Ageing with joy Chang, Chang Ming Sing

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Ageing with joy The effect of a physical activity programme on the well-being of older people A study conducted in five homes for the elderly in Paramaribo

Paranimfen:

Cindy Ambachtsheer-Chang Marion Chang

This research was financially supported by a grant from the Eric Bleumink Fonds. Deze promotiestudie is mogelijk gemaakt door financiële ondersteuning van het Eric Bleumink Fonds. Layout: Claudett de Bruin, I.D. Graphics Photos: Chang Ming Sing Chang Print: Leo Victor N.V. ISBN: 978-90-77113-76-9 Copyright © 2009 by C.M.S. Chang All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photography, recording or any information storage or retrieval system, without prior written permission of the copyright owner. Niets uit deze uitgave mag worden verveelvoudigd, opgeslagen in een geautomatiseerd gegevensbestand of openbaar gemaakt in enige vorm of op enige wijze zonder voorafgaande schriftelijke toestemming van de auteur.

RIJKSUNIVERSITEIT GRONINGEN

Ageing with joy The effect of a physical activity programme on the well-being of older people A study conducted in five homes for the elderly in Paramaribo

Proefschrift

ter verkrijging van het doctoraat in de Medische Wetenschappen aan de Rijksuniversiteit Groningen op gezag van de Rector Magnificus, dr. F. Zwarts, in het openbaar te verdedigen op woensdag 23 september 2009 om 14.45 uur

door

Chang Ming Sing Chang geboren op 11 juli 1947 te Paramaribo - Suriname

Promotores:

Prof. dr. J.R. van Horn Prof. dr. J.W. Groothoff Prof. dr. M.A. Vrede

Copromotor:

Dr. M. Stevens

Beoordelingscommissie:



Prof. dr. S.K. Bulstra Prof. dr. S.A. Reijneveld Prof. dr. J.P.J. Slaets

Preface

In this study several aspects of human life are being considered. First of all we are interested in movement and the different aspects thereof. Since the target group of our study is the elderly human being aspects of ageing have to be considered in depth to understand the limitations ageing can have on movement especially in daily life and functioning. The country where we studied this was the Republic of Suriname with a multitude of races and cultures within its boundaries, a very specific structure of its population and a tropical location with all its characteristics. Suriname is a developing country which imposes restrictions on all available means in terms of infrastructure, financial means and most of all because of existing cultural differences on the society as a whole. The study of physical activity programmes for the elderly has, to our knowledge, never been done before in a developing country and therefore emphasis has to be laid upon the very specific circumstances one has to deal with in such an environment. We will discuss the ageing global population with reflection on the situation in Suriname. The meaning of the words ‘physical activity’ in a former Dutch colony like Suriname is explained and the setting of physical activity programmes in an elderly population in homes for the elderly is introduced. Like in the rest of the world in Suriname there are more women than men especially in the elderly. This has an impact on the way physical activity programmes have to be structured and conducted as will be discussed in this study. Together with the general theoretical considerations of the concept of movement and physical activity aspects of health in relation to the process of ageing the structured programmes for physical activity as can be applied to the population in general and the elderly in particular will be discussed. Next to the material and methods used in this study we will also discuss the results obtained in relation to those derived from literature.

Table of contents

List of abbreviations

8

Chapter 1 General introduction and aims of this thesis Part 1 General overview older population in the world and in Suriname Part 2 Health, physical fitness and physical activity

11 12 27

Chapter 2 How to influence health and fitness in elderly by physical activity: A review of literature

41

Chapter 3 Material and methods

65

Chapter 4 Results



89

Chapter 5 Discussion and conclusions

103

Summary

119

Samenvatting

122

Appendices Appendix I Vragenlijst (A-I) Appendix II Fitheidstest Appendix III Bewegingsprogramma

125 126 146 158

Dankwoord

177

Curriculum vitae

181

United Nations Principles for Older Persons

182

Graduate School for Health Research SHARE

184

List of abbreviations

1RM AAHPERD ACSM AdeKUS ADL AOV BMI BOG Health) BT CBS CHD CVD DBP DPN FFT FIMS FMeW GALM GE GFE GFI HDL-C HMAD IADL IYOP LEB LPA LTPA LWG MDD MET-min-wk



Ageing with joy

1 Repetition Maximum American Alliance for Health, Physical Education, Recreation and Dance American College of Sports Medicine Anton de Kom University of Suriname Activities of Daily Living Algemene Ouderdoms Voorziening Body Mass Index Bureau voor Openbare Gezondheidszorg (Bureau of Public Balance Training Central Bureau of Statistics Coronary Heart Disease Cardio Vascular Disease Diastolic Blood Pressure Diabetic Peripheral Neuropathy Functional Fitness Test Federacion International de Medicine de Sportes (International Federation of Sports Medicine) Faculteit der Medische Wetenschappen (Faculty of Medical Sciences of AdeKUS) Groningen Active Living Model Group Exercise Groningen Fitness Test for the Elderly Groningen Frailty Indicator High-Density Lipoprotein Cholesterol Hypertensive-Metabolic-Atherosclerotic Disease Instrumental Activities of Daily Living International Year of Older Persons Life Expectancy at Birth Leisure-time Physical Activity Leisure Time Physical Activity ‘s Lands Weldadigheids Gesticht Major Depressive Disorder Metabolic equivalent per minute per week

MI MMSE NCD PAHO PAR-Q PPT QOL RAND-36 RCT SA SBP SD SF-36 SPSS SRD TC TFR TG UN USA VU WHO

Myocard Infarct Mini Mental State Examination Non Communicable Disease Pan American Health Organization Physical Activity Readiness Questionnaire Physical Performance Test Quality Of Life RAND-36-item Health Survey Randomized Controlled Trial Sport Activity Systolic Blood Pressure Standard Deviation MOS Short Form (General Health Survey) 36 questions Statistical Package for the Social Sciences Surinaamse Dollar Tai Chi Total Fertility Rate Tri Glycerides United Nations United States of America Vrije Universiteit Amsterdam World Health Organization

List of abbreviations



10

Ageing with joy

Chapter 1 General Introduction and Aims of this Thesis

Introduction The world’s population has been growing rapidly during the last decennia and will even more increase in the next two decades. The situation in Suriname is similar to this global trend. Within this increasing number the group of elderly people (as generally used by the UN being over 60 years of age)1 deserve to be mentioned separately as this group through a variety of reasons grows faster than the other age groups. Ageing in Suriname, and in general also in the world, is considered as a stage in life for slowing down, to retire, to rest and to be less active. On the other hand ageing is also associated with illness, less physical fitness, and greater dependency. However, over the past years research has shown the positive impact of physical activity on health and physical fitness, eventually leading to maintain or even increase the quality of life. This chapter is divided into two parts: Part 1 and Part 2. In the first part a general overview of the demographics of older population of the world, and the trends contributing to the increase in the number of the elderly group is presented together with the changes in disease which lead to this increase. Also a description will be given of Suriname, the population and the general health status. The situation of the elderly in Suriname as well as of the facilities for the elderly in Paramaribo, the capital of Suriname, is described. In Part 2 the theoretical background of health, physical fitness, physical activity and the relation between each of them, and the impact of physical activity on health of individuals is discussed. To understand the role of each of the different items involved in these processes it is important to clearly define each one of them. In the first paragraph of this part the different definitions are mentioned and extensively discussed, while the second paragraph tries to explain the relationships as formulated in the Toronto model (Bouchard et al., 1990)2 between physical activity, healthrelated fitness and health. In the last paragraph of this chapter the relation between ageing and physical fitness as mentioned in the literature is briefly indicated. It will be discussed in great length in the next chapter together with the influence physical activity programmes can have on the health and physical fitness of elderly people. This chapter ends with formulating the aims of this study.

Chapter 1 | General Introduction and Aims of this Thesis

11

Part 1 General Overview Older Population in the World and in Suriname 1.1 World demographics 1.1.1 The increasing population According to the United Nations report ‘World Population Prospects: The 2004 Revision’ (2005)3 the world population has reached 6.5 billion by end of 2005. Approximately 5.3 billion (or 81%) is said to be living in the less developed regions. It is anticipated that the world population will continue to increase dramatically in the next few decades (see Table 1.1). Table 1.1 Population of the world, major developments groups and major areas. 1950, 1975, 2005 and 2050, by projections variants Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2005). World Population Prospects: The 2004 Revision Highlights. New York: United Nations.

