0.001). Ball play areas increased MVPA in 5th graders in September and May (p < 0.001). Overall, ball play areas increased 5th graders' relative MVPA, and helped maintaining it with increasing age in boys but not in girls, whereas woodland stimulated and contributed to maintaining girls' MVPA with increasing age. Outdoor temperature significantly impacted (p < 0.01) MVPA throughout all seasons. CONCLUSION: We conclude that school outdoor environment design and outdoor play time impact physical activity on a daily basis and may contribute to increasing girls' physical activity and moderate the sharp decline in physical activity by age. The school outdoor environment may thus be a potential health promoter during school time.

Translation of children's cycling into steps: the share of cycling in 10-year-olds' physical activity.

BACKGROUND: Active travel has a potential to increase children's physical activity (PA). Pedometers offer a valid option to measure PA, but do not capture cycling activity. Children's self-reported cycling distances can be analyzed by the Geografic Information System (GIS). AIM: To combine pedometry and GIS mapping to identify the relative amount of cycling in children's PA. STUDY GROUP: Of all children in 4th grade (n=187) in Staffanstorp Sweden, 144 had valid pedometer data. Fifty-six children were non-cyclists while 88 children (32 boys, 47 girls, 9 gender unknown) reported at least one cycle journey. METHODS: Cycle trips were entered into GIS and calculated to total cycling distance. Average length of the single distances cycled per day was 676 m (SD=534 m). A previously reported cycling speed (13.5 km/h) was used to calculate time spent cycling. Consequently distance=676 m, speed=13.5 km/h=13,500 m/3600 s=3.75 m/s and time=676m/3.75m/s=180.26 s=3 min. Expenditure of 4 and 5 metabolic equivalents (METs) has in children been reported equivalent to 122 and 127 steps/min, respectively. We estimated 4.7 METs (13.5 km/h) as 126 steps for every min of cycling (127-122=5×0.7=125.5). RESULTS: The daily mean cycle distance was 676 m, on average 379 additional steps/day for cycling children (min. 21, max. 1385, SD=299) with no gender difference. Additional "steps" obtained by cycling corresponded to on average 3% of their PA. CONCLUSION: The relative contribution of cycling in 10-year-old children's PA level is quite small and stable between children across different levels of activity levels, regardless of gender.

Accelerometer measured level of physical activity indoors and outdoors during preschool time in Sweden and the United States.

BACKGROUND: It is important to understand the correlates of physical activity (PA) to influence policy and create environments that promote PA among preschool children. We compared preschoolers' PA in Swedish and in US settings and objectively examined differences boys' and girls' indoor and outdoor PA regarding different intensity levels and sedentary behavior. METHODS: Accelerometer determined PA in 50 children with mean age 52 months, (range 40-67) was recorded during preschool time for 5 consecutive weekdays at 4 sites. The children wore an Actigraph GTIM Monitor. RESULTS: Raleigh preschool children, opposite to Malmö preschoolers spent significantly more time indoors than outdoors (P<.001). Significantly more moderate-to-vigorous intensity physical activity (MVPA) was observed outdoors (P<.001) in both settings. Malmö children accumulated significantly more counts/min indoors (P<.001). The percent of MVPA during outdoor time did not differ between children at Raleigh and Malmö. CONCLUSION: Physical activity counts/minutes was significantly higher outdoors vs. indoors in both Malmö and Raleigh. Malmö preschoolers spent 47% of attendance time outdoors compared with 18% for Raleigh preschoolers which could have influenced the difference in preschool activity between the 2 countries. Time spent in MVPA at preschool was very limited and predominantly adopted outdoors.

Comparison of pedometer and accelerometer measures of physical activity during preschool time on 3- to 5-year-old children.

AIMS: To compare pedometer steps with accelerometer counts and to analyse minutes of engagement in light, moderate and vigorous physical activity in 3- to 5-year-old children during preschool time. METHODS: Physical activity was recorded during preschool time for five consecutive days in 55 three- to five-year-old children. The children wore a Yamax SW200 pedometer and an Actigraph GTIM Monitor. RESULTS: The average time spent at preschool was 7.22 h/day with an average step of 7313 (±3042). Steps during preschool time increased with increasing age. The overall correlation between mean step counts and mean accelerometer counts (r = 0.67, p < 0.001), as well as time in light to vigorous activity (r = 0.76, p < 0.001), were moderately high. Step counts and moderate to vigorous physical activity minutes were poorly correlated in 3 years old (r = 0.19, p < 0.191) and moderately correlated (r = 0.50, p < 0.001) for children 4 to 5 years old. CONCLUSION: Correlation between the preschool children's pedometer-determined step counts and total engagement in physical activity during preschool time was moderately high. Children's step counts at preschool were low, and the time spent in moderate and vigorous physical activity at preschool was very short.

Objectively measured physical activity level during a physical education class: a pilot study with Swedish youth.

UNLABELLED: The aim of this study is to advance our knowledge of the contribution of a typical physical education (PE) class to children's daily physical activity. METHODS: The pilot project is a part of a survey study comprising 11 fourth grader classes (250 pupils). One class of 19 pupils (9 girls) participated in the pilot study. Daily step counts were measured by Yamax pedometers during four consecutive weekdays. During PE class, the participants wore a second pedometer and an Actigraph GT1M accelerometer. RESULTS: The total average step count during PE class was 2512, average 74 steps/min. The counts for the whole day were 16668, and 19 steps/min respectively. The total share of moderate-vigorous physical activity (MVPA) of the PE class was 50.4% (52.5% and 48.3% for boys and girls respectively). There was an inverse correlation between daily mean step count and contribution of PE class step to daily mean step (r = -0.64, p = .003). CONCLUSION: The contribution of PE class to MVPA was in high in both boys and girls. Considering the suggested independent role of physical fitness for cardiovascular health in children, the PE class must be seen as an important health factor, especially for otherwise inactive children.

