Establishment of clinical exercise physiology as a regulated healthcare profession in the UK: a progress report.

In 2021, a 'call to action' was published to highlight the need for professional regulation of clinical exercise physiologists to be established within UK healthcare systems to ensure patient safety and align training and regulation with other health professions. This manuscript provides a progress report on the actions that Clinical Exercise Physiology UK (CEP-UK) has undertaken over the past 4 years, during which time clinical exercise physiologists have implemented regulation and gained formal recognition as healthcare professionals in the UK. An overview of the consultation process involved in creating a regulated health profession, notably the development of policies and procedures for both individual registration and institutional master's degree (MSc) accreditation is outlined. Additionally, the process for developing an industry-recognised scope of practice, a university MSc-level curriculum framework, the Academy for Healthcare Science Practitioner standards of proficiency and Continuing Professional Development opportunities is included. We outline the significant activities and milestones undertaken by CEP-UK and provide insight and clarity for other health professionals to understand the training and registration process for a clinical exercise physiologist in the UK. Finally, we include short, medium and long-term objectives for the future advocacy development of this workforce in the UK.

Is breathing frequency a potential means for monitoring exercise intensity in people with atrial fibrillation and coronary heart disease when heart rate is mitigated?

PURPOSE: Moderate-intensity aerobic exercise is safe and beneficial in atrial fibrillation (AF) and coronary heart disease (CHD). Irregular or rapid heart rates (HR) in AF and other heart conditions create a challenge to using HR to monitor exercise intensity. The purpose of this study was to assess the potential of breathing frequency (BF) to monitor exercise intensity in people with AF and CHD without AF. METHODS: This observational study included 30 AF participants (19 Male, 70.7 ± 8.7 yrs) and 67 non-AF CHD participants (38 Male, 56.9 ± 11.4 yrs). All performed an incremental maximal exercise test with pulmonary gas exchange. RESULTS: Peak aerobic power in AF ( V ˙ O2peak; 17.8 ± 5.0 ml.kg-1.min-1) was lower than in CHD (26.7 ml.kg-1.min-1) (p < .001). BF responses in AF and CHD were similar (BF peak: AF 34.6 ± 5.4 and CHD 36.5 ± 5.0 breaths.min-1; p = .106); at the 1st ventilatory threshold (BF@VT-1: AF 23.2 ± 4.6; CHD 22.4 ± 4.6 breaths.min-1; p = .240). % V ˙ O2peak at VT-1 were similar in AF and CHD (AF: 59%; CHD: 57%; p = .656). CONCLUSION: With the use of wearable technologies on the rise, that now include BF, this first study provides an encouraging potential for BF to be used in AF and CHD. As the supporting data are based on incremental ramp protocol results, further research is required to assess BF validity to manage exercise intensity during longer bouts of exercise.

Effects of a Transoceanic Rowing Challenge on Cardiorespiratory Function and Muscle Fitness.

Ultra-endurance sports and exercise events are becoming increasingly popular for older age groups. We aimed to evaluate changes in cardiac function and physical fitness in males aged 50-60 years who completed a 50-day transoceanic rowing challenge. This case account of four self-selected males included electro- and echo-cardiography (ECG, echo), cardiorespiratory and muscular fitness measures recorded nine months prior to and three weeks after a transatlantic team-rowing challenge. No clinically significant changes to myocardial function were found over the course of the study. The training and race created expected functional changes to left ventricular and atrial function; the former associated with training, the latter likely due to dehydration, both resolving towards baseline within three weeks post-event. From race-start to finish all rowers lost 8.4-15.6 kg of body mass. Absolute cardiorespiratory power and muscular strength were lower three weeks post-race compared to pre-race, but cardiorespiratory exercise economy improved in this same period. A structured program of moderate-vigorous aerobic endurance and muscular training for>6 months, followed by 50-days of transoceanic rowing in older males proved not to cause any observable acute or potential long-term risks to cardiovascular health. Pre-event screening, fitness testing, and appropriate training is recommended, especially in older participants where age itself is an increasingly significant risk factor.