Population (millions) Populations in 2050 (millions) Major area

1950

1975

2005

Low

Medium

High

Constant

World

2,519

4,074

6,465

7,680

9,076

10,646

11,658

More developed regions Less developed regions Least developed countries Other less developed countries

813 1,707 201 1,506

1,047 3,027 356 2,671

1,211 5,253 759 4,494

1,057 6,622 1,497 5,126

1,236 7,840 1,735 6,104

1,440 9,206 1,994 7,213

1,195 10,463 2,744 7,719

Africa Asia Europe Latin America and the Caribbean Northern America Oceania

224 1,396 547 167 172 13

416 2,395 676 322 243 21

906 3,905 728 561 331 33

1,666 4,388 557 653 375 41

1,937 5,217 653 783 438 48

2,228 6,161 764 930 509 55

3,100 6,487 606 957 454 55

Distinct trends in fertility and mortality are underlying this pattern of growth. There has been a decline in the proportion of children and young people and an increase in the proportion of people age 60 and over, which resulted in a transition of the age distribution figure. The demographic consequence of the decline of both fertility and mortality is that the composition of age groups has changed dramatically in the past decades. The triangular population pyramid of 2002 will be changed into a more urn-like diagram in 2025 (see Figure 1.1). One can expect this to be a temporary phenomenon since in the future this will be leveled out again, especially in developing countries with a high life expectancy at birth (LEB). The situation, seen from a gender perspective in general, shows women throughout the world in general have a higher life expectancy than men (United Nations, 2001)4.

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Ageing with joy

Figure 1.1 Global population pyramid in 2002 and 2025

As has been already explained before, the ageing of a population is the result of 2 major factors i.e. decreasing mortality, which automatically translates into an increased LEB and a decreased total fertility rate (TFR), which leads to a diminished or possibly even negative accrual of the younger age groups that are in time necessary to replace the older ones. The net result of these two processes will be the steady increase of the number of older people in the different age groups within the population. In this instance it leads to a deformation of the population pyramid but it can be only temporarily. Figure 1.2 shows the increasing of life expectancies at birth in different regions of the world over the past decades.5 In this diagram the line of Latin America and the Caribbean shows a steep increase of the LEB.

Figure 1.2 Life expectancy at birth in the world’s regions from 1950 to 2035 Source: United Nations, 1999.

Chapter 1 | General Introduction and Aims of this Thesis

13

The world is currently at the threshold of rapid global ageing. Within the next decades there will be an increase of the absolute as well the relative numbers of older people. This rapid growth will be observed in both developed and developing countries. The percentage of older people in the different parts of the world may differ to a great extent. The UN considers anyone above the age of 60 to be old, whereas in The Netherlands and the European Union 65 marks the age at which people are generally being retired, while in some instances even people 55 of age are called old. This discrepancy in the different definitions of the term ‘old’ may make generalized data difficult to interpret. Figure 1.3 shows that the largest percentage of elderly of the total population in the next few decades will be in the less developed world. With regard to Latin America and the Caribbean, including Suriname, within 50 years this percentage will be doubled, thus contributing to the total world population to a considerable extent from 7 percent in 1975 to 14 percent in 2025. Figure 1.3 Percentage of older persons (60 years and older) of the total population in 1975, 2000, and 2025 LAmC = Latin America and the Caribbean; NAm = North America. Source: United Nations, 1999.

Between 1990 and 2025 more developed countries (such as most of the European countries, the USA and Japan) will experience a significant increase from 30% to 130% in their older population, whereas less developed countries (such as the African, some Asian and Latin American countries) will show an increase which will be even more dramatic (up to 400%) over the same period (see Figure 1.4)6.

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Ageing with joy

Figure 1.4 Increase in the older population (60 years and older) from 1990 to 2025 in selected countries Source: Kinsella & Taeuber, 1992.

1.1.2 Influence of diseases Another trend which can be observed in all developed countries and is also seen in most of the developing world during the last decades is the shift in the pattern of diseases. The reason for this shifting is the industrialization which leads to changes in patterns of living and working. These changes affect developing countries most since they experience the rapid increase of non communicable diseases (NCDs) while infectious diseases, malnutrition and childbirth problems are still manifest. This transition of pattern of diseases results in changing of causes of death and morbidity. Many diseases become chronic instead of leading to death in an early stage. Chronic illnesses such as heart diseases, cerebral vascular diseases, cancer, high blood pressure and depression are becoming more and more the leading causes of morbidity and mortality. Figure 1.5 shows the transition of the epidemiology in 1990 to 2020 in developing countries and in newly-industrialized nations7. In 1990, 49% of the disease burden in these countries was attributable to communicable diseases and 51% to NCDs, mental health disorders and injuries. By 2020, NCDs alone are expected to be responsible for 43% of the deaths and will become the leading disease burden in these countries in the next decade. Together with mental health disorders and injuries the total disease burden will be 78%, while infectious diseases such as diarrhoeal diseases or tuberculosis are expected to become increasingly less common. Since diseases have not been described as separate entities but more as a part of the concept ‘illness’ it does not seem appropriate to describe every single disease in terms of ‘incidence’ or ‘prevalence’ etc. Each of the chronic diseases results in a diminished urge to move and decreased mobility especially in elderly people and ‘illness’ and not ‘one of the diseases’ leads for that reason to an exacerbation in itself and an increase of the impairment.

Chapter 1 | General Introduction and Aims of this Thesis

15

Figure 1.5 Global burden of disease in 1990 and 2020 in developing and newlyindustrialized countries, contribution by disease group Source: Murray & Lopez, 1996.

All the chronic diseases mentioned before are significant causes of disability, which can make it difficult to carry out the activities of daily living and will result in dependency of the person especially in the aged. This leads to an increasing burden for the individual patient and also for the society as a whole. Other data available, however, suggest that old age should not per se be seen as equal to frailty, sickness and dependency. Disabilities associated with ageing and the onset of chronic disease can in many instances be prevented or delayed. Research in the USA (Manton and Gu, 2001)8 (see Figure 1.6) showed that in spite of the substantial increase in the numbers of older people population the actual number of disabled older persons (aged 65 years and over) has remained unchanged since 1982. These results are said to be related to increased education levels, improved standards of living and better health, changed lifestyle behaviours (i.e. increases of physical activity, decline in smoking behaviour), and an increase in the use of aids (i.e. walking aids, telephones). Figure 1.6 Number of older persons in the US. Total older population versus activities of daily living-disabled population Source: Manton & Gu, 2001

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Ageing with joy

1.1.3 Promotion of an active lifestyle Generally spoken ageing and a decline of fitness go hand in hand. This decline partly is natural: the primary ageing process. On the other hand the decline for example of physical fitness is also based on the lifestyle which is characterized by a less versatile and less intensive physical activity, and on the deterioration of health: the secondary ageing process. Less versatile and less intensive physical activity partly comes into being by a natural decrease and partly because of the less demands of daily life. Deterioration of health develops by a progression of increase of chances of degenerative diseases with ageing: the so-called old-people’s diseases. As people age, their quality of life is largely determined by their ability to maintain autonomy and independence. To attain this goal the developed countries have introduced physical activity programmes especially designed for the older adults and the elderly. The effects of these programmes are of such a magnitude that they will be indispensable to cope with the problems that arise from the growing of the large cohort of elderly people. In the next part of this chapter and in Chapter 3 we will elaborate on this extensively.

1.2 Suriname 1.2.1 Geography, history and demographics Suriname, forming part of the three Guianas, is located on the north-east coast of South America, between 2° and 6° N and between 52° and 56° W. The Peoples Republic of Guyana (former British Guiana) is the neighboring country in the west, French Guiana in the east and Brazil in the south. Being situated close to the equator Suriname is known for its tropical climate. Suriname became independent on 25 November 1975 and has at present the status of a constitutional democratic republic. Before this period Suriname was a Dutch colony and afterwards an autonomic part of the Kingdom of the Netherlands. Other former rulers in the past were the Spanish, the Portuguese, the British and the French. English and French names of places are still witnesses of these periods. Also the left hand traffic in Suriname is a relic of the British period. The official language of the country is Dutch. Suriname is known as a multi-ethnical and multicultural society with the Amerindians as its indigenous population and descendants of immigrants who came from three continents of the world: Europe, Africa and Asia. The former rulers and settlers came from various parts of Europe: Spain, the United Kingdom, France, Portugal, Germany, and The Netherlands. They brought slaves from various areas of Western Africa. Descendants of the slaves, who stayed at the plantations and in the coastal area until their freedom, are now called the Creoles. And descendants of the ones, who ran away into the jungle and formed their own society in the interior, are called the Marroons. After the abolition of the slavery in 1863 there was a shortage of workers and to compensate this deficit laborers from various parts of Asia were brought to Suriname during the period 1853-1930. The first immigrants were the

