Changes in Daily Steps and Body Mass Index and Waist to Height Ratio during Four Year Follow-Up in Adults: Cardiovascular Risk in Young Finns Study

In e na ional Jou nal o En i onmen al Resea ch and Public Heal h A icle Changes in Daily S eps and Body Mass Index and Wais o Heigh Ra io du ing Fou Yea Follow-Up in Adul s: Ca dio ascula Risk in Young Finns S udy Kaspe Salin 1,*, Mi ja Hi ensalo 1, Cos an G. Magnussen 2,3, Ris o Telama 1, Nina Hu i-Kähönen 4, Jo ma Viika i 2, Olli Rai aka i 2and Tuija Tammelin 5 1Facul y o Spo & Hea h Sciences, Uni e si y o Jy äskylä, 40014 Jy äskylän, Finland; [email p o ec ed] (M.H.); is o. [email p o ec ed] (R.T.) 2Resea ch Cen e o Applied and P e en i e Ca dio ascula Medicine and Depa men s o Clinical Physiology and In e nal Medicine, Uni e si y o Tu ku and Tu ku Uni e si y Cen al Hospi al, 20500 Tu ku, Finland; [email p o ec ed] (C.G.M.); [email p o ec ed] (J.V.); [email p o ec ed] (O.R.) 3Menzies Ins i u e o Medical Resea ch Hoba , Uni e si y o Tasmania, Hoba , TAS 7000, Aus alia 4 Depa men o Pedia ics, Uni e si y o Tampe e and Tampe e Uni e si y Hospi al, 33100 Tampe e, Finland; [email p o ec ed] 5LIKES Resea ch Cen e o Physical Ac i i y and Heal h, 40014 Jy äskylä, Finland; [email p o ec ed] *Co espondence: kaspe [email p o ec ed] Recei ed: 30 June 2017; Accep ed: 1 Sep embe 2017; Published: 5 Sep embe 2017 Abs ac : Aims: O e he s udy yea s, he e was a signi ican inc ease in body mass index (BMI) and wais - o-heigh a io (W HR) in middle aged Finnish adul s. Me hods: Da a we e ob ained om 1033 Finnish adul s om he Ca dio ascula Risk in Young Finns S udy in 2007 and 2011. Coho s udy pa icipan s wo e an Om on Walking S yle One (HJ-152R-E) pedome e o i e days and we e g ouped in o hose who inc eased, main ained and dec eased hei s eps be ween 2007 and 2011. Pai ed samples - es was used o compa e body mass index (BMI) and wais - o-heigh a io (W HR) change alues be ween he change g oups in s udy yea s. Resul s: Among s udy popula ion BMI and W HR inc ease be ween s udy yea s was s a is ically signi ican (p< 0.001). Only hose, who inc eased hei o al s eps o a leas 2000 s eps, main ained hei BMI in he same le el, while people who dec eased o main ained hei o al s eps in he same le el, BMI and W HR inc eased du ing ou yea s ollow-up. Conclusions: This da a sugges s ha inc easing s eps in middle age is associa ed wi h main aining BMI a he same le el. Keywo ds: physical ac i i y; pedome e ; adul s; ollow-up; body mass index; wais - o-heigh a io 1. Backg ound In ecen decades, physical inac i i y has eme ged as a majo heal h p oblem. Recen da a show physical inac i i y o be he ou h leading cause o dea h wo ldwide [ 1 ], wi h 6–10% o all dea hs om non-communicable diseases wo ldwide being a ibu able o physical inac i i y [ 2 , 3 ]. Physical inac i i y is also associa ed wi h obesi y and o he majo isk ac o s o ch onic disease [ 2 ]. Al hough leisu e ime physical ac i i y (PA) has inc eased, occupa ional PA has dec eased in high income and apidly de eloping coun ies wi h cu en es ima es sugges ing ha 31% o he wo ld’s popula ion is no mee ing PA ecommenda ions [ 4 ]. Du ing he 20 yea s ollow-up (1975–2014) o 19.2 million pa icipan s, BMI inc eased om 21.7 o 24.2 among men and om 22.1 o 24.4 among women [ 5 ]. O e all, he wo ldwide p opo ion o adul