The Power to Move Kids

Category: Study Summaries

Canada Releases Sedentary Behaviour Guidelines for Children Aged 0-4

| March 27, 2012 | 2 Comments

SBRN is pleased to host regular summaries of peer-reviewed research in the area of sedentary behaviour, written by graduate students and young investigators working in a range of disciplines. Information on the author of today’s article can be found at the bottom of this post.  If you are interested in writing a summary of an article that you found interesting, please contact us here.

The full-text of today’s study is available for free through the website of Applied Physiology, Nutrition and Metabolism.  The article can be accessed here.

Introduction

Sedentary behaviour among children in the early years (defined in the paper as aged 0-4 years) is gaining increasing attention. Accumulating evidence suggests that the sedentary behaviour habits formed in this age group, in particular screen-based sedentary behaviour habits, have potential short- and long-term health implications. This evidence combined with the recognized public health importance of growth and development during this time period led the Canadian Society for Exercise Physiology to develop the first Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0-4 years). These guidelines addressed a need established by health care professionals, child care providers, and other stakeholders in Canada regarding guidance on sedentary behaviour in the early years. The purpose of this paper was to outline the process and outcomes for the development of these new national guidelines, which have just been released.

What was done?

The paper outlines three main steps that were involved in developing the guidelines. First, a systematic review was conducted to identify the best available evidence regarding sedentary behaviour and six health outcomes (adiposity, bone health, motor development, psychosocial health, cognitive development, cardio-metabolic health) among infants (<1 year), toddlers (1-2 years), and preschoolers (3-4 years). The evidence from the systematic review was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Second, a consensus meeting was held in December 2011with the Guideline Development and Research Committee to discuss the evidence from the systematic review and draft the guidelines. Third, in addition to the stakeholder input that was acquired throughout the process, a stakeholder consultation was conducted through an on-line survey to obtain feedback on the draft guidelines. All components were guided by the Appraisal of Guidelines for Research Evaluation (AGREE) II instrument, which assessed the scientific rigour and transparency of the entire guideline development process.

What was found?

In terms of the systematic review, the detailed results are published in a separate paper. In summary, 23 papers were included in the review that examined the effects of television viewing on adiposity, cognitive development, or psychosocial health. Overall, there was low to high quality evidence across the infant, toddler, and preschool age groups to suggest that television viewing is positively associated with adiposity and negatively associated with cognitive development and psychosocial health. However, consistent dose-response evidence was lacking; therefore, expert consensus, international harmonization, and stakeholder input was used to inform the guidelines. In terms of the stakeholder consultation, 925 stakeholders completed the survey and 92% completely agreed or agreed with the guideline documents. Furthermore, the 212 additional comments provided by the stakeholders were used to make revisions to the final guideline documents.

What are the guidelines?

“For healthy growth and development, caregivers should minimize the time infants (aged<1 year), toddlers (aged 1-2 years), and preschoolers (aged 3-4 years) spend being sedentary during waking hours. This includes prolonged sitting or being restrained (e.g., stroller, high chair) for more than 1 h at a time. For those under 2 years, screen time (e.g., TV, computer, electronic games) is not recommended. For children 2-4years, screen time should be limited to under 1 hr per day; less is better.”

The guidelines paper can be found at the link below, while information sheets can be accessed at www.csep.ca/guidelines.

Reference

Tremblay MS, LeBlanc AG, Carson V, Choquette L, Connor Gorber S, Dillman C, Duggan M, Gordon MJ, Hicks A, Janssen I, Kho ME, Latimer-Cheung AE, LeBlanc C, Murumets K, Okely AD, Reilly JJ, Stearns JA, Timmons BW, & Spence JC. Canadian Sedentary Behaviour Guidelines for the Early Years (aged 0-4 years). Appl. Physiol. Nutr. Metab. 2012.

Valerie Carson

 

About the author: Valerie Carson is in the final year of her PhD in the School of Kinesiology and Health Studies at Queen’s University. Her current research focuses on sedentary behaviour and health in young people.

 

Is Screen-Based Sedentary Behavior Associated with Change in Cardiorespiratory Fitness during Childhood?

| January 24, 2012 | 3 Comments

Image by {N}Duran

SBRN is pleased to host summaries of peer-reviewed research in the area of sedentary behaviour, written by graduate students and young investigators working in a range of disciplines. Information on the author of today’s article can be found at the bottom of this post.  If you are interested in writing a summary of an article that you found interesting, please contact us here.