Chapter 1 | General Introduction and Aims of this Thesis

17

Chinese who came in 1853. In 1873, the first East Indians (from former British East India, presently known as India) were brought in Suriname as contract laborers. Descendants of these immigrants are currently known as Hindustanis. In 1890, the first Javanese (from Java) from the former Dutch East Indies (another former colony of Holland, presently known as Indonesia) were also brought to Suriname as contract laborers. All those immigrants brought their cultures from abroad with them and have to a certain extent kept their traditions throughout the years. In the period directly prior to the Independence in 1975 many Surinamese were uncertain about the future of the country; at that time more than 150.000 persons migrated to The Netherlands. Following the political instability during this period, a coup d’etat took place in 1980 and a military regime replaced the civilian government. A decline in the political and the economical situation resulted in another mass immigration during the nineties. In 1991 a democratic elected government was established and stability in the political situation gradually restored. 1.2.2 Language Suriname as a Dutch speaking country is surrounded by countries with three other different languages: English, French and Portuguese. Because of the composition of its population Suriname is also a multi-lingual country. Everybody can speak at least three different languages: Dutch, Surinamese and a mother tongue. Even though Dutch is the official language, used in the administration and schools, all languages from the former immigrants (the mother tongue) are still spoken. Sranan Tongo, the native Surinamese tongue (a lingua franca), which once was used as a communication tool between the different linguistic groups, is presently spoken by everybody. This native tongue is a mix of all languages that once were spoken in the Surinamese history. Sranan Tongo has developed since slavery and comprises also elements of English, Dutch, Spanish, Portuguese and French. Other languages still frequently used in Suriname are Chinese, Sarnami Hindi, Javanese, and the various Marroon and Indigenous languages. English is compulsory in the educational system while Spanish is also taught at the secondary schools. With the increase of tourists from neighboring French Guiana and immigrants from Brazil, especially the younger population in Suriname has added French and Portuguese to their language skills. 1.2.3 Religion With the many ethnic groups present, Suriname has also a multi-religious society. The Indigenous people and the Marroons who live in the interior still maintain their traditional religion. The Europeans brought Christianity in the past and according to the last census report in 2004 about 40% of the total population of Suriname is Christian9. The majority of Christians can be found in the black society living in the city (Creoles), and in small groups of Javanese, Chinese, Hindustani and Caucasians. About 15% of the total population of Suriname is Muslim (Javanese and Hindustani) and 20% is Hindu.

18

Ageing with joy

1.2.4 The population of Suriname At the last census, held in August 2004, the total population of Suriname was 493.000. According to the statistics of the General Bureau of Statistics - Suriname (Algemeen Bureau voor de Statistiek / Censuskantoor)9 248.000 were men and 245.000 women. (Table 1.2). Table 1.2 Total population of Suriname, divided in age and gender groups Source: General Bureau of Statistics - Suriname, August 2005 Age group

0 - 14 years 15 - 59 years 60 + Not reported Total

Total

146.327 299.410 42.175 4.917 492.829

Males

Females

Number

Percentage

Number

Percentage

74.308 151.032 19.712 2.794 247.846

15.1 % 30.6 % 4.0 % 0.6 % 50.3 %

72.019 148.378 22.463 1.758 244.618

14.6 % 30.1 % 4.6 % 0.4 % 49.7 %

Sex not reported

365 365

The population pyramid of Suriname Census 2004 (See Figure 1.7) shows an equal distribution between men and women in the age group 0 to 19 years, a higher number of men than women in the age group 20 to 49 years, while from 50 years on the numbers of women are higher than the numbers of men. Figure 1.7 Age distribution of the Surinamese population in men and women, Census 2004 Source: General Bureau of Statistics - Suriname, August 2005

Chapter 1 | General Introduction and Aims of this Thesis

19

The largest ethnic groups are the group of the black people, which can be divided in the group of the Marroons (14.7%) and the group of the Creoles (17.7%), the Hindustani group (27.4%), the Javanese group (14.6%), and the so called Mix group (12.4%). The distribution in ethnicity of the total Surinamese population is shown in Table 1.3. Table 1.3 Number and percentage of the different ethnic groups in Suriname at 2 August 2004, divided in groups of men and women Source: General Bureau of Statistics - Suriname, August 2005 Ethnic group

Total Population

Percentage of the total population

Men

Women

Sex not reported

Indigenous Marroon Creole Hindustani Javanese Chinese Caucasian Other Mixed Not reported Total

18.037 72.553 87.202 135.117 71.879 8.775 2.899 2.264 61.524 32.579 492.829

3.7 % 14.7 % 17.7 % 27.4 % 14.6 % 1.8 % 0.6 % 0.5 % 12.4 % 6.6 % 100%

9.039 33.873 43.958 68.948 36.808 4.721 1.660 1.232 31.411 16.196 247.846

8.988 38.680 43.210 66.084 35.048 4.054 1.239 1.032 30.085 16.198 244.618

10 34 85 23 28 185 365

Table 1.4 shows the distribution in age ranges of the group of the population in Suriname 60 year and older, while Table 1.5 reflects the distribution in ethnicity of this population. Table 1.4 Population in Suriname 60 years and older at 2 August 2004, divided in groups of men en women Source: General Bureau of Statistics - Suriname, August 2005 Age group

60 – 64 years 65 – 69 years 70 – 74 years 75 – 79 years 80 – 84 years 85 – 89 years 90 – 94 years 95 - 98 + yrs Total

Total

Men

Women

Sex not reported

13.259 10.602 8.659 5.152 2.853 1.075 460 129 42.189

6.200 5.148 4.101 2.418 1.235 392 184 34 19.712

7.059 5.452 4.554 2.732 1.618 677 276 95 22.463

2 4 2 6 14

The largest percentage people of 60 years and older is found in the group of the Caucasians (17.6%), followed by the Creoles (12.2%), and the Javanese group (11.5%) (See Table 1.5). In general there are more women than men. Only in the small ethnic groups (Chinese, Caucasian and Other) the number of men is higher than the number of women, while the ratio men : women in the group of the Javanese is almost equal (49.8% : 50.2%).

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Ageing with joy

Table 1.5 Number and percentage ethnic groups 60 years and older in Suriname at 2 August 2004, divided in men and women Source: General Bureau of Statistics - Suriname, August 2005 Ethnic group

Indigenous Marroon Creole Hindustani Javanese Chinese Caucasian Other Mixed Not reported Total

Total Population

18.037 72.553 87.202 135.117 71.879 8.775 2.899 2.264 61.524 32.579 492.829

Total > 60 Population

1.596 4.486 10.605 10.171 8.258 737 510 234 3.943 1.649 42.189

Percentage > 60 of the total population 8.8 % 6.2 % 12.2 % 7.5 % 11.5 % 8.4 % 17.6 % 10.3 % 6.4 %

Men > 60

776 1.918 4.736 4.762 4.113 420 307 153 1.718 809 19.712

Percent. men > 60 of total > 60 48.6 % 42.8 % 44.7 % 46.8 % 49.8 % 57.0 % 60.2 % 65.4 % 43.6 %

Women > 60

820 2.568 5.863 5.408 4.143 317 203 81 2.225 835 22.463

Percent. Women > 60 of total > 60 51.4 % 57.2 % 55.3 % 53.2 % 50.2 % 43.0 % 39.8 % 34.6 % 56.4 %

In Suriname like in South America the situation with regard to the changes in the age distribution does not differ very much from the rest of the world. There is a definite increase of the number of older people also in Suriname, which has a history of its own that gives rise to an even greater number of elderly relatively speaking than the countries that surround it. In 1990 the mean life expectancy for the total population of Suriname was 68.7 years. The average life expectancy for men was 66.2 years, while for women 71.2 years. In 2000 the mean life expectancy for the total population has been increased to 70.7 years, while the average life expectancy for men was 68.1 years, and for women 73.3 years (Alleyne, 2002)10. 1.2.5 Mortality in Suriname Suriname experiences the same difficulties and the same transition in epidemiology as other countries in South America. Definite data however on the incidence and prevalence of the non-communicable diseases are still lacking. Data of the Bureau Openbare Gezondheidszorg (Bureau of Public Health, 2004)11 have shown a dramatic increase of the mortality rate of non communicable diseases in the past decade, which may be a reflection of the incidence and prevalence. Heart and vascular diseases are leading causes of death in Suriname (see Figure 1.8). Cerebro-vascular accidents are included in this number. Together with diabetes mellitus this disease accounts for 1000 deaths (33.3%) of all causes of deaths in Suriname. Cancer takes the second place in this ranking with 341 deaths (11.3%).