s wi h a BMI o 25 kg/m 2 o g ea e ha e inc eased om 28.8% o 36.9% in men and om 29.8% o 38.0% in women be ween he yea s 1980 and 2013 [6]. Based on sel - epo ed ques ionnai es, 48.6% o adul s in Finland do no mee he ecommenda ions o heal h enhancing physical ac i i y (HEPA) [ 7 ]. Howe e , sel - epo ed ques ionnai es o PA ha e In . J. En i on. Res. Public Heal h 2017,14, 1015; doi:10.3390/ije ph14091015 www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2017,14, 1015 2 o 10 se e al limi a ions when compa ed wi h objec i ely measu ed PA [ 8 ]. Recen da a ha e eme ged om s udies wi h objec i e measu emen s o PA [ 9 – 12 ] ha sugges a decline o o al PA and an inc ease o seden a y ime among adul s in economically de eloped coun ies. Howe e , he e a e signs o gende and age di e ences be ween coun ies. In some coun ies, he decline in daily s eps ha e been obse ed only among men [9], women [10], o in ce ain age g oups [9]. Obesi y is o en conside ed o be a esul o ei he excessi e ood in ake o insu icien physical ac i i y [ 13 ]. High seden a y ime is ela ed o highe body weigh and inc eased isk o obesi y [ 14 ]. In addi ion, low PA has been ound o be a isk ac o o highe p e a elnce o ad e se ca diome abolic heal h indica o s [ 15 ]. Recen s udies using objec i e measu emen s o PA ha e ound ha sho e m changes in daily s eps do no in luence body mass index (BMI) [ 16 ]. Simila ly, e en hough indi iduals ha e inc eased hei PA, he inc ease has no been enough o p e en weigh gain [ 17 ]. Likewise among obese indi iduals, he end o daily s eps is s able o e en declining while among no mal and o e weigh people end o daily s eps is inc easing among he adul popula ion in he USA [ 18 ]. In ecen s udies, i has been s a ed ha alongside BMI, o he measu es should be used o measu e cen al obesi y, like wais ci cum e ence, and wais - o-hip a io [ 19 ] and wais - o-heigh a io (W HR) [ 20 ]. No esea ch has examined he associa ions be ween PA change o e a longe ime pe iod using objec i e measu emen s wi h BMI, and W HR in popula ion-based samples. The e o e, he aim o his s udy is o e alua e changes in PA du ing a ou yea s ollow-up pe iod among Finnish adul s and explo e he associa ions be ween changes in daily s eps wi h changes o BMI and W HR. 2. Me hods 2.1. S udy Design and Pa icipan s Da a was ob ained om he ongoing coho s udy, Ca dio ascula Risk Young Finns S udy (YFS) ha began in 1980 [ 21 ]. The popula ion o his s udy consis ed o women and men aged 30, 33, 36, 39, 42 and 45 yea s who pa icipa ed in he 2007 and 2011 ollow-ups. In o al, he e we e 2204 pa icipan s who a ended clinics in 2007 o which 1874 (85.0%) comple ed he pedome e s udy. In 2011, 2005 (55.7% o he baseline pa icipan s) pa icipa ed in s udy clinics, o whom 1525 comple ed he pedome e s udy (76.1%). Pa icipan s who had a leas 5 eco ded days and a leas 8 h pe day o pedome e wea ime in bo h 2007 and 2011 we e included. The e o e, s ep da a om 1033 pa icipan s was used. F om hese pa icipan s, 1033 also had weigh and heigh da a a ailable. The s udy pa icipan s ga e w i en in o med consen in acco dance wi h he Helsinki Decla a ion and he s udy p o ocol was e iewed and app o ed by he e hics commi ee o he pa icipa ing uni e si ies (Decision numbe 533/2006). 