Introduction

Cardiorespiratory fitness (CRF) has been shown to be negatively associated with metabolic risk factors in youth. On this basis researchers have examined relationships between physical activity (PA) and CRF, showing time spent in moderate-to-vigorous (MVPA) intensity activity to be associated with increased CRF. However with the recent appreciation of sedentary behaviour (SB) as an independent risk factor for health in children and adults, cross-sectional studies in children have reported SB to be independently (controlling for PA, BMI, Gender etc.) and negatively associated with indirect measures of CRF.

To elucidate the direction of this relationship longitudinal studies are required. No extant studies have examined independent relations between SB and change in CRF during childhood. Therefore Mitchell et al. sought to determine if time spent in screen-based SB was independently associated with changes in CRF in children from ages 11 to 13.

What did they do?

The authors reported a final sample of 2,097 boys and girls. CRF was measured using a 20m shuttle run test at ages 11 and 13. Number of laps completed was used as an indirect measure of CRF. At both time points participants self-reported the previous two days screen-based SB (i.e. TV/DVDs, Computer, & Game Console use) and time spent in VPA using the Self-Administered Physical Activity Checklist (SAPAC).

Gender, socioeconomic status (SES), household education level (HEL) and body mass index (BMI) were measured as covariates. Longitudinal regression models were used to determine if screen time was associated with changes at the 10th, 25th, 50th, 75th and 90th shuttle run lap percentiles from age 11 to 13, controlling for covariates.

What did they find?

Screen time increased by 0.3 h from ages 11 to 13, with the greatest increase seen for the children at the 75th percentile, but change in screen time did not differ by gender. The number of shuttle run laps was greater in boys compared to girls at baseline. In addition, there was an increase in number of laps from age 11 to 13 in boys, but not girls. Therefore associations between SB and CRF were examined for boys and girls separately. In boys screen time was negatively associated (adjusted for BMI, HEL and VPA) with changes in laps at the 25th, 50th and 75th shuttle run percentiles, but not at the 10th or 90th percentiles. The associations were progressively stronger from the 25th to the 75th percentiles.

In girls screen time was negatively associated with changes in laps at the 50th, 75th and 90th percentiles. As with boys, the strength of association increased from the 50th to the 90th shuttle run percentile in girls. Additionally, these associations were not ameliorated when controlling for MVPA, however this data was not reported.

What’s the take-home message?

Despite differential results for change in CRF between boys and girls, it appears for most children (those above the lower tail of the CRF distribution) that increased time spent engaged in screen-based SB may lead to lower CRF, regardless of how much PA they engage in. However the negative associations reported were not stable across the CRF distribution. That is, there appeared to be no significant relation at the lower end (10th percentile) in boys and girls, and at the upper end (90th percentile) in boys. The authors speculated that genetic predisposition may account for this non-uniform association, with some individuals at the lower end of the CRF distribution displaying a resistance to age and SB driven changes in CRF.

Whilst this is the first longitudinal study of SB-CRF relations in children, and included a large sample size, there are limitations. PA, SB and CRF were measured using indirect methods. Objective measurement of PA and SB and direct measurement of CRF may alter associations, as previous investigation using accelerometer measured SB in European adolescents, did not find the association between SB-CRF to be independent of MVPA.

Where possible, future research should employ objective/direct measures of PA, SB, and CRF and seek to replicate these findings in other ethnicities and age ranges.

Reference

Mitchell, J.A., Pate, R.R., & Blair, S.N. (In Press). Screen-Based Sedentary Behavior and Cardiorespiratory Fitness from Age 11 To 13. Medicine and Science in Sports & Exercise, Published Ahead of Print, DOI: 10.1249/MSS.0b013e318247cd73.

Ash Routen

About the author: Ash Routen is in the final months of his doctoral studies at the University of Worcester, UK examining the impact of pedometer interventions on habitual PA in kids, with an interest in the assessment of body composition and objective physical activity measurement in kids. He can be found on Twitter @AshRouten.