The effects of prehabilitation on body composition in patients undergoing multimodal therapy for esophageal cancer.

Prehabilitation aims to optimize a patient's functional capacity in preparation for surgery. Esophageal cancer patients have a high incidence of sarcopenia and commonly undergo neoadjuvant therapy, which is associated with loss of muscle mass. This study examines the effects of prehabilitation on body composition during neoadjuvant therapy in esophageal cancer patients. In this cohort study, changes in body composition were compared between esophageal cancer patients who participated in prehabilitation during neoadjuvant therapy and controls who did not receive prehabilitation. Assessment of body composition was performed from CT images acquired at the time of diagnosis and after neoadjuvant therapy. Fifty-one prehabilitation patients and 28 control patients were identified. There was a significantly greater fall in skeletal muscle index (SMI) in the control group compared with the prehabilitation patients (Δ SMI mean difference = -2.2 cm2/m2, 95% CI -4.3 to -0.1, p=0.038). Within the prehabilitation cohort, there was a smaller decline in SMI in patients with ≥75% adherence to exercise in comparison to those with lower adherence (Δ SMI mean difference = -3.2, 95% CI -6.0 to -0.5, P = 0.023). A greater decrease in visceral adipose tissue (VAT) was seen with increasing volumes of exercise completed during prehabilitation (P = 0.046). Loss of VAT during neoadjuvant therapy was associated with a lower risk of post-operative complications (P = 0.017). By limiting the fall in SMI and promoting VAT loss, prehabilitation may have multiple beneficial effects in patients with esophageal cancer. Multi-center, randomized studies are needed to further explore these findings.

Charter to establish clinical exercise physiology as a recognised allied health profession in the UK: a call to action.

The UK population is growing, ageing and becoming increasingly inactive and unfit. Personalised and targeted exercise interventions are beneficial for ageing and the management of chronic and complex conditions. Increasing the uptake of effective exercise and physical activity (PA) interventions is vital to support a healthier society and decrease healthcare costs. Current strategies for exercise and PA at a population level mostly involve self-directed exercise pathways, delivered largely via the fitness industry. Even for those who opt-in and manage to achieve the current recommendations regarding minimum PA, this generic 'one-size-fits-all' approach often fails to demonstrate meaningful physiological and health benefits. Personalised exercise prescription and appropriate exercise testing, monitoring and progression of interventions for individuals with chronic disease should be provided by appropriately trained and recognised exercise healthcare professionals, educated in the cognate disciplines of exercise science (eg, physiology, biomechanics, motor control, psychology). This workforce has operated for >20 years in the Australian public and private healthcare systems. Accredited exercise physiologists (AEPs) are recognised allied health professionals, with demonstrable health and economic benefits. AEPs have knowledge of the risks and benefits of distinct forms of exercise, skills in the personalised prescription and optimal delivery of exercise, and competencies to support sustained PA behavioural change, based on the established scientific evidence. In this charter, we propose a road map for the training, accreditation and promotion of a clinical exercise physiology profession in the UK.

The changing landscape of cardiac rehabilitation; from early mobilisation and reduced mortality to chronic multi-morbidity management.