2.2. An h opome ic Measu es Heigh , weigh , and wais ci cum e ence we e measu ed by educa ed and expe ienced measu e s (e.g., nu ses). Body mass index (BMI) was calcula ed as weigh (kg)/heigh (m) 2 . Wais - o-heigh a io (W HR) was calcula ed as wais (cm)/heigh (cm). 2.3. Measu emen o Physical Ac i i y Pa icipan s we e issued an Om on Walking S yle One (HJ-152R-E) pedome e and we e ins uc ed o a ach he pedome e du ing waking hou s on hei wais band o bel in he same posi ion o se en consecu i e days and o main ain a pedome e log. Based on ques ionnai e da a, he le el o sel - a ed PA did no di e signi ican ly be ween hose who pa icipa ed and who did no pa icipa e in he pedome e s udy in 2007. The s udy pa icipan s ga e w i en in o med consen and he s udy p o ocol was e iewed and app o ed by he e hics commi ee o he pa icipa ing uni e si ies. Pedome e logs we e used o eco d he ime o pedome e emo al and a he end o he day o eco d he s eps aken on he display. Pa icipan s we e asked o con inue wi h hei ypical ac i i ies In . J. En i on. Res. Public Heal h 2017,14, 1015 3 o 10 and o emo e he pedome e only while ba hing o swimming. Pa icipan s could epo commen s and p oblems abou hei pedome e use in he pedome e log and could con ac he s udy pe sonnel. On he 8 h day, pa icipan s we e ins uc ed o send hei pedome e log and he pedome e o he s udy cen e s using a padded mailbag in a sel -add essed, s amped en elope ha was p o ided o all pa icipan s. The Om on pedome e collec s ae obic s eps and minu es in addi ion o o al s eps. Ae obic s eps a e hose aken du ing ac i i ies ha las o a leas en minu es wi hou in e up ion a a pace o 60+ s eps pe minu e. We compa ed Om on Walking S yle One pedome e s wi h he s eps measu ed by Ac iG aph accele ome e s (GT1M) in a subsample o 45 pa icipan s o 6 o 7 successi e days ( o al o 304 days). The Spea man’s ank co ela ion coe icien was 0.966 (p< 0.001) [22]. All hose who had a leas i e eco ded days wi h a wea ime a leas 8 h, we e included in all analyses. Sickness o inju y s a us, excep ional s ep coun s epo ed as an un ypical day, o p oblems wi h pedome e use, we e conside ed and compensa ed by he mean o o he days. A daily wea ime was impu ed i he pa icipan had epo ed a leas wo days wea ime o eigh hou s. Pa icipan s epo ed se e al easons o daily nonpa icipa ion o in e up ion o pedome e wea . The main easons in 2007 we e los (n= 52) o b oken pedome e (n= 23), illness (n= 30), o o he easons such as un ypical day (n= 22). The emainde o he pa icipan s (n= 203) chose no o pa icipa e in he pedome e s udy o did no send pedome e in o ma ion back o he esea ch cen e . In 2011, main easons o nonpa icipa ion we e; los de ice (n= 1), illness (n= 105, and o he easons such as un ypical day (n= 31). The emainde o he pa icipan s (n= 388) chose no o pa icipa e in he pedome e s udy o did no send pedome e in o ma ion back o he esea ch cen e . The inal sample size was 1518 impu ed and co ec ed s eps in 2007 and 1359 in 2011. Toge he , he e we e 1033 pa icipan s who had p ope da a om bo h yea s. The e was no seasonal a ia ion in o al s eps be ween summe and win e mon hs nei he in 2007 (p= 0.677) no 2011 (p= 0.059) and wea ime was conside ed in he analyses. To al s eps and ae obic s eps we e used as con inuous a iables in desc ip i e analysis and in co ela ion analyses bu as ca ego ical a iables when analyzing upwa d and downwa d p opo ions o change