Chapter 1 | General Introduction and Aims of this Thesis

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Figure 1.8 The 10 most important causes of deaths in Suriname, 2002 Source: Bureau Openbare Gezondheidszorg, 2002

Heart Cancer PeriExternal Diabetes and natal causes Mellitus Vascular periods (injuries, Diseases assault & suicide)

AIDS

GastroTractus Acute intestinal urogenitalis pulmonary diseases diseases diseases

Chronical liver diseases

Other diseases

Figure 1.9 shows the distribution of causes of death in all ages per ethnical group with the highest scores. The Hindustani population has the highest rate, 38.4% (N=321) for heart diseases, followed by the Creole people with 27.3% (N=228). Death caused by diabetes mellitus shows the same pattern: Hindustani population as the highest, 43.3 % (N=71) and second, Creole with 22.0% (N=37). The frequency of deaths caused by cancer is different; the Creole population has a higher percentage, 44 % (N=144), followed by the Javanese with 20.4% (N=66). Figure 1.9 Number of deaths by different causes in all ages per different ethnical group in 2002 Source: Buro Openbare Gezondheidszorg, 2002

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Given the ratio between men and women 60 years and older, who died in 2002, heart/vascular diseases (331:282) and cancer (126:107) appear to be higher among men, while the main cause for deaths among women (40:54) appears to be diabetes mellitus (Fig. 1.10). Figure 1.10 Number of deaths by different causes men and women 60 years and older in 2002 Source: Bureau Openbare Gezondheidszorg, 2002

1.3

The status of elderly care in Suriname

1.3.1 Bureaucratic institutions Like many other traditions and customs also the political and bureaucratic system of Holland was copied in Suriname. This also holds true for the healthcare system of Suriname which is also in principle the same as in Holland. The Minister of Health, who is politically responsible for the healthcare system has at his disposal a department, which is in charge of the primary health care in Suriname and which is called BOG (Bureau Openbare Gezondheidszorg i.e. Bureau of Public Health). The governmental policy regarding healthcare, especially at older age, was more focused on curative care than on prevention. There is still no national plan for senior citizens available. Also at the level of health sector reform planning there is still no clear policy defined as yet by the government for the elderly. This is also reflected in the fact that care for the elderly is a matter that is governed by the department of Social Affairs and not by the Department of Health. In policy statements, mention is only made that more attention will be given to the elderly, although the World Health Organization (WHO) and the Pan American Health Organization (PAHO) have urged for more awareness of the governments and provided guidelines for the coming decennium in the area of health care for the elderly (Active Ageing: A Policy Framework, April 2002)12.

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1.3.2 History of care for the elderly in Suriname The care for the elderly as has been developed during the last years has a very definite history in Suriname. In 1919, the government of Suriname started with a home for the elderly called ‘s Lands Weldadigheids Gesticht (LWG). The objective of this institution was to provide accommodation and care to those, who had no relatives to take care of them. In 1980, LWG was closed because of its outdated and insufficient facilities, and all residents moved to Huize Ashiana. At present, Huize Ashiana has about 350 residents, aged between 60 and 90 years. 1.3.3 The socio-economic position of elderly people in Suriname In the past people, mostly coming from The Netherlands and especially working for the government and the bigger firms and plantations in Suriname e.g. administrative personnel and civil servants, had a lower life expectancy. Many tropical diseases such as malaria, diphtheria, and cholera could often not be effectively cured and were not under control yet. It was very normal that young people died in the tropics. Because of that fact a regulation was made for those people and the term ‘tropical years’ was established, for every year working in the tropics (for instance Suriname) counted double when the person went back to Holland. Reasoning for this rule was that working in the tropics meant working harder and also in a harder environment. Rest after hard work was justified then and people could retire at a lower age than people in the Netherlands, the age of retirement now being 65 in the Netherlands while in Suriname being 60 years. When Suriname got independent in 1975 this rule was still valid and the age of retirement in Suriname is presently still 60 years (Landsverordening 1957)13. At the age of 60 years a person becomes eligible for receiving an AOV (Algemene Ouderdoms Voorziening i.e. General Old Age Pension), which in September 2008 stands at SRD 275 (US $ 100) per month14. To become eligible for this allowance, the elderly person has to be registered at the AOV office of the Ministry of Social Affairs. According to this office the total number of registered elder people as of July 1st 2005 stood at 39.232 of which 17.858 are men and 21.374 women. About 7% of the people over 60 are not registered. This AOV allowance is considered far below the average poverty line, which is about 350 SRD per month (about US $ 127) according to the report Basic Indicators 2005-1 from the General Bureau of Statistics. As in many countries in the world in Suriname ageing is traditionally considered as a stage in life for slowing down, to retire, to be less active and to rest. The concept of ‘rest after hard work’ is still in the way of thinking of many of Suriname’s people. It is very normal to be passive if a person is getting older. Children will stimulate their parents to be passive and sedentary when they have reached a certain age. ‘It is time to rest now’, the parents have worked hard enough in their life. Even gardening and housekeeping is sometimes not allowed. It is easier to hire somebody to do this kind of ‘work’. The whole society accepts this approach. Another example that illustrates this way of thinking is that the retiree often gets

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a rest chair as a present at his or her retirement. Most of the people also see the home for the elderly as a rest home, a home where you can rest for the duration of your remaining years. As part of the elderly care in The Netherlands, there are special homes for the elderly. Primarily those homes were created to be rest homes for the elderly who have worked hard in their lives. The Surinamers who moved to Holland in the eighties and nineties and left their parents in Suriname experienced the Dutch solution of care for the elderly and it seemed to be logical to copy this concept in Suriname and they strove to place their parents in this kind of homes. 1.3.4 The present situation of care for the elderly in Suriname According to the directory published by the Ministry of Social Affairs15 there are fourteen homes for the elderly in Suriname, of which ten are situated in Paramaribo. The largest, Huize Ashiana, is fully funded and managed by the Ministry of Social Affairs, which is also responsible for the training of the nursing staff of all homes. The total number of residents in all homes is estimated at 1000 and of whom 900 are originating from the greater Paramaribo area. Officially there are no real nursing homes in Suriname but only homes for the elderly where people at a certain age can be admitted when they are still healthy and mobile and able to take proper care of themselves. In these homes they can stay the rest of their lives even when they become chronically ill and invalid and then need proper nursing care. The net effect for Suriname is then that all homes for the elderly in reality are a mix of both types of care. There are however some homes which function predominantly as nursing homes which will take mostly elderly who need to be nursed. In this kind of homes the residents do not have to cook and do not have to clean their rooms. Nurses and aids are there to take care of them. This will stimulate the residents to be more passive and to be sedentary. There is one home, Huize Margriet, where the majority of residents are more independent and selfreliant. They cook their own meal everyday, and they clean their own rooms. Those residents are more active, do their own household, do their own shopping and are more socially active. Most of the personnel of these homes are not highly qualified or trained. Most of them are trained as aids for the elderly. Sometimes there is only one qualified nurse. The concept of ‘rest after hard work for the older people’ is also in their mind and this will not bring them to stimulate the residents to be more active. They also see the homes as a place for the elderly to rest, where there is no physical activity possible. It is their job to give as much as possible all the care to the elderly. Because this way of thinking about their job in the homes there is always too much work to do and there is constantly a lack of trained personnel. They are not used to the concept that resting and relaxing do not have to mean to be less active and should be trained in the idea that gardening or walking can be also relaxing. The concept of active ageing, as formulated by the WHO in their document ‘Active Aging: A Policy Framework’ (2002)12, also involves social activity as well as participation in the community in which the elderly stay. This concept is as yet not

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very much adopted by most of the personnel taking care of the elderly in Suriname. They are generally of the opinion that a rest-home is a prior stop to the cemetery. The elderly have to spend their last years of their life in such a home, resting and waiting. The Surinamese society is as yet not very much aware how important the environment can be. Not only the staff and other personnel that surround the elderly in those last days, but the localization of the home is even important. Environment of the homes can be very discouraging to be physically active. A home that is build next to a cemetery, with a view to that cemetery is not stimulating to live. It will make people sad and depressed. The presence of many stairs or the non-functioning of the solitary elevator is not stimulating nor for the staff neither for the residents to walk. Well maintained walking paths in a nice garden with many blooming flowers, with benches in the shades, will stimulate people to walk and be more active. All homes for the elderly have occasional activities to stimulate social contacts. Those activities involve mostly playing bingo and handicraft-classes. In general however the attitude prevails that old age deserves rest especially rest in physical sense. A number of initiatives were undertaken to incorporate physical activity in the programmes for the elderly residents. This is done more on a voluntary basis and initiated by the residents as well as the trainer and has no structural implications. Given their status of independence and self-reliance a few residents of those homes are doing some gardening, in addition to their household activities. As yet there is no structural policy to promote an active lifestyle as has been urged by the WHO and PAHO in accordance with the trend in the developed countries. 1.3.5 Homes for the elderly; ethnical and religious differences According to the directory of the Ministry of Social Affairs of Suriname there are, as mentioned above, fourteen homes for the elderly in Suriname. Most of these homes are managed by religion groups; there are Roman Catholic, Protestant, Muslim, and Hindu homes. Because of the fact that religion is related to some ethnicity, the residents and the management are from a certain ethnical group. For example a Hindu home for the elderly will have a Hindustani management and all the residents will be also from the Hindustani ethnicity. Muslim homes have either Javanese management with Javanese residents or Hindustani management with Hindustani elderly. The Christian homes have ethnically speaking a mixed population. The ethnical groups in Suriname deal differently with physical activity, depending on their different cultures, gender, and sometimes even their religion. One can expect the participants of different ethnicities to respond differently to exercise programmes, although this can not be certain on the beforehand. A bias can be expected here however because of the differences in the various homes in the ethnicity as well as in the age and also in the social strata the residents of the homes are originating from.

