Validation of a continuous measure of cardiometabolic risk among adolescents

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Kaigang Li ◽  
Denise L. Haynie ◽  
Xiang Gao ◽  
Leah M. Lipsky ◽  
Tonja Nansel ◽  
...  
Keyword(s):  
Roc Curve ◽  
Cardiometabolic Risk ◽  
Fasting Blood Glucose ◽  
Early Adulthood ◽  
Density Lipoprotein ◽  
Continuous Measure ◽  
Standardized Residuals ◽  
National Cohort ◽  
Z Scores ◽  
Student’S T

Abstract Objectives We validated a continuous cardiometabolic risk (CMR) measure among adolescents. Methods Five metabolic syndrome (MetS) components including waist circumference, triglycerides, high-density lipoprotein cholesterol, fasting blood glucose, and mean arterial pressure were assessed in a national cohort of U.S. adolescents (n=560; 16.5 ± 0.5 y/o at baseline) in 10th grade (2010, Wave 1 (W1)), and follow-up assessments four (W4) and seven (W7) years later. Separately by wave, linear regressions were fitted to each MetS component controlling for age, sex, and race/ethnicity, and yielded standardized residuals (Z-scores). Wave-specific component Z-scores were summed to obtain composite CMR Z-scores. Four- and seven-year CMR change (CMR-diff W1–W4 and W1–W7). and average CMR risk (CMR-avg; (W1 + W4)/2 and (W1 + W7)/2) were calculated using the CMR Z-scores. W7 MetS was determined using adult criteria. Student’s t-test and receiver operating characteristic (ROC) curve were conducted. Results Participants meeting the adult criteria for MetS at W7 (74 of 416, 17.8%) had statistically significant (p<0.01) higher values for W1 CMR Z-scores (0.92 vs. −0.21), W4 CMR Z-scores (1.69 vs. −0.28), W7 CMR Z-scores (2.21 vs. −0.55), W1–W4 CMR-avg (1.53 vs. −0.27), W1–W7 CMR-diff (1.29 vs. −0.21), and W1–W7 CMR-avg (1.46 vs. −0.48) than those not meeting MetS criteria. Most results were similar for males and females in the sex-stratified analyses. The areas under the ROC curve were 0.61, 0.71, and 0.75 for W1, W4 and W7 Z-scores. Conclusions Findings support the validity of the continuous CMR Z-scores calculated using linear regression in evaluating and monitoring CMR profiles from adolescence to early adulthood.

Comparing the validity of continuous metabolic syndrome risk scores for predicting pediatric metabolic syndrome: the CASPIAN-V study

2019 ◽  
Vol 32 (4) ◽  
pp. 383-389 ◽  
Author(s):  
Mehri Khoshhali ◽  
Ramin Heshmat ◽  
Mohammad Esmaeil Motlagh ◽  
Hasan Ziaodini ◽  
Mahdi Hadian ◽  
...  
Keyword(s):  
Metabolic Syndrome ◽  
Fasting Blood Glucose ◽  
Density Lipoprotein ◽  
Principal Component ◽  
Hdl Cholesterol ◽  
Cross Sectional Study ◽  
Risk Scores ◽  
Cross Sectional ◽  
Z Scores ◽  
Iranian Children

Abstract Background The aim of this study was to compare the validity of various approaches to pediatric continuous metabolic syndrome (cMetS) scores including siMS scores (2 waist/height + fasting blood glucose [FBG]/5.6 + triglycerides [TG]/1.7 + systolic blood pressure [BP]/130 + high-density lipoprotein [HDL]/1.02), Z-scores, principal component analysis (PCA) and confirmatory factor analysis (CFA) for predicting metabolic syndrome (MetS). Methods This nationwide cross-sectional study was conducted on 4200 Iranian children and adolescents aged 7–18 years. The cMetS was computed using data on HDL, cholesterol, TGs, FBG, mean arterial pressure (MAP) and waist circumference (WC). The areas under the receiver operating characteristic curves (AUCs) were used to compare the performances of different cMetS scores. Results Data of 3843 participants (52.4% boys) were available for the current study. The mean (standard deviation [SD]) age was 12.6 (3) and 12.3 (3.1) years for boys and girls, respectively. The differences in AUC values of cMetS scores were significant based on the Delong method. The AUCs (95% confidence interval [CI]) were for Z-scores, 0.94 (0.93, 0.95); first PCA, 0.91 (0.89, 0.93); sum PCA, 0.90 (0.88, 0.92), CFA, 0.79 (0.76, 0.3) and also for siMS scores 1 to 3 as 0.93 (0.91, 0.94), 0.92 (0.90, 0.93), and 0.91 (0.90, 0.93), respectively. Conclusions The results of our study indicated that the validity of all approaches for cMetS scores for predicting MetS was high. Given that the siMS scores are simple and practical, it might be used in clinical and research practice.