om 2007 o 2011. Changes in daily s eps be ween he ollow-up (2007 & 2011) we e ca ego ized o wo main ca ego ies (inc ease s and dec ease s) and hese we e di ided o h ee mo e subca ego ies depending on he amoun o inc ease/dec ease (>2000/1000–1999/0–999 s eps/day). In u he analysis, hese g oups we e me ged o h ee ca ego ies inc ease s (>2000 s eps/day o mo e), dec ease s (>2000 s eps/day o mo e) and main aine s (0–1999 s eps/day inc ease o dec ease). The same ca ego ies we e also used in he compa ison o BMI change among pa icipan s. Ae obic s eps we e classi ied in h ee ca ego ies acco ding o change in ae obic s eps/day be ween 2007 and 2011 (1) Main aine s (inc ease o dec ease <1000 s eps/day), (2) Dec ease s (decline > 1000 s eps/day), and (3) Inc ease s (inc ease >1000 s eps/day) (Table 1). Table 1. Changes in daily s eps and ae obic s eps om 2007 o 2011, N= 1033. Change in S eps % o Pa icipan s in Each Ca ego y To al S eps/Day All Women Men Inc ease ≥2000 25.3 (261) 24.8 (130) 25.8 (131) Main ain 56.1 (579) 59.2 (311) 52.8 (268) Dec ease > 2000 18.7 (193) 16.0 (84) 21.5 (109) Ae obic S eps */Day Inc ease (+1000) 24.7 (255) 25.1 (132) 24.2 (123) Main ain 47.9 (495) 44.8 (235) 51.2 (260) Dec ease (−1000) 27.4 (283) 30.1 (158) 24.6 (125) * Ae obic s eps a e hose aken du ing ac i i ies ha las o a leas en minu es wi hou in e up ion a a pace o 60+ s eps pe minu e. In . J. En i on. Res. Public Heal h 2017,14, 1015 4 o 10 2.4. S a is ical Analysis Pa icipan desc ip i es o 2007 and 2011 a e shown as mean ± SD o no mally dis ibu ed a iables and median (25 h, 75 h pe cen ile) o o al and ae obic s eps pe day owing o igh -skewed dis ibu ions. Co ela ion be ween s ep changes and BMI changes (and W HR change) we e calcula ed wi h Pea son’s co ela ion o ind ou linea associa ion be ween PA and BMI and W HR change. Pea son’s co ela ion was used o ind whe he he e a e associa ions be ween BMI and W HR changes and s ep changes. P opo ion o pa icipan s in inc ease s’, main aine s’, and dec ease s PA g oups (mee ing he h ee ca ego ies desc ibed abo e) a e displayed as p opo ions o males, emales and he o al sample. Pai ed samples - es was used o compa e BMI alues among hose who dec eased, inc eased o main ained hei s eps be ween 2007 and 2011. All s a is ical analyses we e pe o med using SPSS e sion 22.0 (IBM, New Yo k, NY, USA). Signi icance le el was se o 0.05. 3. Resul s Table 1shows he p opo ions o pa icipan s ac oss he change in s ep ca ego ies. 25.3% o pa icipan s (women = 24.8%, men 25.8%) inc eased and 18.7% (women = 16.0%, men = 21.5%) dec eased hei ac i i y by a leas 2000 o al s eps be ween 2007 and 2011. The e was no di e ence in he p opo ion o men and women be ween he inc ease and dec ease change g oups (p= 0.726). To ally, 47.9% o he pa icipan s (women = 44.8%, men = 51.2%) did no change ae obic s eps pe day ( ± <1000 s eps) while abou one ou h dec eased o inc eased hei ae obic s eps. Among women he e we e mo e changes in ae obic s eps han among men (p< 0.001). A highe p opo ion o women ei he dec eased (30.1%) o inc eased (25.1%) hei ae obic s ep coun s compa ed wi h men (dec eased, 24.6%; inc eased, 24.2%). Table 2shows he cha ac e is ics o he 1033 pa icipan s included in he inal sample. In 2007, pa icipan s a e aged 7713 o al s eps/day and 1999 ae obic s eps/day. In 2011, pa