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Part 2 Health, Fitness and Physical Activity

1.4 Definitions 1.4.1 Health The World Health Organization (WHO) defines health in its Constitution as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.’16 At the International Consensus Conference on Physical Activity, Physical Fitness, and Health, in Toronto2 health was defined as ‘a human condition with physical, social, and psychological dimensions, each characterized on a continuum with positive and negative poles. Positive health is associated with a capacity to enjoy life and to withstand challenges; it is not merely the absence of disease. Negative health is associated with morbidity and, in the extreme, with premature mortality.’ Both definitions of health acknowledge the importance of the physical and the psychological components as well. Both emphasize the effect of the surrounding environment on the individual person, e.g. the effect of society, the effect of different cultures, ethnicity, climate, habitat, and religion on the person and visa versa. What may be normal and completely acceptable in one society may be absolutely wrong in another. Then there are also the racial differences which together with the cultural ones may make even neighboring countries totally different from each other with respect to the concept of health. Even gender may lead to these differences. This necessitates to take into consideration a lot of factors which hitherto have only been discussed in a very limited way in relation to health. 1.4.2 Fitness The terminology of fitness has been interpreted differently. For this study however it is necessary to use the term of physical fitness. In the western world fitness is often associated with health. The terminology ‘fitness’ is normally used to describe the suitability or the competency of the physical condition and has a subjective character; one cannot measure fitness in itself. Physical health is often compared with physical fitness and the latter has been defined in many ways. However, a generally accepted approach is to define physical fitness as ‘the ability to carry out daily tasks with vigor and alertness, without undue fatigue, and with ample energy to enjoy leisure-time pursuits and to meet unforeseen emergencies.’17 The WHO defined physical fitness as ‘the ability to perform muscular work satisfactorily.’16 This implies that the individual has attained those characteristics that permit a good performance of a given physical task in a specified physical, social, psychological and spiritual environment. Physical fitness relates to many different physically measurable factors such as body composition, reaction time, agility, balance, skeletal muscular power, speed, flexibility, and cardio-respiratory endurance. Physical fitness is a set of these

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attributes that people have or achieve that relates to the ability to perform physical activity.2 Because these attributes differ in their importance to athletic or physical performance versus health, a distinction has been made between performancerelated fitness and health-related fitness18,19. Performance-related fitness refers to components, which are necessary for optimal work and sport performances. It is defined in terms of the individual’s ability in athletic competition, a performance test, physical endurance or occupational work. Physical fitness as associated with performance and health, depending on age and health status has also been studied by Lemmink20. For healthy young people with the normal daily demands of occupational work and sport, physical fitness is associated with performance, while for inactive middle aged adults and adults with health problems this is associated with health. For the elderly fitness is associated on the one hand with adequately executing and maintaining (instrumental) activities of daily living ((I)ADL) and on the other with health. ADL are activities which are the basics of daily functioning e.g. dressing, washing, getting up from a chair, transferring over a short distance, eating and drinking. IADL are activities, more complex than ADL, which are executed in relation with the environment e.g. shopping, gardening, cycling, and using the public transportation. Health is related to preventing and limiting health problems. Adequately executing and maintaining (I)ADL and health affects each other and both are of great importance for the extent of independency and the quality of life of the elderly. In this context motor fitness, which term has been coined for the first time by Lemmink, of the elderly refers to motor suitability or competency for executing and maintaining physical activity which are important for independent functioning in daily life. Performance-related fitness depends heavily upon body size, body composition, motivation, nutritional status, motor skills, muscular strength, power or endurance, and cardio-respiratory power and capacity. In general and in contrast to popular thinking, performance-related fitness shows only a limited relationship to health. Although a good health must be a prerequisite to perform especially in manual labor. Physical fitness to optimally perform in daily life in the elder person can also be defined as performance-related fitness. Health-related fitness refers to those components of fitness that are affected favorably or unfavorably by habitual physical activity and related to health status. It has been defined as a state characterized by a) an ability to perform daily activities with vigor and b) a demonstration of traits and capacities that are associated with a low risk of premature development of hypo kinetic diseases and conditions. This includes morphological (e.g. body composition, subcutaneous fat distribution, abdominal visceral fat, bone density, flexibility), muscular (e.g. power, strength, endurance), motor (e.g. balance, coordination), cardio-respiratory (e.g. blood pressure, maximal aerobic power and capacity, heart and lung function) and metabolic fitness components (e.g. glucose and insulin metabolism, blood lipid and lipoprotein profile, and the ratio of lipid to carbohydrate oxidized in a variety of situations)21. Motor fitness of the elderly was defined by Lemmink as ‘the degree that

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elderly people command over those motor characteristics (motor aptitude) that are necessary for executing and sustaining motor activities in daily life.’20 He used the same aforementioned dimensions and selected coordination, reaction time, and equilibrium as components of the motor dimension, strength as a component of the muscular dimension, flexibility as a component of the morphological dimension, and aerobic endurance as a component of the cardio-respiratory dimension. Coordination, reaction time, equilibrium, and flexibility primarily affect the ability to execute motor activities, whereas strength and aerobic endurance also relate to the ability to sustain motor activities in daily life. 1.4.3 Physical activity Physical activity, defined as ‘bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above the basal level’17, is generally accepted as relevant to health. Physical activity can be categorized in various ways e.g. type, intensity, and purpose, depending on the context in which it occurs. Common categories include occupational, household activities, leisure-time physical activities, transportation and other chores e.g. playing with children or nursing elderly relatives. Leisuretime activity is described by Stevens22 as an activity undertaken in the individual’s discretionary time that leads to any substantial increase in the total daily energy expenditure and can be further subdivided into categories such as competitive sports, recreational activities (e.g., hiking, cycling), and exercise training. However, there are wide inter-individual variations, depending partly upon such personal aspects as age, the duration of paid work and the amount of household activities. The terms ‘physical activity’ and ‘exercise’ or ‘exercise training’ have been used synonymously in the past. However, exercise has been used more recently to denote a subcategory of physical activity: ‘physical activity that is planned, structured, repetitive, and purposive in the sense that improvement or maintenance of one or more components of physical fitness is the objective’19. Exercise training also has denoted physical activity performed for the sole purpose of enhancing physical fitness17. While physical activity may lead to general fitness of the individual and his or her body exercise will only lead to fitness specific to the particular exercise and for a certain purpose. 1.4.4 Quality of life In 1994 the WHO12 defined ‘quality of life’ as ‘an individual’s perception of his or her position in life in the context of the culture and value system where they live, and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept, incorporating in a complex way a person’s physical health, psychological state, level of independence, social relationships, personal beliefs and relationship to salient features in the environment.’ As people age, their quality of life is largely determined by their ability to maintain autonomy and independence. One can discern that quality of life is closely related to the concept of health as defined by the WHO. Both have many factors in common by which they are

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influenced and both are in reality perceptions of the individual. To test these perceived aspects a number of questionnaires have been developed in the course of time by many different authors. Also for the elderly these questionnaires have been used to evaluate their health status in physical sense as well as in psychological as psychomotor sense. In chapter 3 we will deal extensively with the questionnaires used in this study.

