THE MILLION WOMEN STUDY

Reported frequency of physical activity in a large epidemiological study: relationship to specific activities and repeatability over time
MEG Armstrong, BJ Cairns, J Green, G K Reeves, and V Beral for The Million Women Study Collaborators

Cancer Epidemiology Unit Nuffield Department of Clinical Medicine University of Oxford www.millionwomenstudy.org

THE MILLION WOMEN STUDY Overview

Background Physical activity assessments in the Million Women Study Frequency of physical activity at baseline and reported specific activities at follow-up Repeatability over time of reported frequency of physical activity at baseline Summary Methodological considerations

THE MILLION WOMEN STUDY Background

Objective measures of physical activity (PA) are:
Expensive Impractical Insensitive to seasons

Questionnaires usually used as:

Less expensive Less likely to interfere with usual PA Assessment of many variables with one instrument Simple to administer and score

However, questionnaires are:

Subjective Prone to measurement error (memory, a portion of activity)

THE MILLION WOMEN STUDY Background

In prospective studies PA assessed at baseline often used to assess influence of PA on health outcomes during follow-up Yet, baseline assessments might not represent actual PA during extended follow-up periods:
Measurement errors during assessment Change in PA behaviours over time Could lead to underestimation of associations between baseline PA and health outcomes

THE MILLION WOMEN STUDY

Physical activity assessments in the Million

Women Study

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The cohort
Prospective cohort study of 1.3 million UK women Recruited through 66 breast screening clinics in 1996-2001
Mean age of 56 years (range 50-64) 1 in 4 of UK women in age range

Self-administered questionnaire at baseline and at follow-up

THE MILLION WOMEN STUDY Data collection

At baseline women were asked:
How often do you do any strenuous exercise? How often do you do any exercise? (91%) 6 frequency options No distinction between summer/winter activity

18 655 repeat baseline questionnaires were completed

17 617 strenuous activity data repeats 12 748 any activity data repeats

THE MILLION WOMEN STUDY Data collection

65% response rate between baseline and follow-up

~ 3 years after baseline over 600 000 women answered:

About how many hours each week do you spend doing: housework, gardening, walking, cycling, any work or exercise causing sweating or a fast heartbeat? Reported separately on summer/winter except for housework

589 896 responded to the activity questionnaires on both baseline and follow-up

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Frequency of physical activity at

baseline and reported specific activities at follow-up

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Methods
Mean estimated excess energy expenditure (EE) for strenuous & specific activities reported at follow-up compared across baseline PA categories Metabolic equivalents (METs) assigned to each activity according to Ainsworths Compendium1 of activities.
A MET = ratio of the metabolic rate required by a given work task, to the standard resting metabolic rate obtained while sitting quietly

Spearman correlation coefficients & P-values for trend

1Ainsworth

BE, et al: Med Sci Sport Exer 2000, 32(9):S498-S516.

THE MILLION WOMEN STUDY

METs
Housework (3 METs), gardening (4 METs), walking (3.5 METs), cycling (8 METs), strenuous (8 METs). Limitations? Multiplying by these gives gross metabolic cost ie. Gross metabolic cost = resting METs cost + PA METs cost Estimated net energy expenditure more appropriate for non24 hour EE:
Middle aged to older - greater proportion of total PA composed of low intensity activities

THE MILLION WOMEN STUDY

Why estimated net energy expenditure?
One example: Person A: does no vigorous activity in a week (0) Person B: does one hour of vigorous activity in a week (1)

Using Ainsworths multiplier of 8: Person A: estimated at 0x8 MET hours (0) Person B: estimated at 1x8 MET hours (8)
But, person A expended resting MET value of 1 during same time period a discrepancy. Use 7 instead of 8, to account for resting EE

THE MILLION WOMEN STUDY

Why estimated net energy expenditure?
Another example: Person A: does one hour of housework in a week Person B: does one hour of cycling in a week

Ainsworths multiplier is 3 for housework and 8 for cycling:

Person A: proportion of EE attributed to resting metabolic rate = 33% Person B: proportion of EE attributed to resting metabolic rate = 12.5%

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Excess MET-hours for activity at follow-up in relation to baseline frequency of strenuous activity
Hours and excess MET-hours per week spent doing various activities reported ~3 years after baseline Strenuous activity Freq of strenuous PA reported at baseline Never < Once per week Once per week 2 to 3 times per week Number of women 261,857 79,962 115,573 96,415 hours mean 0.8 1.1 1.5 2.4 MET-hours mean (SD) 5.6 (21.3) 7.8 (20.2) 10.7 (20.5) 16.5 (25.0) Aggregate of various activities hours mean 21.7 22.7 23.4 24.8 MET-hours mean (SD) 52.4 (39.0) 57.3 (38.0) 61.5 (38.5) 69.5 (42.5)