scholarly journals The Clustering of Low Diet Quality, Low Physical Fitness, and Unhealthy Sleep Pattern and Its Association with Changes in Cardiometabolic Risk Factors in Children

Nutrients ◽  
2020 ◽  
Vol 12 (2) ◽  
pp. 591
Author(s):  
Xianwen Shang ◽  
Yanping Li ◽  
Haiquan Xu ◽  
Qian Zhang ◽  
Ailing Liu ◽  
...  
Keyword(s):  
Physical Activity ◽  
Risk Factors ◽  
Blood Pressure ◽  
Diet Quality ◽  
Cardiometabolic Risk ◽  
Fasting Glucose ◽  
Density Lipoprotein ◽  
Sleep Pattern ◽  
Cardiometabolic Health ◽  
Z Scores

The clustering of diet quality, physical activity, and sleep and its association with cardiometabolic risk (CMR) factors remains to be explored. We included 5315 children aged 6–13 years in the analysis. CMR score (CMRS) was computed by summing Z-scores of waist circumference, an average of systolic and diastolic blood pressure, fasting glucose, high-density lipoprotein cholesterol (multiplying by −1), and triglycerides. Low diet quality and low cardiorespiratory fitness (CRF) were more likely to be seen in a pair, but low diet quality was less likely to be clustered with unhealthy sleep patterns. Low diet quality, low CRF, and unhealthy sleep pattern was associated with a 0.63, 0.53, and 0.25 standard deviation (SD) higher increase in CMRS, respectively. Compared to children with no unhealthy factor (−0.79 SD), those with ≥1 unhealthy factor had a higher increase (−0.20 to 0.59 SD) in CMRS. A low diet quality-unhealthy sleep pattern resulted in the highest increase in CMRS, blood pressure, and triglycerides. A low diet quality–low CRF-unhealthy sleep pattern resulted in the highest increase in fatness and fasting glucose. Unhealthy factor cluster patterns are complex; however, their positive associations with changes in CMR factors are consistently significant in children. Some specific patterns are more harmful than others for cardiometabolic health.

scholarly journals Traditional Brazilian Diet and Olive Oil Reduce Cardiometabolic Risk Factors in Severely Obese Individuals: A Randomized Trial

Nutrients ◽  
2020 ◽  
Vol 12 (5) ◽  
pp. 1413 ◽  
Author(s):  
Annelisa Silva e Alves de Carvalho Santos ◽  
Ana Paula dos Santos Rodrigues ◽  
Lorena Pereira de Souza Rosa ◽  
Matias Noll ◽  
Erika Aparecida Silveira
Keyword(s):  
Olive Oil ◽  
Cardiometabolic Risk ◽  
Low Density Lipoprotein ◽  
Virgin Olive Oil ◽  
Density Lipoprotein ◽  
Extra Virgin Olive Oil ◽  
Severely Obese ◽  
Secondary Endpoints ◽  
Student’S T ◽  
Risk Parameters

