Thorax Online First, published on March 1, 2017 as 10.1136/thoraxjnl-2016-209209 Chronic obstructive pulmonary disease ORIGINAL ARTICLE Thorax: first published as 10.1136/thoraxjnl-2016-209209 on 1 March 2017. Downloaded from Socio-environmental correlates of physical activity in patients with chronic obstructive pulmonary disease (COPD) Ane Arbillaga-Etxarri,1,2,3,4 Elena Gimeno-Santos,1,2,3 Anael Barberan-Garcia,5,6 Marta Benet,1,2,3 Eulàlia Borrell,7 Payam Dadvand,1,2,3 Maria Foraster,8,9 Alicia Marín,10 Mònica Monteagudo,11,12 Robert Rodriguez-Roisin,6 Pere Vall-Casas,13 Jordi Vilaró,14 Judith Garcia-Aymerich,1,2,3 on behalf of the Urban Training Study Group ▸ Additional material is ABSTRACT published online only. To view Background Study of the causes of the reduced levels Key messages please visit the journal online (http://dx.doi.org/10.1136/ of physical activity in patients with COPD has been thoraxjnl-2016-209209). scarce and limited to biological factors. Aim To assess the relationship between novel socio- For numbered affiliations see What is the key question? end of article. environmental factors, namely dog walking, ▸ What is the relationship between socio- grandparenting, neighbourhood deprivation, residential environmental factors, namely dog walking, Correspondence to surrounding greenness and residential proximity to green grandparenting, neighbourhood deprivation, Dr Judith Garcia-Aymerich, or blue spaces, and amount and intensity of physical residential surrounding greenness and Barcelona Institute of Global Health (ISGlobal), activity in COPD patients. residential proximity to green or blue spaces, Barcelona, Spain; Methods This cross-sectional study recruited 410 and amount and intensity of physical activity in [email protected] COPD patients from five Catalan municipalities. Dog COPD patients? walking and grandparenting were assessed by Received 19 July 2016 questionnaire. Neighbourhood deprivation was assessed What is the bottom line? Revised 12 January 2017 ▸ The study shows, for the first time, that Accepted 5 February 2017 using the census Urban Vulnerability Index, residential surrounding greenness by the satellite-derived interpersonal relationship factors, specifically Normalized Difference Vegetation Index, and residential dog walking and grandparenting, are related to proximity to green or blue spaces as living within 300 m both the amount and intensity of physical http://thorax.bmj.com/ of such a space. Physical activity was measured during activity in COPD patients independent of 1 week by accelerometer to assess time spent on airflow limitation and other biological or moderate-to-vigorous physical activity (MVPA) and vector psychological parameters. magnitude units (VMU) per minute. Why read on? Findings Patients were 85% male, had a mean (SD) ▸ Understanding the socio-environmental age of 69 (9) years, and post-bronchodilator FEV1 of 56 characteristics of COPD patients, including (17) %pred. After adjusting for age, sex, socio-economic family duties and/or leisure time preferences, is status, dyspnoea, exercise capacity and anxiety in a central to tailoring physical activity on September 26, 2021 by guest. Protected copyright. linear regression model, both dog walking and fi recommendations in the clinical setting as well grandparenting were signi cantly associated with an as to designing and testing interventions to increase both in time in MVPA (18 min/day (p<0.01) modify their physical activity behaviour. and 9 min/day (p<0.05), respectively) and in physical activity intensity (76 VMU/min (p=0.05) and 59 VMUs/ min (p<0.05), respectively). Neighbourhood deprivation, surrounding greenness and proximity to green or blue changes.2 However, maintaining a sufficient amount spaces were not associated with physical activity. of physical activity is critical for the patients’ prog- Conclusions Dog walking and grandparenting are nosis, quality of life and mortality.3 Thus, increasing associated with a higher amount and intensity of physical activity has been recently included as a rele- physical activity in COPD patients. vant health outcome of a wide range of interven- Trial registration number Pre-results, tions, including pharmacological treatment,4 NCT01897298. pulmonary rehabilitation5 and interventions based on behavioural strategies such as self-monitoring, self-efficacy, motivation, goal setting and feedback.6 To cite: Arbillaga-Etxarri A, Of note, only one study so far has shown a sustained Gimeno-Santos E, Barberan- INTRODUCTION long term increase in physical activity, exclusively in Garcia A, et al. Thorax fi Published Online First: Patients with COPD are substantially less active than a subgroup of patients who were not suf ciently [please include Day Month their healthy peers1 due