AIM: This paper aims to demonstrate how the rationale and delivery of cardiac rehabilitation (CR), in those countries with long term established standards of practice, has changed over the past eight decades. METHODS: A narrative report based on the evolution of key published guidelines, systematic reviews and medical policies since the 1940s. RESULTS: Case reports of the value of exercise in cardiac disease can be dated back to 1772. Formative groundwork for exercise-based CR was published between 1940 and 1970. However, it was not until the late 1980s that a large enough data set of controlled trials was available to show significant reductions in premature all-cause and cardiac mortality. Since the mid 1990s, cardiac mortality has been greatly reduced due to enhanced public health, emergency care and more sensitive diagnostic techniques and aggressive treatments. As a result, there appears to be an associated reduced potency of CR to affect mortality. New rationales for why, how and where CR is delivered have emerged including: adapting to a longer surviving ageing multi-morbid population, where healthcare cost savings and quality of life have become increasingly important. CONCLUSIONS: In light of these results, an emerging focus for CR, and in some cases "pre-habilitation", is that of a chronic disability management programme increasingly delivered in community and home settings. Within this delivery model, the use of remote personalised technologies is now emerging, especially with new needs accelerated by the pandemic of COVID-19.IMPLICATIONS FOR REHABILITATIONWith continued advances in medical science and better long term survival, the nature of cardiac rehabilitation has evolved over the past eight decades. It was originally an exercise-focused intervention on short term recovery and reducing cardiac and all-cause mortality, to now being one part of a multi-factor lifestyle, behavioural, and medical chronic disease management programme.Throughout history, the important influence of psycho-social well-being and human behaviour has, however, always been of key importance to patients.The location of rehabilitation can now be suited to patient need, both medically and socially, where the same components can be delivered in either a traditional outpatient clinic, community settings, at home and more recently all of these being supported or augmented with the advent of mobile technology.

Acute glycaemic management before, during and after exercise for cardiac rehabilitation participants with diabetes mellitus: a joint statement of the British and Canadian Associations of Cardiovascular Prevention and Rehabilitation, the International Council for Cardiovascular Prevention and Rehabilitation and the British Association of Sport and Exercise Sciences.

Type 1 (T1) and type 2 (T2) diabetes mellitus (DM) are significant precursors and comorbidities to cardiovascular disease and prevalence of both types is still rising globally. Currently,~25% of participants (and rising) attending cardiac rehabilitation in Europe, North America and Australia have been reported to have DM (>90% have T2DM). While there is some debate over whether improving glycaemic control in those with heart disease can independently improve future cardiovascular health-related outcomes, for the individual patient whose blood glucose is well controlled, it can aid the exercise programme in being more efficacious. Good glycaemic management not only helps to mitigate the risk of acute glycaemic events during exercising, it also aids in achieving the requisite physiological and psycho-social aims of the exercise component of cardiac rehabilitation (CR). These benefits are strongly associated with effective behaviour change, including increased enjoyment, adherence and self-efficacy. It is known that CR participants with DM have lower uptake and adherence rates compared with those without DM. This expert statement provides CR practitioners with nine recommendations aimed to aid in the participant's improved blood glucose control before, during and after exercise so as to prevent the risk of glycaemic events that could mitigate their beneficial participation.

A comparison of self-reported and device measured sedentary behaviour in adults: a systematic review and meta-analysis.

BACKGROUND: Sedentary behaviour (SB) is a risk factor for chronic disease and premature mortality. While many individual studies have examined the reliability and validity of various self-report measures for assessing SB, it is not clear, in general, how self-reported SB (e.g., questionnaires, logs, ecological momentary assessments (EMAs)) compares to device measures (e.g., accelerometers, inclinometers). OBJECTIVE: The primary objective of this systematic review was to compare self-report versus device measures of SB in adults. METHODS: Six bibliographic databases were searched to identify all studies which included a comparable self-report and device measure of SB in adults. Risk of bias within and across studies was assessed. Results were synthesized using meta-analyses. RESULTS: The review included 185 unique studies. A total of 123 studies comprising 173 comparisons and data from 55,199 participants were used to examine general criterion validity. The average mean difference was -105.19 minutes/day (95% CI: -127.21, -83.17); self-report underestimated sedentary time by ~1.74 hours/day compared to device measures. Self-reported time spent sedentary at work was ~40 minutes higher than when assessed by devices. Single item measures performed more poorly than multi-item questionnaires, EMAs and logs/diaries. On average, when compared to inclinometers, multi-item questionnaires, EMAs and logs/diaries were not significantly different, but had substantial amount of variability (up to 6 hours/day within individual studies) with approximately half over-reporting and half under-reporting. A total of 54 studies provided an assessment of reliability of a self-report measure, on average the reliability was good (ICC = 0.66). CONCLUSIONS: Evidence from this review suggests that single-item self-report measures generally underestimate sedentary time when compared to device measures. For accuracy, multi-item questionnaires, EMAs and logs/diaries with a shorter recall period should be encouraged above single item questions and longer recall periods if sedentary time is a primary outcome of study. Users should also be aware of the high degree of variability between and within tools. Studies should exert caution when comparing associations between different self-report and device measures with health outcomes. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019118755.