Cardioprotective effects associated with extra virgin olive oil (EVOO) have been studied within the Mediterranean diet. However, little is known about its consumption in the traditional Brazilian diet (DieTBra) or without any dietary prescription, particularly in severely obese individuals. This study aimed to assess the effectiveness of DieTBra and EVOO in cardiometabolic risk factor (CMRF) reduction in severely obese individuals. We conducted a parallel randomized clinical trial with 149 severely obese individuals (body mass index ≥ 35.0 kg/m2) aged 18–65 years, assigned to three groups: 52 mL/day of EVOO (n = 50), DieTBra (n = 49), and DieTBra + 52 mL/day of EVOO (n = 50). Participants were followed up for 12 weeks. Low-density lipoprotein cholesterol (LDL-c) was the primary endpoint and several cardiometabolic parameters were secondary endpoints. Endpoints were compared at baseline and at the end of the study using analysis of variance, the Kruskal–Wallis test, and Student’s t-test. The TC/High-density lipoprotein (HDL) ratio (−0.33 ± 0.68, p = 0.002) and LDL/HDL ratio (−0.26 ± 0.59, p = 0.005) decreased in the EVOO group. Delta values for all variables showed no significant statistical difference between groups. However, we highlight the clinical significance of LDL-c reduction in the EVOO group by 5.11 ± 21.79 mg/dL and in the DieTBra group by 4.27 ± 23.84 mg/dL. We also found a mean reduction of around 10% for Castelli II (LDL/HDL) and homocysteine in the EVOO group and TG and the TG/HDL ratio in the DieTBra group. EVOO or DieTBra when administered alone lead to reduction in some cardiometabolic risk parameters in severely obese individuals.

scholarly journals Meal Patterns and Changes in Cardiometabolic Risk Factors in Children: A Longitudinal Analysis

Nutrients ◽  
2020 ◽  
Vol 12 (3) ◽  
pp. 799
Author(s):  
Xianwen Shang ◽  
Yanping Li ◽  
Haiquan Xu ◽  
Qian Zhang ◽  
Ailing Liu ◽  
...  
Keyword(s):  
Cardiometabolic Risk ◽  
Density Lipoprotein ◽  
Positive Association ◽  
High Protein ◽  
Carbohydrate Intake ◽  
Meal Patterns ◽  
Low Carbohydrate ◽  
Favorable Change ◽  
Z Scores ◽  
Beta Coefficient

We examined whether energy and macronutrient intake from different meals was associated with changes in cardiometabolic risk (CMR) factors in children. CMR score (CMRS) was computed by summing Z-scores of waist circumference, the average of systolic and diastolic blood pressure, fasting glucose, high-density lipoprotein cholesterol (multiplying by −1), and triglycerides. We included 5517 children aged 6–13 years from six major cities in China. Five meal patterns were identified according to energy intake: balanced, breakfast dominant, lunch dominant, dinner dominant, and snack dominant patterns. These patterns were not significantly associated with changes in CMR factors. Carbohydrate intake (% energy) at lunch was positively associated with the change in CMRS (beta coefficient (95% CI): (0.777 (0.509, 1.046) in quintile 5 versus quintile 1). A positive association between carbohydrate intake at dinner and change in CMRS was observed. High protein intake at both lunch and dinner was associated with a favorable change in CMRS. Moderate fat intake at lunch was associated with a lower increase in CMRS. Meal patterns driven by energy were not significantly associated with CMR factors; however, a low carbohydrate-high protein-moderate fat lunch and low carbohydrate-high protein dinner were associated with favorable changes in CMRS in children.

scholarly journals Handgrip Strength and Current Smoking Are Associated with Cardiometabolic Risk in Korean Adolescents: A Population-Based Study

2020 ◽  
Vol 17 (14) ◽  
pp. 5021
Author(s):  
Sae Yun Kim ◽  
Jung Soo Lee ◽  
Yeo Hyung Kim
Keyword(s):  
Cardiometabolic Risk ◽  
Handgrip Strength ◽  
Risk Index ◽  
Density Lipoprotein ◽  
Population Based ◽  
Cardiometabolic Health ◽  
Inverse Association ◽  
Current Smoking ◽  
Z Scores ◽  
Independent Association

This study aimed to identify the independent association of handgrip strength and current smoking with cardiometabolic risk in adolescents. Data of 1806 adolescents (12–18 years) from the Korea National Health and Nutrition Examination Surveys were analyzed by complex samples logistic regression analyses. Handgrip strength was normalized by body weight into relative handgrip strength. A cardiometabolic risk index score was calculated from the z-scores of the following components: waist circumference, triglycerides, high-density lipoprotein cholesterol, glucose, and blood pressure. Relative handgrip strength showed an inverse association with high cardiometabolic risk, with an adjusted odds ratio of 8.5 (95% confidence interval [CI], 3.7–19.3) for boys and 5.7 (95% CI, 2.9–11.2) for girls on comparing the lowest and the highest age-and sex-specific quartiles of relative handgrip strength. The adjusted odds ratios for high cardiometabolic risk on comparing the second quartile and the highest quartile of relative handgrip strength were 3.9 (95% CI, 1.7–8.9) in boys and 2.6 (95% CI, 1.3–5.3) in girls. Current smoking was independently associated with high cardiometabolic risk in boys aged 15–18 years. These findings suggest the need to increase muscle strength in adolescents and reduce smoking in older boys to promote cardiometabolic health.