4 to 6 times per week Daily

Correlation coefficient P for trend

19,394
16,431

3.4
3.5

23.9 (34.1)
24.3 (50.8) 0.37 < 0.0001

27.2
31.1 0.12 < 0.0001

81.3 (50.6)
90.6 (69.1) 0.22 < 0.0001

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Excess MET-hours for activity at follow-up in relation to baseline frequency of any activity
Hours and excess MET-hours per week spent doing various activities reported ~3 years after baseline Strenuous activity Freq of any PA reported at baseline Never Number of women 107,346 49,073 92,317 149,138 hours mean 0.8 0.9 1.2 1.6 MET-hours mean (SD) 5.8 (24.5) 6.6 (21.2) 8.1 (19.5) 11.4 (20.6) Aggregate of various activities hours mean 21.0 20.6 21.3 22.7 MET-hours mean (SD) 50.3 (41.4) 50.9 (37.8) 53.9 (37.0) 60.0 (37.5)

< Once per week

Once per week 2 to 3 times per week

4 to 6 times per week Daily

Correlation coefficient P for trend

57,585
134,437

2.0
1.7

13.8 (24.0)
12.0 (30.0) 0.17 < 0.0001

24.2
27.0 0.17 < 0.0001

66.0 (39.6)
71.2 (49.0) 0.22 < 0.0001

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Various reported physical activities at follow-up in relation to frequency of strenuous activity at baseline
Hours and excess MET-hours per week spent doing various activities reported ~3 years after baseline
walking Baseline reported freq of strenuous PA
hours mean MET-hours mean (SD) n = 589,632 hours mean

cycling
MET-hours mean (SD) n = 589,632 0.1 0.2 0.3 0.4 0.6 0.6 0.9 (5.7) 1.5 (6.8) 1.9 (7.7) 2.8 (9.8) 4.4 (13.1) 4.4 (16.5) 0.15 2.4 3.1 3.3 3.5 3.8 4.1

gardening
hours mean MET-hours mean (SD) n = 589,632 7.3 (9.9) 9.4 (10.8) 9.8 (11.0) 10.5 (12.1) 11.4 (13.9) 12.3 (15.7) 0.15

housework
hours mean MET-hours mean (SD) n = 589,632 14.4 13.8 13.5 13.3 13.4 15.4 28.8 (23.0) 27.5 (21.2) 27.0 (21.1) 26.6 (21.0) 26.7 (21.6) 30.9 (25.7) -0.03

Never < Once per week Once per week 2 to 3 times per week 4 to 6 times per week Daily

3.9 4.4 4.8 5.2 5.9 7.5

9.7 (12.8) 11.1 (12.1) 12.0 (12.4) 13.1 (13.2) 14.8 (14.9) 18.6 (20.4) 0.18

Correlation coefficient
P for trend

< 0.0001

< 0.0001

< 0.0001

< 0.0001

THE MILLION WOMEN STUDY

Various reported physical activities at follow-up in relation to frequency of any activity at baseline
Hours and excess MET-hours per week spent doing various activities reported ~3 years after baseline
walking Baseline reported freq of any PA
hours mean MET-hours mean (SD) n = 589,896 hours mean

cycling
MET-hours mean (SD) n = 589,896 0.1 0.1 0.2 0.3 0.4 0.4 0.6 (4.9) 0.9 (4.7) 1.3 (6.1) 1.8 (7.6) 2.7 (9.1) 2.6 (10.9) 0.11 < 0.0001 2.2 2.6 2.8 3.0 3.2 3.6

gardening
hours mean MET-hours mean (SD) n = 589,896 6.7 (9.8) 7.9 (9.8) 8.4 (10.0) 9.1 (10.6) 9.6 (11.2) 10.8 (13.0) 0.14 < 0.0001

housework
hours mean MET-hours mean (SD) n = 589,896 14.7 13.7 13.5 13.4 13.5 14.8 29.3 (23.7) 27.3 (21.8) 27.0 (21.6) 26.8 (20.8) 27.0 (20.5) 29.6 (23.3) 0.01 0.002

Never < Once per week

3.2 3.3 3.7 4.4 5.2 6.5

7.9 (12.7) 8.2 (11.2) 9.2 (11.3) 11.0 (11.5) 13.0 (12.1) 16.3 (15.9) 0.31 < 0.0001

Once per week

2 to 3 times per week 4 to 6 times per week Daily Correlation coefficient P for trend

THE MILLION WOMEN STUDY Comments

Older populations more sedentary might see decreased between person variability Measurement error may as proportion of PA comprised of light intensity activities increases Social desirability bias may influence accuracy of data from PA questionnaires All may reduce power of a PA instrument to discriminate

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Domestic activities = PA
Do people consider housework when asked about PA? Domestic activities = large proportion of PA in middle aged and older. Eg. British women 60-791:
Without domestic activities only 21% met PA recommendations With domestic activities >2/3rds met recommendations

Physical impairments may report never active but still actually do domestic activities?
1Lawlor

DA, et al., J Epidemiol Community Health 2002, 56:473-478.