Standing Desks – Not Just For Adults Anymore

| November 17, 2011 | 0 Comments

SBRN is pleased to host weekly summaries of peer-reviewed research in the area of sedentary behaviour, written by graduate students and young investigators working in a range of disciplines. Information on the author of today’s article can be found at the bottom of this post.  If you are interested in writing a summary of an article that you found interesting, please contact us here.  

The AlphaBetter Standing Desk

I am a big fan of standing workstations – they reduce sedentary time, and they are extremely cheap.  In fact, I’m writing this post using a standing desk that I made for under $30.  But standing desks certainly aren’t mainstream at the moment, and they haven’t made many inroads into the holy grail of desk-work: schools.

The average child spends about 7 hours per day – half their waking hours – sitting down. Much of that sitting is done at school, so an obvious question is whether standing desks might be a way to reduce sedentary time for school-aged children.  A new study by Dr Mark Benden and colleagues has investigated that very question, and suggests that standing desks reduce sitting time, and may have real benefits for teachers as well.

What did they do?

Dr Benden and his team performed their study in a group of 4 first-grade classrooms – 2 classrooms were randomly allocated to receive desks that could be used while standing or sitting, while the other 2 classrooms used standard desks.  The intervention lasted an entire school year.  Kids were allowed to choose when they wanted to stand or sit.  Energy expenditure was objectively measured in both the treatment and control groups, and interviews were used to assess teacher and parent views of the standing workstations among the treatment group.

What did they find?

Although they were able to sit or stand as they pleased, students in the treatment group spent an overwhelming majority of their time standing.  An average of 91% of class-time was spent standing in the treatment group students, with 3/4 of the students standing 100% of the time they were at their desks.  Not surprisingly, students in the treatment group expended .18 more calories per minute than their peers in the control group (that’s an extra 10 calories per hour).  The difference between the two groups was even larger among overweight students – overweight children in the treatment group burned 0.38 calories per minute more than overweight students in the control group.

The standing desks also appear to get the thumbs up from teachers and parents:

…interviews with teachers and parents of students in the treatment group indicated a positive effect on child behavior and classroom performance, which is supported by the interviews with teachers and parents of students in the treatment group indicated a positive effect on child behavior and classroomperformance, which is supported by the literature.

The majority of parents (70%) whose children were in the treatment classrooms felt that standing in the classroom positively affected their child’s classroom behavior. A
teacher in one of the treatment classrooms stated:

“When standing, the students were more focused, and I could keep their attention for longer. . . . I have one student with severe ADHD, and this really helped him academically.”

What is the take-home message?

This pilot study suggests that sit-stand desks may be a viable way to reduce sedentary time for young children, without having a deleterious impact on the teaching environment. While the differences in caloric expenditure between the two groups wasn’t enormous, it’s still a step in the right direction.  Personally, I am more interested in the impact of sedentary behaviour on markers of cardiometabolic risk (insulin, glucose, triglycerides, cholesterol, etc), and unfortunately this study did not assess whether there were any differences in these risk factors between groups.  But I know there are plans for other, larger studies examining the impact of standing desks in more detail, and hopefully they will begin to assess some of these other risk factors then.

I have included a video below of a similar experiment in Minnesota, which used standing desks with little swings for moving your feet while you stand.  That’s something I had never thought of before, but I think it’s a great idea – I’d love to have that option working at my standing desk right now!

Reference: Benden ME, Blake JJ, Wendel ML, & Huber JC Jr (2011). The impact of stand-biased desks in classrooms on calorie expenditure in children. American journal of public health, 101 (8), 1433-6 PMID: 21421945

Travis Saunders

 

About the author: Travis Saunders is a PhD student researching the relationship between sedentary time and chronic disease risk in children and youth. He is also a Certified Exercise Physiologist and competitive distance runner. You can connect with Travis on Twitter.

This article was originally published on Obesity Panacea.

 

Standing Desks: Do they work?

| November 10, 2011 | 3 Comments

SBRN is pleased to host weekly summaries of peer-reviewed research in the area of sedentary behaviour, written by graduate students and young investigators working in a range of disciplines. Information on the author of today’s article can be found at the bottom of this post.  If you are interested in writing a summary of an article that you found interesting, please contact us here.