Office workers' experiences of attempts to reduce sitting-time: an exploratory, mixed-methods uncontrolled intervention pilot study.

BACKGROUND: Office workers typically sit for most of the workday, which has been linked to physical and mental ill-health and premature death. This mixed-methods study sought to identify barriers and facilitators to reducing sitting and increasing standing among office workers who received an intervention prototype (the 'ReSiT [Reducing Sitting Time] Study'). The intervention comprised a sit-stand workstation and tailored advice to enhance motivation, capability and opportunity to displace sitting with standing. METHODS: Twenty-nine UK university office workers (aged ≥18y, working ≥3 days per week, most time spent at a seated desk) participated in a 13-week uncontrolled study. They were initially monitored for one-week. In a subsequent face-to-face consultation, participants received sitting time feedback from a prior one-week monitoring period, and selected from a set of tailored sitting-reduction techniques. Quantitative data comprising sitting, standing and stepping time, which were objectively monitored for 7 consecutive days across three post-intervention timepoints, were descriptively analysed. Qualitative data, from semi-structured interviews conducted at 1, 6 and 12-weeks post-intervention, were thematically analysed. RESULTS: Compared to baseline, mean sitting time decreased at weeks 1, 6 and 12 by 49.7mins, 118.2mins, and 109.7mins respectively. Despite prior concerns about colleagues' reactions to standing, many reported encouragement from others, and standing could be equally conducive to social interaction or creating private, personal space. Some perceived less cognitively-demanding tasks to be more conducive to standing, though some found standing offered a valued break from challenging tasks. Participants prioritised workload over sitting reduction and were more likely to stand after rather than during work task completion. Temporary context changes, such as holidays, threatened to derail newfound routines. CONCLUSIONS: Our findings emphasise the importance of understanding workers' mental representations of their work, and the social functions of sitting and standing in the workplace. Workplace intervention developers should incorporate a pre-intervention sitting time monitoring period, encourage workers to identify personally meaningful tasks and cues for standing, and build organisational support for sitting-reduction. We will use these insights to refine our intervention for self-administered delivery. TRIAL REGISTRATION: ISRCTN29395780 (registered 21 November 2016).

Submaximal Exercise Testing in Cardiovascular Rehabilitation Settings (BEST Study).