to progressive airflow active at baseline.7 Year] doi:10.1136/thoraxjnl- limitation, abnormal gas exchange, skeletal It has been argued that this absence of effective- 2016-209209 muscle dysfunction, comorbidities and behavioural ness could be due to lack of knowledge concerning Arbillaga-Etxarri A, et al. Thorax 2017;0:1–7. doi:10.1136/thoraxjnl-2016-209209 1 Copyright Article author (or their employer) 2017. Produced by BMJ Publishing Group Ltd (& BTS) under licence. Chronic obstructive pulmonary disease the causes of physical activity behaviour.8 Remarkably, the institutions and written informed consent was obtained from Thorax: first published as 10.1136/thoraxjnl-2016-209209 on 1 March 2017. Downloaded from number of studies on physical activity determinants in COPD each participant. patients is lower than the number of studies assessing interven- tions to modulate this behaviour.3 Moreover, study of physical Variables and instruments activity determinants in COPD patients has been limited to indi- All patients answered an interviewer-administered questionnaire vidual factors, mostly in the psychological and biological areas. about dog ownership (question: ‘Do you have a dog at home?’), This is in contrast with the commonly accepted socio-ecological dog walking (if positive to having a dog, ‘Do you walk the models guiding most research on physical activity determinants dog?’), having grandchildren (‘Do you have grandchildren?’) in the general population and in patients with other chronic and grandparenting (if positive to having grandchildren, ‘Do diseases.9 you take care of them or collaborate in their care?’). The ques- Socio-ecological models explain physical activity as being tionnaire also included data on education, marital status, affected by psychological, biological and socio-environmental working status, occupation, number of people living at home, characteristics, and their interactions, both at the individual and smoking status, dyspnoea (assessed using the modified Medical population levels. To facilitate the study of socio-environmental Research Council scale (mMRC)), health-related quality of life characteristics and physical activity, three main dimensions have (assessed using the COPD Assessment Test (CAT)), and anxiety been described: social inequality, interpersonal relationships and and depression symptoms (assessed using the Hospital Anxiety neighbourhood characteristics.10 In patients with COPD, only and Depression scale (HAD)). SES was obtained from questions social inequality has been investigated as a potential determinant on employment characteristics, and classified using the National of physical activity through the application of common mea- Statistics Socio-economic Classification into six categories (I, sures of socio-economic status (SES), such as educational or professional; II, managerial and technical; IIIN, skilled non- occupational categories, and has shown inconsistent associations manual; IIIM, skilled manual; IV, partly skilled; and V, unskilled with physical activity.3 However, interpersonal relationships occupations). Comorbidities were assessed from medical such as walking the dog or grandparenting have not previously records. Body mass index (BMI) was obtained by physical been investigated despite the potential of interpersonal relation- examination. FEV1 and FVC before and after bronchodilator ships to affect physical activity behaviour.10 Likewise, neigh- use, and distance walked in the 6-min walking test (6MWD) bourhood characteristics, such as the proximity of parks within were determined following standardised methodology. walking distance or lower neighbourhood deprivation levels, We geocoded patients’ addresses to assess individual measures have been associated with higher levels of physical activity in of neighbourhood deprivation, residential surrounding green- the general population,11 although they have not previously ness, and residential proximity to green or blue spaces. been tested in patients with COPD. Neighbourhood deprivation was assessed using the Urban We aimed to assess the relationship of novel socio- Vulnerability Index14 which is a measure of neighbourhood SES environmental factors (dog walking, grandparenting, neighbour- at the census tract level (median area of 0.26 km2) ranging from hood deprivation, residential surrounding greenness, and 0 (lowest) to 1 (highest level of neighbourhood deprivation). residential proximity to green or blue spaces) with the physical To measure residential surrounding greenness, we used the activity level of stable mild-to-very severe patients with COPD Normalized Difference Vegetation Index (NDVI) which is an http://thorax.bmj.com/ from five Mediterranean municipalities. indicator of green (ie, photosynthetically