Me at my desk

Introduction

It should come as no surprise that the office is a primary setting for the accumulation of sedentary time in adults. Recent research has even indicated that sedentary occupations are associated with negative health consequences such as heart disease and type 2 diabetes. To make matters worse, we are currently in the midst of a disturbing trend in occupational energy expenditure. Data from the last 50 years has indicated that occupational energy expenditure has fallen by approximately 140 calories for men and 120 calories for women. While this may not seem like a lot, it does account for a a significant amount of weight gain over the last five decades. In order to combat sedentary time in the workplace many individuals have begun modify their work environment by installing standing or treadmill-based desks. Gilson et al. sought to examine the efficacy and utility of standing “hot desks” for sedentary office workers.

What did they do?
The authors recruited 11 participants who worked in an office with an open floor plan. They were each given a SenseWear activity monitoring device to wear during waking hours for two weeks. During the first week the participants maintained their normal office behavior. Before the second week of data collection the authors installed four height adjustable desks. Each desk was equipped so that any employee could accomplish their normal tasks while at the desk. The participants were given information about reducing sedentary time and encouraged to use the desks. Participants recorded their desk usage (frequency, duration, sitting vs. standing) via log books.

What did they find?

Although the desk were adjustable, during the intervention period the desk were only used in standing positions. On average, participants used the desks for one hour per day. Mean usage was highly variable with a minimum of no use and a maximum of 9.5 hours of use over the 5 day intervention period. Data gathered from the SenseWear accelerometer indicated that there was no significant changes in sedentary, light, or moderate intensity activity.

What is the take home message?

To date, this is the first study to examine the effects of using standing desks in a free-living office environment. It appears that providing office employees with standing workstations will increase time spent standing and working. Although this is worthwhile result, the change in behavior is not reflected in objective monitored sedentary time. There are many possible explanations, but this speaks to the issue of using objective monitors, primarily accelerometers, to measure sedentary behaviors. Accelerometers work by measuring ground reaction force in different planes. If there is no movement, for example when standing still, the data may be misinterpreted as sedentary time. Future research should employ more sophisticated sensors such as the ActivPal that can differentiate between sitting and standing.

Reference: Nichols D. Gilson, Alessandro Suppini, Gemma C. Ryde, Helen E. Brown, Wendy J. Brown, Does the use of standing ‘hot’ desks change sedentary work time in an open plan office?, Preventive Medicine, In Press.

Ernesto Ramirez

About the author: Ernesto Ramirez is currently a doctoral student in the Joint Doctoral Program (Health Behavior) at San Diego State University and University of California, San Diego. He is currently working at the Center for Wireless and Population Health Systems (CWPHS). He focuses on how to use existing and new technologies to better measure/understand behavioral patterns and then harnesses technology solutions to create effective interventions for individuals. He is interested in building and using systems that will take advantage of sensing, mobile, and social network technologies to better the health of individuals and populations.

 

Does exposure to fast-paced television reduce cognitive function in young children?

| October 25, 2011 | 0 Comments

SBRN is pleased to host weekly summaries of peer-reviewed research in the area of sedentary behaviour, written by graduate students and young investigators working in a range of disciplines. Information on the author of today’s article can be found at the bottom of this post.  If you are interested in writing a summary of an article that you found interesting, please contact us here.

Barney, Purple Dinosaur (Nightmare)

Introduction

Television viewing has become a common activity for many preschool-aged children. As a result, there is increasing interest on the potential short- and long-term health implications associated with this early television exposure. Emerging research suggests that early television viewing may have adverse long-term effects on attention; however, little is known about the short-term effects. A paper recently published in Pediatrics, by Dr. Lillard and Ms. Peterson from the University of Virginia, provides some insight into this relationship.  The main purpose of the study was to examine the influence of fast-paced television shows on short-term executive function. According to the authors, executive function is a group of skills that is important for positive social and cognitive functioning such as attention, working memory, problem solving, self-regulation, and delay of gratification. It is thought that during fast-paced television, executive resources are depleted because of the effort needed by children to encode the information that is rapidly being presented to them.

What did they do?

The authors randomly assigned 60 preschool-aged children (4 years old) to a fast-paced television, educational television, or drawing group. The fast-paced television show (SpongeBob SquarePants)  had scene changes on average every 11 seconds compared to every 34 seconds for the educational television show (Caillou). Within a small room in the university laboratory, the children watched the television show or participated in the drawing activity for 9 minutes and then immediately completed 4 well known executive function tasks (Tower of Hanoi, backward digit span, and head toes knees shoulders, delay of gratification). While children were being tested, parents completed a survey regarding their children’s current television viewing habits and attention problems.