BACKGROUND: This study compared changes in measured versus predicted peak aerobic power (V̇O2 peak) following cardiovascular rehabilitation (CR). Peak cardiopulmonary exercise testing (CPET) results were compared to four V̇O2 peak estimation methods: the submaximal modified Bruce treadmill, Astrand-Ryhming cycle ergometer, and Chester step tests, and the Duke Activity Status Index (DASI). METHODS: Adults with cardiovascular disease (CVD) who completed a 12-week CR program were assessed at baseline and 12 weeks follow-up. CPET, the DASI and three subsequent submaximal exercise tests were performed in a random order. RESULTS: Of the 50 adults (age: 57 ± 11 years) who participated, 46 completed the 12-week CR program and exercise tests. At baseline 69, 68, and 38% of the treadmill, step and cycle tests were successfully completed, respectively. At follow-up 67, 80, and 46% of the treadmill, step and cycle tests were successfully completed, respectively. No severe adverse events occurred. Significant improvements in V̇O2 peak were observed with CPET (3.6 ± 5.5 mL.kg-1.min-1, p < 0.001) and the DASI (2.3 ± 4.2 mL.kg-1.min-1, p < 0.001). Bland-Altman plots of the change in V̇O2 peak between CPET and the four V̇O2 peak estimation methods revealed the following: a proportional bias and heteroscedastic 95% limits of agreement (95% LoA) for the treadmill test, and for the cycle and step tests and DASI, mean bias' and 95% LoA of 1.0 mL.kg-1.min-1 (21.3, -19.3), 1.4 mL.kg-1.min-1 (15.0, -12.3) and 1.0 mL.kg-1.min-1 (13.8, -11.8), respectively. CONCLUSION: Given the greater number of successful tests, no serious adverse events and acceptable mean bias, the step test appears to be a valid and safe method for assessing group-level mean changes in V̇O2 peak among patients in CR. The DASI also appears to be a valid and practical questionnaire. Wide limits of agreement, however, limit their use to predict individual-level changes.

What is the effect of aerobic exercise intensity on cardiorespiratory fitness in those undergoing cardiac rehabilitation? A systematic review with meta-analysis.

OBJECTIVE: Assess the role of exercise intensity on changes in cardiorespiratory fitness (CRF) in patients with cardiac conditions attending exercise-based cardiac rehabilitation. DESIGN: Systematic review with meta-analysis. DATA SOURCES: MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO and Web of Science. ELIGIBILITY CRITERIA FOR SELECTION: Studies assessing change in CRF (reported as peak oxygen uptake; V̇O2peak) in patients post myocardial infarction and revascularisation, following exercise-based cardiac rehabilitation. Studies establishing V̇O2peak via symptom-limited exercise test with ventilatory gas analysis and reported intensity of exercise during rehabilitation were included. Studies with mean ejection fraction <40% were excluded. RESULTS: 128 studies including 13 220 patients were included. Interventions were classified as moderate, moderate-to-vigorous or vigorous intensity based on published recommendations. Moderate and moderate-to-vigorous-intensity interventions were associated with a moderate increase in relative V̇O2peak (standardised mean difference±95% CI=0.94±0.30 and 0.93±0.17, respectively), and vigorous-intensity exercise with a large increase (1.10±0.25). Moderate and vigorous-intensity interventions were associated with moderate improvements in absoluteV̇O2peak (0.63±0.34 and 0.93±0.20, respectively), whereas moderate-to-vigorous-intensity interventions elicited a large effect (1.27±0.75). Large heterogeneity among studies was observed for all analyses. Subgroup analyses yielded statistically significant, but inconsistent, improvements in CRF. CONCLUSION: Engagement in exercise-based cardiac rehabilitation was associated with significant improvements in both absolute and relative V̇O2peak. Although exercise of vigorous intensity produced the greatest pooled effect for change in relative V̇O2peak, differences in pooled effects between intensities could not be considered clinically meaningful. REGISTRATION: Prospero CRD42016035638.

The ReSiT study (reducing sitting time): rationale and protocol for an exploratory pilot study of an intervention to reduce sitting time among office workers.

BACKGROUND: Desk-based workers engage in long periods of uninterrupted sitting time, which has been associated with morbidity and premature mortality. Previous workplace intervention trials have demonstrated the potential of providing sit-stand workstations, and of administering motivational behaviour change techniques, for reducing sitting time. Yet, few studies have combined these approaches or explored the acceptability of discrete sitting-reduction behaviour change strategies. This paper describes the rationale for a sitting-reduction intervention that combines sit-stand workstations with motivational techniques, and procedures for a pilot study to explore the acceptability of core intervention components among university office workers. METHODS: The intervention is based on a theory and evidence-based analysis of why office workers sit, and how best to reduce sitting time. It seeks to enhance motivation and capability, as well as identify opportunities, required to reduce sitting time. Thirty office workers will participate in the pilot study. They will complete an initial awareness-raising monitoring and feedback task and subsequently receive a sit-stand workstation for a 12-week period. They will also select from a 'menu' of behaviour change techniques tailored to self-declared barriers to sitting reduction, effectively co-producing and personally tailoring their intervention. Interviews at 1, 6, and 12 weeks post-intervention will explore intervention acceptability. DISCUSSION: To our knowledge, this will be the first study to explore direct feedback from office workers on the acceptability of discrete tailored sitting-reduction intervention components that they have received. Participants' choice of and reflections on intervention techniques will aid identification of strategies suitable for inclusion in the next iteration of the intervention, which will be delivered in a self-administered format to minimise resource burden. TRIAL REGISTRATION: ISRCTN29395780 (registered 21 November 2016).