1.5 Relationships between physical activity, health-related fitness and health Under the title: ‘Sedentary lifestyle: a global public health problem’ the WHO23 published the following statement: ‘Sedentary lifestyle is a major underlying cause of death, disease, and disability. Approximately 2 million deaths every year are attributable to physical inactivity; and preliminary findings from a WHO study on risk factors suggest that sedentary lifestyle is one of the ten leading causes of death and disability in the world. Physical inactivity increases all causes mortality, doubles the risk of cardiovascular disease, type II diabetes, and obesity. It also increases the risks of colon and breast cancer, high blood pressure, lipid disorders, osteoporosis, depression and anxiety. Levels of inactivity are high in virtually all developed and developing countries. In developed countries more than half of adults are insufficiently active. In the rapidly growing large cities of the developing world, physical inactivity is an even greater problem. Crowding, poverty, crime, traffic, low air quality, and a lack of parks, sports and recreation facilities, and sidewalks make physical activity a difficult choice. Even in rural areas of developing countries sedentary pastimes, such as watching television, are increasingly popular. Inevitably, the results are increased levels of obesity, diabetes, and cardiovascular disease. In the entire world, with the exception of sub-Saharan Africa, chronic diseases are now the leading causes of death. Unhealthy diets, caloric excess, inactivity, obesity and associated chronic diseases are the greatest public health problem in most countries in the world. Data gathered on health surveys from around the world is remarkably consistent. The proportion of adults who are sedentary or nearly so ranges from 60 to 85%. WHO is currently assessing the global burden of disease from 22 health risk factors, including physical inactivity. The results of this research will be published in the World Health Report 2002. It is clear that physical inactivity is a major public health problem that affects huge numbers of people in all regions of the world. Effective public health measures are urgently needed to promote physical activity and improve public health around the world.’ The conclusion of this statement is that physical activity is very important in daily life and has definite relations to public health in general and health in each individual. Regular physical activity, combined with adequate diet has shown to be one of the most effective means of controlling mild to moderate obesity and maintaining an ideal body weight in women. In women as it is for men physical activity is very important to prevent illnesses and disability especially since

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in women it can also greatly help prevent and manage osteoporosis. Women, particularly post-menopausal, have a higher risk of developing osteoporosis than men. Weight-bearing activities such as walking, dancing and jogging, is essential for normal skeletal development in the childhood and adolescence, and may help in decreasing bone loss. It also improves muscle strength and balance and reduces the risk of falling, thereby helping to prevent fractures. At the International Consensus Conference on Physical Activity, Physical Fitness, and Health, held in 1988 in Toronto a basic model was used to specify the relationships between physical activity, health-related fitness, and health2. This model, also known as the Toronto Model (see Figure 1.11), specifies that habitual physical activity can influence fitness, which in turn may modify the level of habitual physical activity. Figure 1.11 The Bouchard or Toronto model, describing the relationships between habitual physical activity, health-related fitness, and health status

With increasing fitness for instance, people tend to become more active while the fittest individuals tend to be the most active. The model also specifies that fitness is related to health in a reciprocal manner. Fitness for instance not only influences health, but health status also affects both habitual physical activity level and fitness level as well. Other factors are also associated with individual differences in health status. Likewise, the level of fitness is not determined entirely by an individual’s level of habitual physical activity. Other factors can also affect physical activity, fitness, and health. Four types of influence are important: lifestyle behaviors, personal attributes, physical and social environment. Lifestyle comprises the aggregate of an individual’s actions and behaviors of choice which can affect health-related fitness and health status. Habitual physical activity is one such behavior over which the individual has a large measure of voluntary control. Several personal attributes, e.g. age, gender, socioeconomic status, personality characteristics, and motivation, shape the lifestyle pattern of a person, including the attitude toward physical activity and other healthy habits. Physical environmental conditions, e.g. temperature, humidity, air quality,

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altitude and climatic changes, can affect participation in leisure time physical activity, fitness level, and health status. Such conditions influence not only the ability to exercise, but also the physiological response to the demands of exercise. Finally social environment may be defined as the combination of social, cultural, political, and economic conditions that affect participation in physical activity, health-related fitness, and health status. Social networks, e.g. members of the family, other relatives, friends, social clubs, church organizations, and other groups, may have a positive influence on attitudes toward physical activity and other healthy behaviors. They are all part of the social milieu that can affect both health and the sense of well-being of an individual. The WHO (2005)24 stated that the health benefits of regular physical activity are many. At least 30 minutes of moderate physical activity, for example brisk walking, is enough to bring many of these effects. However, by increasing the level of activity, the benefits will also increase. ‘Regular physical activity: 1. reduces the risk of dying prematurely 2. reduces the risk of dying from heart disease or stroke, which are responsible for one-third of all deaths 3. reduces the risk of developing heart disease or colon cancer by up to 50% 4. reduces the risk of developing type II diabetes 50% 5. helps to prevent / reduce hypertension, which affects one-fifth of the world’s adult population 6. helps to prevent / reduce osteoporosis, reducing the risk of hip fracture by up to 50% in women 7. reduces the risk of developing lower back pain 8. promotes psychological well-being, reduces stress, anxiety and feelings of depression and loneliness 9. helps prevent or control risky behaviours, especially among children and young people, like tobacco, alcohol or other substance use, unhealthy diet or violence 10. helps control weight and lower the risk of becoming obese by 50% compared to people with sedentary lifestyles 11. helps build and maintain healthy bones, muscles, and joints and makes people with chronic, disabling conditions improve their stamina 12. can help in the management of painful conditions, like back pain or knee pain We all know that physical activity - taking a walk, riding a bike, dancing or playing, even gardening - simply makes you feel better. But regular physical activity brings about many other benefits. It not only has the potential to improve and maintain good health, but it can also bring with it important social and economic benefits. Regular physical activity benefits communities and economies in terms of reduced health care costs, increased productivity, better performing schools, lower worker absenteeism and turnover, increased productivity and increased participation in sports and recreational activities.

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In many countries, a significant proportion of health spending is due to costs related to lack of physical activity and obesity. Promoting physical activity can be a highly costeffective and sustainable public health intervention’.

1.6 Physical fitness and ageing Generally spoken ageing and a decline of motor fitness go hand in hand. This decline partly is natural: the primary ageing process. On the other hand the decline of motor fitness is also based on a lifestyle which is characterized by a less versatile and less intensive physical activity, and on the deterioration of health: the secondary ageing process. Less versatile and less intensive physical activity partly comes into being by a natural decrease and partly because of the less demands of daily life. Deterioration of health develops by a progression of degenerative diseases with ageing: the socalled old-people’s diseases. As people age, their quality of life is largely determined by their ability to maintain autonomy and independence. Loss of physical activity will automatically lead to diminished fitness, as follows from the Toronto model, which in turn will have negative effects on health and which in turn will lead to accelerated loss of activity by which the circle closes. This will give rise to a passive and sedentary way of life. ‘Active ageing’ a term adopted by the WHO23 in the late 1990s is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. This process will be elaborated upon in this thesis and forms the basis of the study. The word ‘active’ refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labor force. From the Toronto model it follows that we have to stimulate active ageing through health related fitness by physical activity which is in reality part of the process of active ageing as it will contribute to better wellbeing and improved health and thus quality of life. In Chapter 2 we will enter into this subject to a greater extent and we will show how the physical fitness in elderly people can be influenced in a positive way by physical activity programmes as described in the next paragraph, which has been cited from the WHO25 publication 2005. ‘For people of all ages, physical activity improves the quality of life in many ways. Physical benefits include improvement of balance, strength, coordination, flexibility and endurance. Physical activity has also shown to improve mental health, motor control and cognitive function. Active lifestyles provide older persons with regular activities to make new friendships, maintain social networks, and interact with other people of all ages. Improved flexibility, balance, and muscle tone can help prevent falls - a major cause of disability and chronic illness among older people. It has been found that the prevalence of mental illness is lower

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among people who are physically active. The benefits of physical activity can be enjoyed even if regular practice starts late in life. While being active from an early age can help prevent many diseases, regular movement and activity can also help relieve the disability and pain associated with these conditions. Physical activity can also contribute greatly to the management of some mental disorders such as depression and Alzheimer’s disease. Organized exercise sessions, appropriately suited to an individual’s fitness level, or simply casual walks can provide the opportunity for making new friends and maintaining ties with the community, reducing feelings of loneliness and social exclusion. Physical activity improves self-confidence and self-sufficiency - qualities that are the foundation of psychological well-being. As for people of all ages, older persons should take part in physical activities they enjoy the most. Anyone with a specific condition or disability that could affect their ability to be physically active should seek the advice of a doctor before participating in physical activity. Walking, swimming, stretching, dance, gardening, hiking and cycling are all excellent activities for older persons. The number of people over 60 years old is projected to double in the next 20 years. Most of these older persons will be living in developing countries. Reducing and postponing agerelated disability is an essential public health measure and physical activity can play an important role in creating and sustaining well-being at all ages.’