Trends during a half century in relative squamous cell carcinoma distribution by body site in the Swedish population: support for accumulated sun exposure as the main risk factor.

There is a strong relationship between squamous cell carcinoma (SCC) and exposure to ultraviolet radiation in terms of accumulated exposure. In this study, data from the Swedish Cancer Registry are surveyed to discern a reflection of behavioral and societal changes in relative distribution of SCC by body site. Data for the time period 1960-2004, including a total of 66 221 cases (56 669 people) were analyzed by body site for age and gender cohorts. The age-standardized (European population) incidence per 100 000 of SCC in the year 2004 was 30.4 in males and 15.4 in females. In the year 1960, the corresponding incidences were 7.7 and 3.8; that is, SCC has become four times more frequent in Sweden for both sexes during this period. The standardized incidence of SCC increased on all body sites except eyelids (men and women) and ears (women). Head tumors dominated among patients aged 70 years or more and diagnosed 1960-1964. Among patients less than 70 years old at diagnosis in 2000-2004, tumors of the trunk and limbs dominated. A relative increase of tumors of the scalp and neck was observed in all age groups (men), and of tumors of the trunk and upper limbs in all age groups and both sexes except among patients aged more than 90 years of age. In contrast, a relative decrease of tumors on the face (including the ears) was seen in all age groups. The relative increase of SCC of the trunk and upper limbs is a plausible reflection of intentional tanning.

Does relative melanoma distribution by body site 1960-2004 reflect changes in intermittent exposure and intentional tanning in the Swedish population?

Intermittent exposure to UV-radiation at an early age is a known important factor in the aetiology of malignant melanoma. We surveyed data from the Swedish Cancer Registry for melanoma by body site for age and gender cohorts from 1960 to 2004, in an attempt to discern a reflection of major behavioural and societal changes in the relative distribution of melanoma by body site. The study comprised patients with malignant melanoma from the Swedish Cancer Registry, including information on body site of tumour (January 1, 1960 - December 31, 2004). In total, 46,337 malignant melanomas were diagnosed in 44,623 patients. Trends were assessed by incidence per site, and relative site distribution per age group and calendar period, and dividing body sites by exposure type to the sun: head (mostly continuous), trunk (mostly intermittent), and limbs (mixed exposure). Between calendar periods 1960-1964 and 2000-2004 melanomas increased most rapidly on the upper limbs (men 885%, women 1216%) on the trunk (men 729%, women 759%) and on the lower limbs (men 418%, women 289%) in both genders. The incidence increase of head tumors was slower. Across the life span, melanomas of the trunk and lower limbs dominate among patients < 70 years, whereas tumors of the head are most common among patients >or= 70 years. Tumors of the trunk formed an increasing proportion of all melanomas during the period studied, particularly in females. The relative shift of melanomas from the head to the trunk with mostly intermittent UV exposure coincides with behavioral and societal changes with regard to sun exposure. This supports the hypothesis of a relationship between intentional exposure to ultraviolet radiation and malignant melanoma.

Smoking cessation in general practice: the effects of a quitline.

This cross-sectional study assessed changes between 1999 and 2003 in attitudes among Swedish general practitioners (GPs) toward smoking cessation activities and also assessed the effect of a nationwide quitline on GPs' smoking cessation activities. A random sample of 621 Swedish GPs answered a questionnaire mailed to their home addresses in spring 2003. When possible, the results of the present study were compared with results from a similar study conducted in 1999. Main outcome measures were GPs' self-reported activities, perceived barriers to engaging in smoking cessation, and referrals to the quitline. Between 1999 and 2003, GPs increased their overall smoking cessation activities and were more aware of the complexity of smoking cessation support. Significantly more GPs experienced smoking cessation support as "too time consuming" and preferred to refer smokers to counselors specializing in smoking cessation. GPs referring patients to the quitline were more likely to be active in other smoking cessation activities. One out of five GPs had advised their patients to use oral smokeless tobacco as a means to stop smoking. A paradigm shift regarding awareness of the complexity of smoking cessation support may be ongoing amongst Swedish GPs. The nationwide smoking cessation quitline appears to have had a positive effect on GPs' engagement in smoking cessation.

Impact of preschool environment upon children's physical activity and sun exposure.

BACKGROUND: The physical qualities of outdoor environments are important to trigger healthy behavior in children. We studied the impact of outdoor environments upon spontaneous physical activity and exposure to ultraviolet (UV) radiation in 4- to 6-year-old children at 11 preschools in Stockholm county. METHODS: In May-June 2004, pedometry and measurement of UV radiation were carried out on 197 children from 11 preschools in Stockholm county. Outdoor environments differed regarding vegetation, topography, space, and education. Ambient global UV radiation data were collected, free sky, and ground surface assessed. Arrival, in- and outdoor stay, and departure were recorded. For analysis, linear mixed model analysis was applied. RESULTS: In environments with trees, shrubbery, and broken ground, the mean step count/min was 21.5, and mean exposure to UV radiation as fraction of available UV during play outdoors 14.6%. In delimited environments with little vegetation, the mean step count/min was 17.7 and mean exposure fraction to UV radiation 24.3% (P < 0.001, crude). Step/min range was 8.9-30.0 (girls) and 8.8-37.2 (boys), UV radiation exposure range 4-60% (no difference between genders). CONCLUSION: Spacious preschool environments with trees, shrubbery, and broken ground trigger physical activity and yield sun protection in outdoor play. As many children attend preschool, access to such environments is recommended in community architecture.