Oxygen Costs of the Incremental Shuttle Walk Test in Cardiac Rehabilitation Participants: An Historical and Contemporary Analysis.

BACKGROUND: The incremental shuttle walk test (ISWT) is a standardised assessment for cardiac rehabilitation. Three studies have reported oxygen costs (VO2)/metabolic equivalents (METs) of the ISWT. In spite of classic representations from these studies graphically showing curvilinear VO2 responses to incremented walking speeds, linear regression techniques (also used by the American College of Sports Medicine [ACSM]) have been used to estimate VO2. PURPOSE: The two main aims of this study were to (i) resolve currently reported discrepancies in the ISWT VO2-walking speed relationship, and (ii) derive an appropriate VO2 versus walking speed regression equation. METHODS: VO2 was measured continuously during an ISWT in 32 coronary heart disease [cardiac] rehabilitation (CHD-CR) participants and 30 age-matched controls. RESULTS: Both CHD-CR and control group VO2 responses were curvilinear in nature. For CHD-CR VO2 = 4.4e0.23 × walkingspeed (km/h). The integrated area under the curve (iAUC) VO2 across nine ISWT stages was greater in the CHD-CR group versus the control group (p < 0.001): CHD-CR = 423 (±86) ml·kg-1·min-1·km·h-1; control = 316 (±52) ml·kg-1·min-1·km·h-1. CONCLUSIONS: CHD-CR group vs. control VO2 was up to 30 % greater at higher ISWT stages. The curvilinear nature of VO2 responses during the ISWT concur with classic studies reported over 100 years. VO2 estimates for walking using linear regression models (including the ACSM) clearly underestimate values in healthy and CHD-CR participants, and this study provides a resolution to this when the ISWT is used for CHD-CR populations.

The sedentary office: an expert statement on the growing case for change towards better health and productivity.

An international group of experts convened to provide guidance for employers to promote the avoidance of prolonged periods of sedentary work. The set of recommendations was developed from the totality of the current evidence, including long-term epidemiological studies and interventional studies of getting workers to stand and/or move more frequently. The evidence was ranked in quality using the four levels of the American College of Sports Medicine. The derived guidance is as follows: for those occupations which are predominantly desk based, workers should aim to initially progress towards accumulating 2 h/day of standing and light activity (light walking) during working hours, eventually progressing to a total accumulation of 4 h/day (prorated to part-time hours). To achieve this, seated-based work should be regularly broken up with standing-based work, the use of sit-stand desks, or the taking of short active standing breaks. Along with other health promotion goals (improved nutrition, reducing alcohol, smoking and stress), companies should also promote among their staff that prolonged sitting, aggregated from work and in leisure time, may significantly and independently increase the risk of cardiometabolic diseases and premature mortality. It is appreciated that these recommendations should be interpreted in relation to the evidence from which they were derived, largely observational and retrospective studies, or short-term interventional studies showing acute cardiometabolic changes. While longer term intervention studies are required, the level of consistent evidence accumulated to date, and the public health context of rising chronic diseases, suggest initial guidelines are justified. We hope these guidelines stimulate future research, and that greater precision will be possible within future iterations.