1.7 The development of physical activity programmes People everywhere in the world, in both industrialized and developing countries, are living longer. Progresses have been made in the field of public health, hygiene, medical technology, and environmental conditions. However, at the same time there is a large increase of non-communicable diseases (NCDs) which are mostly chronic illnesses, especially seen in the ageing populations, combined with the increasing numbers of people who are victims of lifestyle problems such as exposure to tobacco and other risk factors, for instance obesity, physical inactivity, and alcohol consumption. It is therefore clear that unless vigorous measures are taken to prevent NCDs commonly associated with the aging process this will inevitably place new and increased demands on health care systems. The challenge will be to implement public policies, strategies, and interventions that provide both collective and individual incentives and disincentives to change risky behaviors and reduce the risks of NCDs as people age. In 1992, the General Assembly of United Nations (UN) declared 1999 to be the International Year of Older Persons (IYOP). To celebrate this and to promote the Global Movement for Active Ageing, WHO launched a campaign on World Health Day 1999 with the slogan ‘active aging makes the difference.’ The aim of the Global Movement was to launch new and innovative activities in the areas of advocacy and policy development to prevent functional decline in aging populations and to promote healthy and active aging.26 In his lecture titled ‘A Retrospective Analysis of International Initiatives and

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Programmes In Response to the International Year’ as published by the International Federation of Sports Medicine (FIMS) in conjunction with World Health Organization (WHO) Sidorenko gave an overview of the many international initiatives that were organized in response to this International Year of Older Persons in 1999 (Active Aging, 2002).27 The definition of active aging is guided by the definition of health as laid down in the WHO Constitution and refers to ‘the process of seizing and maximizing opportunities for mental, physical and social well-being throughout the life course to increase healthy life expectancy and quality of life at older ages.’ More than eighty countries developed national action plans to celebrate this international year. Building on the World Health Day slogan of ‘active aging makes the difference’ and the launch of the Global Movement for Active Ageing, the Global Embrace, a walk event and celebration that encircled the globe on October 2, 1999, celebrated healthy and active aging in a visible, creative way that was attractive to both older and younger people. It is estimated that over 1 million people in 96 countries participated in about 3000 walks all over the globe on that day. Numerous conferences, congresses, and strategic planning initiatives were organized. Most of the worldwide activities for the Year were condensed into the 4 facets of the conceptual framework for A Society for All Ages : 1. the situation of older persons, 2. lifelong individual development, 3. multigenerational relationships, and 4. population aging and development. In addition, initiatives in the area of women and aging were also highlighted. However, no mention was made of initiatives into the development of structural active living programmes, let alone programmes that promote physical activity, whereas in Europe the benefits of physically-active lifestyles for health were the subject of the 4th International Congress on Physical Activity, Ageing and Sports (Heidelberg, Germany, August 1996)28 during which the ‘Heidelberg Guidelines for Promoting Physical Activity Among Older Persons’ were adopted. The Guidelines clearly refer to the age of 50 years as the point in middle age at which the benefits of regular physical activity can be most relevant in preventing or reversing many of the physical, psychological, and social risks that accompany older ages. In the Netherlands too physical inactivity of the population used to be very common. In 1992 the Dutch Heart Foundation published its first report on physical inactivity as an independent risk factor for cardiovascular disease. The Foundation acknowledged that new policies and strategies had to be developed in order to stimulate people to be more physically active. Physical activity has been promoted on a large scale in different lifestyle campaigns by both the Foundation and the Dutch government. However, little or no structural study has been done into the effectiveness of lifestyle and physical activity promotion campaigns. In 1999 the Groningen Active Living Model (GALM), a new behavior change

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strategy to stimulate leisure-time physical activity, was introduced by Stevens et al.29 The GALM strategy aims to stimulate and monitor sedentary older adults who are willing to participate in leisure-time physical activity. The authors showed that this strategy was feasible and could be implemented in the Netherlands on a large scale basis. They also formulated the fundamentals of the application of theoretical models on practical situations by improved strategies thus paving the way for the incorporation of this kind of a programme into the structure of the society as a whole. ‘Improved strategies : 1. New strategies should be based on theoretical models rather than pragmatic principles. In the Netherlands, past behavioral change interventions have lacked a theoretical basis. In a theoretical model, the underlying theory of operations and its effects can be revealed. This leads to a better theoretical understanding of behavior in the long run, and provides a firmer foundation for more effective interventions. 2. The stimulation strategy must be based on a behavioral change model specifically designed to explain behavioral change in relation to becoming and remaining active in leisure-time physical activity. 3. The theoretical model should be multidimensional. Several studies have already indicated that no single variable or small set of variables can be considered the primary determinant of leisure-time physical activity. It is rather a wide variety of variables that have been shown to significantly correlate with or predict leisure time physical activity. 4. The new theoretical model should be dynamic. Prochaska and DiClimente’s stages of-change model, Sallis and Hovell’s theory about the natural history of exercise, and Biddle and Mutrie’s resumption theory all show that becoming and remaining physically active is a time-consuming and dynamic process of behavioral change. We may thus conclude that a process-based model approach is required in order to understand how people change over time. From this perspective, changes in health behavior are viewed as cyclical rather than linear sequences of events. (Stevens, 2001).’ One can see that these strategies are based on several subsets of properties in order to make them more amenable to daily living. One can wonder whether they are applicable to societies other than the Netherlands and could be used in developing countries to effectively introduce similar programmes for the elderly. In view of the findings as mentioned in Part 1 and the theoretical considerations in Part 2 we set out to study the influence of physical activity programmes on the health, physical fitness and wellbeing of senior citizens in Suriname and formulated our intentions on this matter in the next paragraph which deals with the aims of this study.

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1.8 Aims of this thesis Considering the discussion so far we come to the conclusion that it is worthwhile to conduct a study to determine the effects of activity programmes in homes for the elderly on the health status of the growing number of elderly people in Suriname, a developing country. 1. Will such programmes as applied in a structured setting have an influence on the health of the population of the homes for the elderly in Suriname and lead to an enhanced sense of physical and mental wellbeing? 2. Will there be differences between the different ethnic groups? 3. Will the application of such programmes lead to amore active lifestyle of the elderly in such homes in Suriname?



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References: 1. United Nations, Personal correspondence, 2001. 2.

Bouchard C., R.J. Shephard, T. Stephens, J. Sutton, B.D. McPherson. Exercise, fitness, and health: the consensus statement. In: Bouchard C, Shephard RJ, Stephens T, Sutton JR, McPherson BD, editors: Exercise, fitness, and health. A consensus of current knowledge. Champaign (IL), Human Kinetics Books, 1990.

3. United Nations, Department of Economic and Social Affairs, World Population Prospects (The 2004 Revision). New York, 2005. 4. United Nations, Department of Economic and Social Affairs, World Population Prospects (The 2000 Revision). New York, 2001. 5. United Nations, Department of Economic and Social Affairs, World Population Prospects (The 1999 Revision). New York, 2000. 6. Kinsella, K. and C. Taeuber, International population reports. An aging world II, Washington: US Bureau of the Census, 1992; P25, 92-3. 7. Murray, C. and A. Lopez. The global burden of disease. London: Harvard University Press, 1996. 8. Manton, K. G. and X. Gu (). Changes in the prevalence of chronic disability in the United States black and nonblack population above age 65 from 1982 to 1999. Proceedings of the National Academy of Sciences USA, 2001; 98, 6354-6359. 9. Algemeen Bureau voor de Statistiek (General Bureau of Statistics), Censuskantoor, Suriname Census 2004 Volume 1, Demografische en Sociale Karakteristieken, Paramaribo, August 2005. 10. Alleyne G., Director of the Pan-American Health Organization PAHO, Personal communication, 2002. 11. Bureau Openbare Gezondheidszorg (Bureau of Public Health), Ministerie van Volksgezondheid, Doodsoorzaken in Suriname 2002, Paramaribo, December 2004. 12. World Health Organization, Active Ageing: A Policy Framework, WHO’s Ageing and Life Course Programme, April 2002. 13. Landsbesluit 12 februari 1957, Art. 4, lid 1a. Paramaribo: Gouvernementsblad van Suriname 1957; No. 20. 14. Missive van de Raad van Ministers, 7 mei 2008, no.373/RVM. 15. Ministerie van Sociale Zaken en Volkshuisvesting, Sociale gids 2004, November 2004. 16. World Health Organization, Basic Texts, 44th Edition 1, March 2004. Constitution adopted July 1946, 7 April 1948. 17. U.S. Department of Health and Human Services. Physical Activity and Health – A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 18. Pate RR. A new definition of youth fitness. Physician and Sportsmedicine 1983; 11: 77-83. 19. Caspersen CJ, Powell KE, Christensen GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research, Public Health Reports, 1985, 100:126-131.

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20. Lemmink, K., De Groninger Fitheidstest voor Ouderen: ontwikkeling van een meetinstrument, Dissertation, University of Groningen, 1996. 21. Bouchard, C. and R.J. Shephard. Physical activity, fitness and health: the model and key concepts. In: Bouchard, C., R.J. Shephard, T. Stephens, eds., Physical activity, fitness and health. International proceedings and consensus statement. Champaign (IL): Human Kinetics, 1994: 77-88. 22. Stevens M., Groningen Active Living Model, Dissertation, Groningen, 2001. 23. World Health Organization, Sedentary lifestyle: a global public health problem, 2005. 24. World Health Organization, Benefits of physical activity, 2005. 25. World Health Organization, Physical activity and older people, 2005. 26. Brundtland GM, MD, MPH. Director-General World Health Organization, Message from the Director General, 1999. 27. Sidorensko A., The United Nations International Year of Older Persons. A Retrospective Analysis of International Initiatives and Programs In Response to the International Year - A summary. In: Chan, Kai-Ming, W Chodzko-Zajko, W Frontera, A Parker, eds., Active Aging. FIMS (International Federation of Sports Medicine), 2002. 28. World Health Organization, The Heidelberg guidelines for promoting physical activity among older persons, Guidelines Series for Healthy Ageing – I, 1996. 29. Stevens M., P. Bult, M.H.G. de Greef, K.A.P.M. Lemmink, P. Rispens, Groningen Active Living Model (GALM): Stimulating physical activity in sedentary older adults. Preventive Medicine 1999; 29: 267-76.