icipan s a e aged 8112 o al s eps/day and 1986 ae obic s eps/day. O e all, 56.5% o pa icipan s had mo e o al s eps/day in 2011 han 2007 and 51.5% had mo e ae obic s eps/day in 2011 han 2007 (p< 0.001). In 2007, 19.0% o adul s we e ac i e (mo e han 10,000 s eps daily), while in 2011 he pe cen age was 24.8, (p< 0.001). In 2007, 48.9% o pa icipan s we e inac i e (<5000 s eps pe day) compa ed wi h 47.3% in 2011. In bo h yea s, app oxima ely a qua e o men did no achie e any ae obic s eps. BMI changed among pa icipan s om 25.6 o 26.1 du ing he ollow-up pe iod (p< 0.001) and W HR om 0.51 o 0.53 (p= 0.001). A e age weigh gain be ween he s udy yea s was 2.6 kg among women and 1.1 kg among men (p< 0.001). BMI change had a signi ican co ela ion wi h s ep change ( 2 = − 0.146, p= 0.001) and ae obic s ep change ( − 0.075, p= 0.005). W HR change had a signi ican co ela ion wi h s ep change ( 2=−0.100, p= 0.01) and ae obic s ep change ( 2=−0.091, p= 0.05). BMI le els in 2007 and 2011 a e shown o inc eases’, main aine s’, and dec ease s’ PA g oups in Figu es 1and 2. Among hose who inc eased hei daily s eps by mo e han 2000, BMI s ayed a he same le el (p= 0.077). Among hose who main ained hei daily s eps, BMI inc eased (p< 0.001). Among hose, who dec eased hei daily s eps BMI inc eased (p< 0.001). Among hose who s ayed inac i e (n= 67) (<5000 s eps in bo h yea s), BMI in 2007 (26.9) inc eased signi ican ly o yea 2011 (27.7) (p= 0.003) . BMI inc eased in all ae obic s ep change g oups. W HR inc eased among women (p= 0.029–<0.001) bo h in o al and ae obic s ep g oups, while among men in inc ease s g oup W HR did no change (p= 0.140–0.229). In . J. En i on. Res. Public Heal h 2017,14, 1015 5 o 10 Table 2. Baseline cha ac e is ics o he s udy pa icipan s in 2007 and 2011 (N= 1033). Demog aphics Women Men 2007 (n= 641) 2011 (n= 641) p-Value 2007 (n= 392) 2011 (n= 392) p-Value Age (yea s), mean (SD) 38.2 (5.0) 42.2 (4.9) 38.1 (5.0) 42.0 (5.0) Educa ion, yea s mean (SD) 15.8 (3.3) 15.7 (3.4) 15.0 (3.4) 15.0 (3.5) Weigh (kg) 69.9 (14.7) 72.5 (16.3) <0.001 86.4 (15.5) 87.5 (16.0) <0.001 Heigh (cm) 165.9 (6.0) 165.9 (5.7) 179.6 (6.6) 179.8 (6.6) BMI (kg/m2) mean (SD) 25.1 (4.6) 25.8 (5.0) <0.001 26.5 (4.0) 26.7 (4.1) 0.008 W HR 0.50 (0.07) 0.53 (0.08) 0.53 (0.06) 0.54 (0.07) <0.001 Pedome e alues (s eps/day) To al s eps/day 25 h Median 75 h 25 h Median 75 h 25 h Median 75 h 25 h Median 75 h Ae obic s eps/day 6045 7702 9568 6239 8029 10,312 5202 7016 9093 5458 7049 9397 666 2092 3478 498 1820 3687 0 821 2280 0 759 1940 In . J. En i on. Res. Public Heal h 2017,14, 1015 6 o 10 In . J. En i on. Res. Public Heal h 2017, 14, 1015 6 o 10 Figu e 1. BMI in 2007 and 2011 in women and men acco ding o change g oups (inc ease, main ain o dec ease) o o al s eps om 2007 o 2011. p- alues o di e ence be ween 2007 and 2011. Figu e 2. BMI change in he di e en ae obic s ep change g oups among men and women wi h p- alues, 2007–2011. 