Abstract P179: Abdominal Skin-fold Thickness Improves Anthropometric Prediction of Insulin Resistance in Prepubescent Colombian Children

Circulation ◽  
2012 ◽  
Vol 125 (suppl_10) ◽  
Author(s):  
Noel T Mueller ◽  
Mark A Pereira ◽  
Adriana Buitrago ◽  
Diana C Rodriguez ◽  
Alvaro E Duran ◽  
...  
Keyword(s):  
Insulin Resistance ◽  
Waist Circumference ◽  
Roc Curve ◽  
Cardiometabolic Risk ◽  
Model Assessment ◽  
Z Score ◽  
Anthropometric Measures ◽  
Cross Sectional ◽  
Final Model ◽  
Z Scores

Introduction: Body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR), have been considered poor measures of cardiometabolic risk in children, in whom increases in these measures may reflect increases in lean mass more so than fat mass. Hypothesis: We examined the hypothesis that abdominal skinfolds (ASF) have better predictive value than BMI and other anthropometric measures for identifying insulin resistance (IR) in prepubescent Colombian children. Methods: We used data from a population-based cross-sectional study of 1,262 children, aged 6-10 y, in Bucaramanga, Colombia. Logistic regression stepwise variable selection (P<0.05 for entry and retention) was performed to identify anthropometric predictors of IR, as determined by homeostatic model assessment (HOMA). Receiver operating characteristic (ROC) curves were used to compare area under the curve (AUC). Results: There were 57 boys and 70 girls classified as IR (HOMA >90th percentile). Among anthropometric measures compared - including WC, WHtR, and four skinfolds - only age- and sex-specific ASF and BMI z-scores were retained as independent anthropometric predictors of IR. Prediction of IR was marginally better using ASF z-scores than BMI z-scores (P for contrast= 0.13). However, the final Model, which included both ASF and BMI, significantly increased the AUC from 0.80 (95% CI: 0.75-0.84) to 0.82 (95% CI: 0.78-0.86) - an improvement of 0.02 (95% CI: 0.004-0.04; P for contrast= 0.01)(see table ). In the final Model, after adjusting for BMI z, a 1-SD increment in ASF z was associated with 2.38 (95% CI: 1.74-3.26) greater odds of IR; whereas a 1-SD increment in BMI z, after adjustment for ASF z, was associated with 1.46 (95% CI: 1.11-1.91) greater odds of IR. Conclusions: ASF was independent from and marginally better than BMI in predicting IR in Colombian children. Furthermore, integration of ASF with BMI improved IR risk stratification compared to BMI alone, opening new perspectives in the prediction of cardiometabolic risk in children. ROC Curve Contrast Estimation and Testing Results for Anthropometric Measures of Insulin Resistance ROC Curve Contrasts Difference in AUC 95% CI P for Contrast WCz - BMIz 0.006 (-0.016, 0.028) 0.622 WHtRz - BMIz −0.045 (-0.074, -0.016) 0.002 ASFz - BMIz 0.018 (-0.005, 0.040) 0.126 Model (ASFz + BMIz) - BMIz 0.021 (0.004, 0.038) 0.014 BMI z-score (BMIz) was used as reference in all contrast estimates and tests against waist circumference z-score (WCz), waist-to-height z-score (WHtRz), abdominal skinfolds z-score (ASFz), and the best stepwise-selection Model (includes ASFz + BMIz)

scholarly journals Investigation of Hypoglycemic and Hypolipidemic Effects of Methanolic Extracts of Bitter Leaf [Vernonia amygdalina Delile] in Male Rats

2020 ◽  
pp. 30-37
Author(s):  
Kazeem B. Bawa ◽  
Ayobola A. Iyanda
Keyword(s):  
Diabetes Mellitus ◽  
Fasting Blood Glucose ◽  
Density Lipoprotein ◽  
Diabetic Rats ◽  
Male Rats ◽  
Metformin Hydrochloride ◽  
Vernonia Amygdalina ◽  
Methanolic Extracts ◽  
Group A ◽  
Student’S T