What did they find?

Since the tower of Hanoi, backward digit span, and head toes knees shoulders scores were closely related (α = 0.69), they were combined to form a composite executive function score and the delay of gratification score was examined separately. For both outcomes, children in the fast-paced television group had significantly worse scores compared to the children in the two other groups. For example, based on a figure presented by the authors, children in the fast-paced television group had an average z-score of approximately -0.45 for the head toes knees shoulders task compared to approximately 0.18 and 0.30 of the educational television and drawing groups, respectively. These finding were consistent after adjusting for age, television viewing habits, and attention problems. However, there were no significant differences in the executive function scores between the educational television and drawing groups.

What’s the take-home message?

Although limited, the majority of research to date has looked at long-term effects of television viewing on children’s attention and related skills. This study suggests that there may also be short-term effects. Specifically, young children’s social and cognitive functioning (i.e., the ability to behave with self-control and to learn) may be hindered immediately after watching popular fast-paced television cartoons. This is an important message to convey to parents and caregivers of young children. At the same time, further research should explore what features of fast-paced television shows hinder executive function, how long the effects last after a television show, and what implications longer segments of these shows have on executive function.

Reference: Lillard AS, Peterson J. The Immediate Impact of Different Types of Television on Young Children’s Executive Function. Pediatrics 2011;128(4):644-9.

Valerie Carson

About the author: Valerie Carson is in the final year of her PhD in the School of Kinesiology and Health Studies at Queen’s University. Her current research focuses on sedentary behaviour and health in young people.

 

What works in school-based energy balance behaviour interventions and what does not? A systematic review of mediating mechanisms

| October 17, 2011 | 0 Comments

Beginning this week, SBRN is pleased to host weekly summaries of peer-reviewed research in the area of sedentary behaviour, written by graduate students and young investigators working in a range of disciplines. Information on the author of today’s article can be found at the bottom of this post.  If you are interested in writing a summary of an article that you found interesting, please contact us here.

SJSA Grade Six -  The Year I Rebelled

Introduction

The ever present public health challenge of obesity has placed a great deal of focus upon energy balance related behaviours, such as sedentary behaviour. If negative energy balance is to be achieved effective modification of physical activity, sedentary behaviour and dietary habits is required. As evidence for the impact of school-based energy balance behaviour interventions is equivocal, identification of effective intervention mechanisms (i.e. theoretical mediating variables) is important. There appears to be plentiful research on variables related to physical activity, sedentary behaviour and dietary habits, but much less upon variables that are shown to be causally related to behaviour change (mediating variables). This study therefore aimed to identify psychosocial and environmental mediators (causal variables) of energy-balance behaviour interventions in children and adolescents. As this is the Sedentary Behaviour Research Network I’ll concentrate only on findings regarding sedentary behaviour.

What did they do?

The authors systematically searched five electronic databases with terms for energy balance behaviours, mediating variables and intervention/promotion studies. Studies were included if they were school-based RCT’s or quasi-experimental studies, targeted one of the three energy balance behaviours, and had conducted mediation analyses (among other criteria). The metholodigical quality of studies was assessed against 10 criteria, and evidence was ranked as strong, moderate, or insufficient by taking into account the number, metholodigical quality and consistency of outcomes of the studies. All told a fairly standard and rigorous review of pertinent literature.

What did they find?

The authors were interested in three concepts a) did the intervention (e.g. education sessions) change the theoretically proposed mediating variable? (e.g. attitude towards reducing TV time) b) is there a relationship between change in the proposed mediating variable (e.g. attitude towards reducing TV time) and change in the outcome variable (e.g. time spent watching TV?) regardless of whether the participant received the intervention or not?; and c) the extent to which the intervention changed the mediating variable and the impact this had on the sedentary behaviour outcome.

From ten studies (that focused solely on sedentary behaviour) reviewed the authors found no significant effect for the interventions upon the variables of attitude, self-efficacy, social norms or habit strength. They did however find a significant intervention effect upon intrinsic-motivation in one TV viewing intervention study. Negative relationships were seen between change in attitude, self-efficacy, and intrinsic motivation and screen-viewing, and a positive relationship between change in habit strength and screen viewing suggesting that targeting these variables may lead to decreased screen time (note: this is only an association). Contrary to what you would expect, change in social norms (e.g. parental thoughts, and encouragement towards reduced screen-viewing) in both boys and girls was positively related to screen-viewing.