Heart rate and perceived muscle pain responses to a functional walking test in McArdle disease.

The aim of this study was to assess a 12-min self-paced walking test in patients with McArdle disease. Twenty patients (44.7 ± 11 years; 11 female) performed the walking test where walking speed, distance walked, heart rate (HR) and perceived muscle pain (Borg CR10 scale) were measured. Median (interquartile range) distance walked was 890 m (470-935). From 1 to 6 min, median walking speed decreased (from 75.0 to 71.4 m∙min(-1)) while muscle pain and %HR reserve increased (from 0.3 to 3.0 and 37% to 48%, respectively). From 7 to 12 min, walking speed increased to 74.2 m∙min(-1), muscle pain decreased to 1.6 and %HR reserve remained between 45% and 48%. To make relative comparisons, HR and muscle pain were divided by walking speed and expressed as ratios. These ratios rose significantly between 1 and 6 min (HR:walking speed P = .001 and pain:walking speed P < .001) and similarly decreased between 6 and 11 min (P = .002 and P = .001, respectively). Peak ratios of HR:walking speed and pain:walking speed were inversely correlated to distance walked: rs (HR) = -.82 (P < .0001) and rs (pain) = -.55 (P = .012). Largest peak ratios were found in patients who walked < 650 m. A 12-min walking test can be used to assess exercise capacity and detect the second wind in McArdle disease.

Standing-based office work shows encouraging signs of attenuating post-prandial glycaemic excursion.

OBJECTIVES: The main aim of this study was to compare two days of continuous monitored capillary blood glucose (CGM) responses to sitting and standing in normally desk-based workers. DESIGN, SETTING AND PARTICIPANTS: This open repeated-measures study took place in a real office environment, during normal working hours and subsequent CGM overnight measures in 10 participants aged 21-61 years (8 female). MAIN OUTCOMES: Postprandial (lunch) measures of: CGM, accelerometer movement counts (MC) heart rate, energy expenditure (EE) and overnight CGM following one afternoon of normal sitting work compared with one afternoon of the same work performed at a standing desk. RESULTS: Area-under-the-curve analysis revealed an attenuated blood glucose excursion by 43% (p=0.022) following 185 min of standing (143, 95% CI 5.09 to 281.46 mmol/L min) compared to sitting work (326; 95% CI 228 to 425 mmol/L min). Compared to sitting, EE during an afternoon of standing work was 174 kcals greater (0.83 kcals/min; p=0.028). The accelerometer MC showed no differences between the afternoons of seated versus standing work; reported differences were thus a function of the standing work and not from additional physical movements around the office. CONCLUSIONS: This is the first known 'office-based' study to provide CGM measures that add some of the needed mechanistic information to the existing evidence-base on why avoiding sedentary behaviour at work could lead to a reduced risk of cardiometabolic diseases.

International Charter on Cardiovascular Prevention and Rehabilitation: a call for action.

Cardiovascular disease remains the leading cause of death in both women and men globally and is a growing epidemic in low- to middle-income countries. Without systematic access to cardiac rehabilitation (CR), these individuals may experience multiple recurrent acute care events and suffer unnecessarily premature death. The 2 aims of this Charter are (1) to bring together national associations from around the world to harmonize efforts in promoting cardiovascular prevention and rehabilitation and (2) to document consensus among national associations globally, regarding the internationally common core elements and benefits of cardiovascular disease prevention and rehabilitation. The Global Charter on CR calls to action those responsible for administering patient care to (a) establish CR as an obligatory, not optional service, and (b) to support countries to establish and augment programs of CR to ensure broad access to these proven services. In addition, the Charter calls for CR organizations and associations in high-income countries to collaborate with those in low- to middle-income countries, to support capacity building and provide tangible toolkits for program development and maintenance. The aim of this Charter is to maintain and grow this global consortium through partnerships with international organizations and to consider and communicate ongoing consensus of evidence-based standards for CR worldwide.