Different agents used for treatment of diabetes mellitus are associated with serious adverse effects. This necessitates the scientific quest for substitutes that are comparatively less noxious- usually medicinal plants (e.g. Vernonia amygdalina Delile). Diabetes was induced in rats in groups A-D using alloxan. Group E served as control. Once daily for 28 days, diabetic rats in groups B and C were treated with 50 & 100 mg/kg BW of methanolic extracts of Vernonia amygdalina respectively while group D rats were administered with metformin hydrochloride (250 mg/Kg BW). Rats in group A served as untreated diabetic group. Fasted blood samples were collected for estimation of fasting blood glucose (FBG); total cholesterol (TC), triglyceride (TG), and high density lipoprotein-cholesterol (HDL-C) using standard biochemical methods. Statistical analysis was carried out using Student’s t test, P<0.05 was considered significant. After treatment, there were significant decreases in levels of FBG, TC, TG, LDL-C but increase level of HDL-C of B, C, & D when compared with group A. results of the study suggest that methanolic extract of V. amygdalina possesses antidiabetic properties and anti-hypolipidemic effects; this may explain why this plant is traditionally used for the management of diabetes mellitus and its complications.

scholarly journals Genetically Higher Level of Mannose Has No Impact on Cardiometabolic Risk Factors: Insight from Mendelian Randomization

Nutrients ◽  
2021 ◽  
Vol 13 (8) ◽  
pp. 2563
Author(s):  
Mohsen Mazidi ◽  
Abbas Dehghan ◽  
Maciej Banach ◽  
Keyword(s):  
Risk Factors ◽  
Cardiometabolic Risk ◽  
Mendelian Randomization ◽  
Association Studies ◽  
Fasting Blood Glucose ◽  
Density Lipoprotein ◽  
Cardiometabolic Risk Factors ◽  
Significant Heterogeneity ◽  
Genome Wide Association Studies ◽  
Leave One Out

Background: There is a handful of controversial data from observational studies on the serum levels of mannose and risks of coronary artery disease (CAD) and other cardiometabolic risk factors. We applied Mendelian Randomization (MR) analysis to obtain estimates of the causal effect of serum mannose on the risk of CAD and on cardiometabolic risk factors. Methods: Two-sample MR was implemented by using summary-level data from the largest genome-wide association studies (GWAS) conducted on serum mannose and CAD and cardiometabolic risk factors. The inverse variance weighted method (IVW) was used to estimate the effects, and a sensitivity analysis including the weighted median (WM)-based method, MR-Egger, MR-Pleiotropy RESidual Sum and Outlier (PRESSO) were applied. Radial MR Methods was applied to remove outliers subject to pleiotropic bias. We further conducted a leave-one-out analysis. Results: Mannose had no significant effect on CAD (IVW: odds ratio: 0.96 (95% Confidence Interval (95%CI): 0.71−1.30)), total cholesterol (TC) (IVW: 95%CI: 0.60−1.08), low density lipoprotein (LDL) (IVW: 95%CI = 0.68−1.15), high density lipoprotein (HDL) (IVW: 95%CI = 0.85−1.20), triglycerides (TG) (IVW: 95%CI = 0.38−1.08), waist circumference (WC) (IVW: 95%CI = 0.94−1.37), body mass index (BMI) (IVW: 95%CI = 0.93−1.29) and fasting blood glucose (FBG) (IVW: 95%CI = 0.92−1.33), with no heterogeneity for CAD, HDL, WC and BMI (all p > 0.092), while a significant heterogeneity was observed for TC (IVW: Q = 44.503), LDL (IVW: Q = 33.450), TG (IVW: Q = 159.645) and FBG (IVW: Q = 0. 32.132). An analysis of MR-PRESSO and radial plots did not highlight any outliers. The results of the leave-one-out method demonstrated that the links were not driven by a single instrument. Conclusions: We did not find any effect of mannose on adiposity, glucose, TC, LDL, TG and CAD.