4. Discussion Unlike in ea lie s udies [9–11], in his s udy o e all PA measu ed by daily s eps seems o be inc easing in midli e du ing ou yea s ollow-up pe iod. E en hough he change in o al s eps was no s a is ically signi ican , he di ec ion is encou aging. These esul s suppo he p e ious esul s ha BMI end o inc ease du ing middle-age [9]. In his s udy, i was ound ha inc easing daily s eps was associa ed wi h no change in BMI, while dec easing s eps o main aining s eps was associa ed wi h inc eases in BMI. This is in line wi h p e ious esul s ha e en hough indi iduals inc ease hei PA, weigh may s ill inc ease [16]. These esul s a e in line wi h p e ious s udies sugges ing ha highe s eps a e associa ed wi h main aining BMI in he same le el [11]. Likewise, lowe W HR is associa ed wi h highe le els o PA [23]. Gene ally in high-income coun ies leisu e- ime PA has inc eased in adul s, bu a he same ime, occupa ional PA has dec eased [4]. In his s udy, ae obic s eps had dec eased which may indica e dec eases in leisu e ime PA. The s udy popula ion may be in a ce ain episode o li e, when he e is 0.01 <0.001 <0.001 0.474 0.001 0.007 23.50 24.00 24.50 25.00 25.50 26.00 26.50 27.00 27.50 Inc ease >2000 No change Dec ease >2000 Women 2007 Women 2011 Men 2007 Men 2011 <0.001 <0.001 0.020 0.006 0.001 23.5 24 24.5 25 25.5 26 26.5 27 27.5 Inc ease >1,000 s eps No change Dec ease <1,000 s eps Women 2007 Women 2011 Men 2007 Men 2011 <0.001 Figu e 1. BMI in 2007 and 2011 in women and men acco ding o change g oups (inc ease, main ain o dec ease) o o al s eps om 2007 o 2011. p- alues o di e ence be ween 2007 and 2011. In . J. En i on. Res. Public Heal h 2017, 14, 1015 6 o 10 Figu e 1. BMI in 2007 and 2011 in women and men acco ding o change g oups (inc ease, main ain o dec ease) o o al s eps om 2007 o 2011. p- alues o di e ence be ween 2007 and 2011. Figu e 2. BMI change in he di e en ae obic s ep change g oups among men and women wi h p- alues, 2007–2011. 4. Discussion Unlike in ea lie s udies [9–11], in his s udy o e all PA measu ed by daily s eps seems o be inc easing in midli e du ing ou yea s ollow-up pe iod. E en hough he change in o al s eps was no s a is ically signi ican , he di ec ion is encou aging. These esul s suppo he p e ious esul s ha BMI end o inc ease du ing middle-age [9]. In his s udy, i was ound ha inc easing daily s eps was associa ed wi h no change in BMI, while dec easing s eps o main aining s eps was associa ed wi h inc eases in BMI. This is in line wi h p e ious esul s ha e en hough indi iduals inc ease hei PA, weigh may s ill inc ease [16]. These esul s a e in line wi h p e ious s udies sugges ing ha highe s eps a e associa ed wi h main aining BMI in he same le el [11]. Likewise, lowe W HR is associa ed wi h highe le els o PA [23]. Gene ally in high-income coun ies leisu e- ime PA has inc eased in adul s, bu a he same ime, occupa ional PA has dec eased [4]. In his s udy, ae obic s eps had dec eased which may indica e dec eases in leisu e ime PA. The s udy popula ion may be in a ce ain episode o li e, when he e is 0.01 <0.001 <0.001 0.474 0.001 0.007 23.50 24.00 24.50 25.00 25.50 26.00 26.50 27.00 27.50 Inc ease >2000 No change Dec ease >2000 Women 2007 Women 2011 Men 2007 Men 2011 <0.001 <0.001 0.020 0.006 0.001 23.5 24 24.5 25 25.5 26 26.5 27 27.5 Inc ease >1,000 s eps No change Dec ease <1,000 s eps Women 2007 Women 2011 Men 2007 Men 2011 <0.001 Figu e 2. BMI change in he di e en ae obic s ep change g oups among men and women wi h p- alues, 2007–2011. 