Most studies did not find a significant impact of the interventions themselves on sedentary behaviour, and therefore did not report whether a change in the mediating variable led to a change in sedentary behaviour. Studies that did report mediation effects did not see any impact of intrinsic motivation or intervention-related concepts (e.g. incentives for children) on screen viewing.

What’s the take-home message?

It seems our knowledge of how to change sedentary behaviour is quite limited! There were negative associations between change in attitudes towards screen-viewing, self-efficacy, intrinsic motivation and measures of screen-viewing and TV-viewing in both boys and girls. These may therefore be useful variables to target in future sedentary interventions; such studies should examine if these are mediators of change in sedentary behaviour interventions. Interestingly the authors speculate that dissimilar to physical activity, sedentary behaviours may not be the consequence of forethought and planning:

Rather than being influenced by conscious cognitions, sedentary behaviour may instead be influenced by individual biological factors, habit strength and parental factors.

Clearly there is plentiful scope to contribute to our understanding of what the mediating effects of other correlates of sedentary behaviour are in sedentary behaviour interventions; particular examples given by the authors of this paper include parental rules and number of TV’s in the household. Other examples might include parental concern for child TV viewing (especially as change in social norms were positively related to screen-viewing) which was found to be positively associated with TV viewing in a recent paper in IJBNPA (Pearson et al., 2011). It appears more studies are needed by those clever behavioural scientists….

Van Stralen, M.M., Yildirim, M., Te Velde, S.J., Brug, J., Van Mechelen, W., & Chinapaw, M.J.M. (2011). What works in school-based energy balance behaviour interventions and what does not? A systematic review of mediating mechanisms. International Journal of Obesity, 35, 1251-1265.

 

Ash Routen

About the author: Ash Routen is in the final months of his doctoral studies at the University of Worcester, UK examining the impact of pedometer interventions on habitual PA in kids, with an interest in the assessment of body composition and objective physical activity measurement in kids.  He can be found on Twitter @AshRouten.

New Systematic Reviews Find Strong Prospective Relationships Between Sedentary Behaviour and Mortality

| July 21, 2011 | 3 Comments

[Travis' Note: This article has been adapted with permission from a post published on Obesity Panacea on July 12, 2011.]

In the past few years several papers have examined the prospective links between sedentary behaviour and chronic disease morbidity and mortality.  Two recent systematic reviews have attempted to synthesize that research in order to give a clearer picture of the relationship between sedentary behaviour and disease.  The first, published in the American Journal of Preventive Medicine by Karin Proper and colleagues, focused on the prospective association between sedentary behaviour and obesity, CVD and diabetes risk, as well as mortality.  Somewhat surprisingly, they found little evidence that sedentary behaviour was associated with increased body weight or other health risk factors, despite consistent associations between sedentary behaviour and risk of death.  From the paper:

Weight Gain:

Based on the inconsistent findings among the [3] prospective studies identified, there is insufficient evidence for a longitudinal relationship between sedentary behavior and body weight/BMI gain.

Risk of Being Overweight or Obese:

Based on the inconsistent findings among the [4] studies, there is insufficient evidence for the relationship between sedentary behavior and the risk for overweight or obesity.

Increased Waist Girth:

Based on this single study, there is insufficient evidence for the relationship between sedentary behavior and waist gain.

Risk of Developing Diabetes:

Based on the consistent findings of… two low-quality studies, there is moderate evidence for a significant positive relationship between the time spent sitting and the risk for type 2 diabetes.

Risk of Cardiovascular Disease:

Based on the findings of the 4 studies identified, there is insufficient evidence for a significant relationship between sedentary behavior and various CVD risk factors.

Endometrial Cancer:

Based on the inconsistencies found between and within the two studies identified, there is insufficient evidence for the relationship between sedentary behavior andendometrial cancer.

As I said, there’s really not much evidence so far that sedentary behaviour is prospectively linked with these various markers of health.  However, it does seem to be associated with increased risk of death from various causes: Continue Reading