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Repeatability over time of reported frequency of

physical activity at baseline

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Methods
Distributions across PA categories by time between first and repeat response Distributions of change in PA by time between first and repeat response PA ordinal kappa coefficient with quadratic weighting used to assess agreement (equivalent to intraclass correlation1) Differences according to seasonality

1Fleiss

JL, Cohen J. Educ psychol meas 1973,33:613-619.

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Distribution of reported frequency of PA by time between first and repeat baseline questionnaires

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Distributions of changes in reported PA frequency by time between first and repeat baseline questionnaires

THE MILLION WOMEN STUDY Population level vs Individual PA

Distribution similar at population level BUT Agreement between individuals decreases eg.
Australia 1 (45-50 yrs): 14% PA, 12% PA, over 3 yrs

Netherlands 2 (20-59 yrs): 45% changed PA level over 10-year period, equal distribution between decreasers and increasers UK 3 (33 yrs): ~1/3 and ~1/3 USA 4 : 16% PA, 12% their PA level over an 8-year

PA, over 4 yrs

1 2

Guthrie J. Acta Obstet Gynecol Scand 2002, 81:595-602. Picavet HSJ et al., Med Sci Sport Exer 2010, 43(1):74-79. 3 Parsons TJ, et al., Eur J Clin Nutr 2005, 59:49-56. 4 Eaton CB et al., Am J Prev Med 1993, 9(4):209-219.

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Agreement of reported PA, by time between completing identical questionnaires
Number of women
Time between completing identical questions on freq of strenuous PA (avg time between the two)
6 months (0.3 years)
> 6 months - 1 year (0.9 years) > 1 - 2 years (1.5 years) > 2 years (2.6 years) P for trend 238 1,224 7,002 9,153 64% 59% 54% 52% 0.71 (0.59 - 0.83) 0.61 (0.55 - 0.67) 0.55 (0.53 - 0.57) 0.51 (0.49 - 0.53) 0.03

Absolute Agreement

Kappa (95% CI) with quadratic weighting

Time between completing identical questions on the freq of any PA (avg time between the two)
6 months (0.3 years) > 6 months - 1 year (0.9 years) > 1 - 2 years (1.5 years) > 2 years (2.6 years) 221 1,171 6,044 57% 53% 48% 0.67 (0.53 - 0.81) 0.67 (0.61 - 0.73) 0.60 (0.58 - 0.62)

5,312

47%

0.58 (0.56 - 0.60)

0.05

P for trend

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Agreement of reported physical activity, by season of reporting
Number of women Agreement according to season of first response versus repeat response, strenuous PA
Winter first response vs winter repeat response Winter first response vs summer repeat response Summer first response vs summer repeat response Summer first response vs winter repeat response 1,110 665 1,118 1,052 0.52 0.54 0.57 0.51

Kappa (95% CI) with quadratic weighting

Agreement according to season of first response versus repeat response, any PA

Winter first response vs winter repeat response Winter first response vs summer repeat response Summer first response vs summer repeat response Summer first response vs winter repeat response 708 509 830 908 0.57 0.58 0.63 0.58

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Summary

THE MILLION WOMEN STUDY

Simple questions on frequency of PA at baseline associated with hours spend on specific activities & estimated excess MET hours ~3 years later

Weakest associations with housework

Agreement for identical questions on PA frequency asked on two occasions decreased over time Agreement similar for different seasons

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Methodological considerations

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Methodological considerations in PA research
Combination of factors that may influence relationship between PA and disease outcome
Past activity (over the life course)? Present activity at baseline? Changes in PA over follow-up time? Measurement error at baseline?

THE MILLION WOMEN STUDY Measurement error & PA assessment

Variability in answers when completing baseline questionnaire
Difficulty recalling past activity time periods, type Different interpretations housework, intensity Social desirability bias Random reporting errors

Real changes in PA over time Lifestyle changes, retirement etc Could be associated with morbidity

reverse causality

THE MILLION WOMEN STUDY Influences of measurement error

Measurement errors likely to result in attenuation of estimates of association between baseline PA and disease risk Degree of attenuation depends on: Assessment instrument Participant characteristics Intensive assessment may sources of error but often impractical, expensive & alter natural behaviour

THE MILLION WOMEN STUDY Possible Approaches

Correct for regression dilution using objective measurements Assess associations between PA at baseline and disease outcome at follow-up split according to discrete time bands of follow-up Report findings so readers may make their own conclusions

THE MILLION WOMEN STUDY Acknowledgements

Million Women Study steering committee, co-ordinating centre staff, and participants Supported by Cancer Research UK and the Medical Research Council

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QUESTIONS?