4. Discussion Unlike in ea lie s udies [ 9 – 11 ], in his s udy o e all PA measu ed by daily s eps seems o be inc easing in midli e du ing ou yea s ollow-up pe iod. E en hough he change in o al s eps was no s a is ically signi ican , he di ec ion is encou aging. These esul s suppo he p e ious esul s ha BMI end o inc ease du ing middle-age [ 9 ]. In his s udy, i was ound ha inc easing daily s eps was associa ed wi h no change in BMI, while dec easing s eps o main aining s eps was associa ed wi h inc eases in BMI. This is in line wi h p e ious esul s ha e en hough indi iduals inc ease hei PA, weigh may s ill inc ease [16]. These esul s a e in line wi h p e ious s udies sugges ing ha highe s eps a e associa ed wi h main aining BMI in he same le el [ 11 ]. Likewise, lowe W HR is associa ed wi h highe le els o In . J. En i on. Res. Public Heal h 2017,14, 1015 7 o 10 PA [ 23 ]. Gene ally in high-income coun ies leisu e- ime PA has inc eased in adul s, bu a he same ime, occupa ional PA has dec eased [ 4 ]. In his s udy, ae obic s eps had dec eased which may indica e dec eases in leisu e ime PA. The s udy popula ion may be in a ce ain episode o li e, when he e is no so much ime o leisu e ime PA, (e.g., hey ha e amily esponsibili ies). Pe cen ages o inac i e and low ac i e pa icipan s in 2011 (47.3%) we e a bi highe han in a Danish popula ion (42.8%), bu lowe han in B azilian adul s (56.2%) [ 24 ]. Likewise, he pe cen age o hose who we e ac i e (24.7%) in 2011 was a bi lowe han in he Danish popula ion 29.3%) [ 10 ], bu clea ly highe han in B azilian adul s (12.9%) [ 16 ]. The di e ence o a highe pe cen age o ac i e Danish may be explained by a highe amoun o ac i e anspo in Denma k. While 19.5% o Finnish people walk o cycle o wo k [25], in Denma k he pe cen age o hose who solely cycle o wo k, is highe (25%) [26]. E en hough he mean a e age o ae obic s eps had dec eased, he amoun o hose who had inc eased hei ae obic s eps was 51.5%. In addi ion, in Finland he p opo ion o hose who we e ac i e (o e 10,000 s eps) inc eased om 19.0% (2007) o 24.8% (2011) while in Denma k among 18–75 yea s old adul s, i dec eased om 34.8% (2008) o 28.4% (2012). Likewise, in he Czech Republic, he amoun o hose who a e de ined as e y ac i e, a e dec easing be ween 2008 and 2013 [ 27 ]. In Finland impo ance o PA has highligh ed o yea s, and his may explain he eason why s eps ha e inc eased du ing he ollow-up pe iod. I meay be, ha in he Wes e n coun ies same kind o phenomenom will u n up in ecen yea s. In he u u e, mo e conce n should be di ec ed especially o hose men, who a e inac i e, since hey a e mo e likely o main ain a seden a y li es yle han women. Hence, mo e e o s should be di ec ed owa ds low ac i e men. Among women he e we e mo e changes in ac i i y be ween he wo occasions and s eps inc eased. Recen s udies ha e shown ha among low ac i e indi iduals, inc easing PA om low le els can signi ican ly in luence a educ ion in he mo ali y isk [ 28 ]. Among women mo e e o s should be di ec ed o encou aging main aining he PA. E en hough he e we e plen y o women who inc eased PA, he e we e especially low ac i e women a baseline who dec eased hei PA du ing he ollow-up. On he o he hand, mo e encou agemen should be di ec ed o all pa icipan o main ain hei physically ac i e li es yle and heal hy ea ing habi s. To ind ou he s abili y o PA, a igo ous analysis should be done o de e mine he ype o PA, wha kind o spo s keep people o be physically ac i e and wha kind o spo s a e mo e o less seasonal o occasional PA. Also