Astaxanthin Supplementation Lowers Dietary Intake in Healthy Subjects

2020 ◽  
Vol 19 (1) ◽  
pp. 46-51
Author(s):  
Chuenjai Sratongfaeng ◽  
Nithipun Suksumek ◽  
Nithikoon Aksorn ◽  
Pithi Chanvorachote ◽  
Kulwara Meksawan
Keyword(s):  
Dietary Intake ◽  
Controlled Trial ◽  
Low Density Lipoprotein ◽  
Fasting Blood Glucose ◽  
Density Lipoprotein ◽  
Health Indicators ◽  
Lipoprotein Cholesterol ◽  
Blood Levels ◽  
Biological Parameters ◽  
Dietary Intakes

Astaxanthin, a potent antioxidant compound, is well recognized for its beneficial effects to protect from oxidative stress and free radicals. However, the effects of long period of use of astaxanthin on biological parameters, health indicators, and energy intake are still largely unknown. A total of 33 healthy participants aged 21–54 years with body mass index in the range of 18.50−24.90 kg/m2 were enrolled in this randomized controlled trial and were assigned into astaxanthin and placebo groups. The participants in the astaxanthin group received 4 mg of astaxanthin once daily for 12 consecutive weeks. Dietary intakes, as well as blood levels of astaxanthin and biological parameters, were investigated at baseline and week 12. The significant elevation of blood astaxanthin level in the astaxanthin group was notified at week 12. Regarding basic characteristics of blood biochemical parameters, results indicated that the fasting blood glucose, total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were not significantly different between astaxanthin and placebo groups at week 12. Interestingly, the significant decrease in total energy and carbohydrate intakes of the participants in the astaxanthin group (P < 0.05) was found after 12-week supplementation, compared to the baseline. The findings support the safety of long-term supplementation and reveal potential dietary intake lowering effect of astaxanthin in healthy individuals.

SMART STEP – SMARTphone-driven exercise and pedometer-based STEP intervention to promote physical activity among desk-based employees: Study protocol for a three-arm cluster randomized controlled trial

Work ◽  
2021 ◽  
pp. 1-17
Author(s):  
Baskaran Chandrasekaran ◽  
Chythra R Rao ◽  
Fiddy Davis ◽  
Ashokan Arumugam
Keyword(s):  
Physical Activity ◽  
Cognitive Performance ◽  
Sports Medicine ◽  
Cardiometabolic Risk ◽  
Controlled Trial ◽  
Fasting Blood Glucose ◽  
Subcutaneous Fat ◽  
Work Productivity ◽  
Sitting Time ◽  
Sickness Absenteeism

BACKGROUND: Prolonged sitting in desk-based office workers is found to be associated with increased cardiometabolic risk and poor cognitive performance. Technology-based physical activity (PA) interventions using smartphone applications (SmPh app) to promote PA levels might be effective in reducing cardiometabolic risk among sedentary population but the evidence remains inconclusive. OBJECTIVE: The objective is to investigate the effects of a technology-based PA intervention compared to PA education with a worksite manual or no intervention on PA levels, cardiometabolic risk, cognitive performance, and work productivity among desk-based employees. METHOD: A three-arm clustered randomized trial will be conducted. The study will be conducted among various administrative offices of a multifaceted university in India. Desk-based employees aged between 30 and 50 years (n = 159; 53 in each arm) will be recruited. Employees from various constituent institutions (clusters) of the university will be randomized into one of the three following groups - SMART: SmPh app-driven break reminders (visual exercise prompts) plus pedometer-based step intervention, TRADE: worksite PA education with a manual plus American College of Sports Medicine guided PA prescription, or CONTROL: usual work group. At baseline and after the 1st, 3rd and 6th month of the trial period, accelerometer-measured sitting time and PA levels, cardiometabolic risk (fasting blood glucose, triglycerides, insulin, blood pressure, heart rate variability, functional capacity, and subcutaneous fat), cognitive performance (executive function), sickness absenteeism and work limitations will be assessed by a blinded assessor. Therapist delivering interventions will not be blinded. CONCLUSION: This trial will determine whether a combined SmPh-app and pedometer-based intervention is more effective than education or no intervention in altering PA levels, cardiometabolic risk and cognitive performance among desk-based employees in India. This study has the potential to foster institutional recommendations for using SmPh-based technology and pedometers to promote PA at work.

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