u he examina ion could be di ec ed o li e ansi ions, e.g., pa en ing, g adua ing, and mo ing o ano he ci y and how o he heal h habi s (e.g., die ) is ela ed o hese changes. Measu ing PA wi h pedome e s includes se e al limi a ions. Fo example, pedome e s end o unde -de ec ce ain ac i i ies such as cycling and a e aken o du ing wa e -based ac i i ies, such as swimming [ 29 ]. Likewise, he e is he possibili y o eco ding o alse s eps du ing he day [ 30 ]. Hence, among some pa icipan s, he e is he possibili y o unde -de ec ion o PA. The e a e also se e al s eng hs in his s udy. Mos o he objec i ely measu ed PA among adul s ely on c oss-sec ional da a, ollow-up pe iod is sho , o s udy popula ion is small. In his s udy, same popula ion was ollowed ou -yea pe iod and alid da a was ob ained om 1033 pa icipan s. In addi ion, usage o di e en an h opome ic ma ke s gi es mo e eliabili y o he esul s. Howe e , lack o die da a as a p edic o o BMI and W HR changes is a limi a ion in his s udy. In he Ca dio ascula Risk S udy, i has been ound ha some die a y habi s (e.g., high in ake o swee be e ages and high sal among women and high in ake o F ench ies and milk) a e ela ed o weigh gain [ 31 ]. In he ollowing s udies in he u u e, con ounde s, e.g., educa ion, die and socioeconomic s a us will be s udied as a pa o he s udy. In he u u e, s ep change and BMI and/o W HR change s udies should include da a om ea ing habi s and changes in o he heal h beha io as well. 5. Conclusions Inc easing daily s eps du ing middle age is associa ed wi h main aining BMI a he same le el. In his s udy, i was ound ha inc easing daily s eps o 2000 s eps was associa ed main ain BMI a In . J. En i on. Res. Public Heal h 2017,14, 1015 8 o 10 he same le el as ou yea s be o e. Since indi iduals’ me abolic a e declines wi h age, PA should be inc eased wi h age o main ain BMI a he same le el as p e iously [ 32 ]. Main aining PA a he same le el as ou yea s be o e was associa ed wi h an inc ease in BMI. Also, one o he issues eme ging om his s udy is high s abili y o PA among men. Those who had low ac i i y in 2007 we e likely had low ac i i y in 2011. Acknowledgmen s: This wo k was suppo ed by Finnish Cul u al Founda ion, Minis y o Educa ion and Cul u e (Majo , g an numbe : 83/626/2014). We wish o hank Ha o Hakonen om he LIKES Resea ch Cen e o Physical Ac i i y and Heal h o s a is ical help wi h he s ep da a. Au ho Con ibu ions: Jo ma Viika i con ibu ed he design o he s udy. Mi ja Hi ensalo, and Kaspe Salin pe o med he s a is ical analysis, Kaspe Salin and Mi ja Hi ensalo d a ed he manusc ip . Mi ja Hi ensalo, Olli Rai aka i, Cos an G. Magnussen, Nina Hu i-Kähönen, Ris o Telama and Tuija Tammelin p o ided he da abases o he analysis, assis ed wi h he design and aided in he in e p e a ion o da a. All au ho s ead and app o ed he inal manusc ip . Con lic s o In e es : The au ho s decla e no con lic o in e es . Abb e ia ions BMI Body mass index YFS Young Finns S udy HEPA Heal h enhancing physical ac i i y PA Physical ac i i y SD S anda d de ia ion W HR Wais - o-heigh a io Re e ences 1. Kohl, H.W.; C aig, C.L.; Lambe , E.V.; Inoue, S.; Alkanda i, J.M.; Lee ongin, G.; Kahlmeie , S. The pandemic o physical inac i i y: Global ac ion o public heal h. Lance 2012,380, 294–305. 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