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Chapter 2 How to Influence Health and Fitness in Elderly by Physical Activity: a Review of Literature Introduction Many studies regarding physical activity and its effects on health and fitness have been published. In this chapter we will give a review of the literature on this issue. First the search strategy will be reported in paragraph 2.1. In the first part of paragraph 2.2 the general aspects of inactivity and the risks of inactivity will be discussed. Paragraph 2.3 will elaborate on the importance of physical activity for the elderly, followed by a sub paragraph about the factors which could influence physical activity. Paragraph 2.4 gives an overview of literature describing the different influences of physical activity on fitness and health, as well as on quality of life in elderly. The last paragraph 2.5 deals with literature about the dose-response relation between physical activity on fitness and health and the training of different aspects of fitness with the elderly.

2.1 Search strategy A structured search strategy was conducted to identify relevant studies relating physical activity programmes for elderly and the effectiveness of such programmes on health and fitness. Special interest was given to studies done in developing countries, and especially in the Caribbean. We did a search in the databases of PUBMED, SILVERPLATTER, MEDLINE, UN, WHO, PAHO, PEDro and hand searched reference lists of identified reviewed articles. We selected articles from 1997 until August 2008. The following keywords were used: elderly, ageing, geriatric, middle-age, aged, geriatric-nursing, nursing-homes, caregivers, physical activity, exercise, physical fitness, physical therapy, exercise therapy, epidemiology, mortality, prevention, prevention-and-control. Diabetes Mellitus, cardiovascular diseases, heart diseases, neoplasm, chronic disease, South America, Caribbean Region, Suriname, developing countries, co-morbidity, obesity, social support, depression, social adjustment, interpersonal relations, self-efficacy, anxiety, cause of death, motor skills disorders, psychomotor disorders, movement disorders, psychomotor performance, emotions, Alzheimer Disease, dementia, depression, health promotion, life-style, cross-cultural

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comparison, health behaviour, risk factors, program evaluation, Quality of Life, and health status.

2.2 General aspects of inactivity As people age the lifestyle will change gradually from an active productive life to a passive and even sedentary pattern. Several factors such as social, economic, psychological, environmental and others are the cause for this phenomenon. According to WHO (2005)1 a sedentary lifestyle is currently becoming a public health problem in the world and is a major underlying cause of death, disease, and disability. Approximately 2 million deaths every year are attributable to physical inactivity; and preliminary findings from a WHO study on risk factors suggest that a sedentary lifestyle is one of the ten leading causes of death and disability in the world. Physical inactivity increases all causes of mortality, doubles the risk of cardiovascular disease, type II diabetes, and obesity. It also increases the risks of colon and breast cancer, high blood pressure, lipid disorders, osteoporosis, depression and anxiety. The Toronto Model2 as shown in Chapter 1 described the relationship between habitual physical activity, health related fitness and health status. This model specifies that habitual physical activity can influence fitness, which in turn may modify the level of habitual physical activity. However, the model can work also the other way. A sedentary lifestyle for instance will affect fitness and health as well. As mentioned in the previous chapter fitness for instance influences health, but health status also affects both habitual physical activity level and fitness level as well. Other factors as lifestyle, physical and social environment, and personal attributes can also affect physical activity, fitness, and health. As people age functional capacity (e.g. respiratory capacity, muscular strength, and cardiovascular output) increases in childhood and peaks in early adulthood, eventually followed by a decline3 (see Fig. 2.1). Figure 2.1 Development of the functional capacity as people age

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The slope of decline throughout the life course, however, is largely determined by factors related to the individual lifestyle – such as smoking, alcohol consumption, levels of physical activity and diet – as well as external and environmental factors. The gradient of decline may become as steep as to result in premature disability. However, the acceleration in decline can be influenced and may be reversible at any age. Changes in the environment can lower the disability threshold, thus decreasing the number of disabled people and thereby reduce the level of impairment. Paffenbarger et al. (1994)4 discerned two possible sequences as to the influence of physical activity on physiological fitness, health and longevity. The first showed that where physical activity like exercise is adequate fitness is likely to be maintained or improved, good health is preserved, quality of life is favourable, systemic disease such as hypertensive-metabolic-atherosclerotic disease (HMAD) is avoided or deferred and length of life is maximal: Physical activity physiological fitness high quality of life low HMAD risk long life. While the second pattern showed the likely consequences of a downward trend of existence where lack of exercise reduces fitness to unfitness or debilitation, lifestyle and quality of life become unfavourable , health deteriorates toward HMAD, and risk increases of premature death or shortened life: physical inactivity physiological unfitness low quality of life high HMAD risk Short life. All of these patterns strongly support the hypothesis that adequately vigorous and continuing physical activity is conducive to maximal good health and longevity 2.2.1 Risks of inactivity Results of many studies as has been mentioned in the previous paragraph showed that inactivity in otherwise physically capable persons may lead to a variety of problems in daily life as well as to a reduced span of life. Bungum and Morrow (2000)5 have stated that physical activity is a recognized component of healthy lifestyles. Inactivity is associated with several chronic diseases, including coronary heart disease, hypertension and Type II diabetes. Data indicate that only about 10% of Americans are aerobically active and approximately one-third of the American population engages in physical activities that are less vigorous and frequent than the recommended levels to achieve a health benefit. They also have found in literature that more than 60% of American adults do not meet guidelines for moderate leisure time physical activity and that many would obtain health benefits by increasing their leisure time physical activity. They found suggestions that small, positive increases in physical activity would enable many people to reduce their risk of chronic diseases and could contribute to an enhanced quality of life, concluding that increased physical activity, in most cases, is a desired public health behaviour. Simonsick et al. (1993)6 found in their study that a high level of (recreational) physical activity reduces the likelihood of mortality over both 3 and 6 years. Moderate to high activity reduces the risk of physical impairments over 3 years; this effect diminishes after 6 years. A consistent relationship between activity and new myocardial infarction or stroke or the incidence of diabetes or angina was not found after 3 or 6 years. The findings of these authors suggest that physical activity

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offers benefits to physically capable older adults, primarily in reducing the risk of functional decline and mortality. However they also state that future work must use more objective and quantifiable measures of activity and assess changes in activity levels over time. Similar effects were noted by Hallal et al. (2003)7 who studied the prevalence and associated variables in physical inactivity in Brazilian adults. The prevalence of physical inactivity was 41.1%. After multivariate analyses, inactivity was positively associated with age and socioeconomic status, and inversely associated with selfreported health status. Those with white skin color and women who live alone rather than with a partner were more likely to be physical inactive. Body mass index showed a significant U-shaped relationship with inactivity among men. They found that the prevalence of physical inactivity in this Brazilian adult population is high; even though lower than reported in studies of leisure-time activity alone in other populations. They conclude that studies in developing countries may be seriously biased if activities during labor, transportation, and housework are not assessed. King (2001)8 also stated that physical inactivity has been established to be an independent risk factor for a range of chronic diseases and conditions. Older adults are at particular risk for leading sedentary lifestyles. One of the major issues has been discussed like the ongoing challenge of developing assessment tools that are sensitive to the more moderate-intensity physical activities favored by older adults.

2.3 The importance of physical activity for the elderly Identifying predictors of functional limitations among the elderly is essential for planning and implementing appropriate preventive services (Laukkanen et al., 1998)9. The purpose of this prospective study was to examine baseline physical activity as a predictor of health and functional ability outcomes 5 years later in people age 75 and 80 years at baseline. It was found that the more physically active subjects had better health and functional ability compared to their more sedentary counterparts. The degree of physical activity did not predict future disability but still maintained its predictive role at the level of disease severity. It has been suggested in this study that the level of habitual physical activity is an important predictor of health and functional ability among elderly people. But there may be a reciprocal causal relationship between physical activity and health in elderly people. Physical activity counseling should therefore be included in preventive health strategies for the elderly. The important position stand of the American College of Sports Medicine on exercise and physical activity for older adults as worded by Mazzeo et al. (1998)10 delineates the importance of physical activity programmes for the elderly. It has been stated that participation in a regular exercise programme is an effective intervention/modality to reduce/prevent a number of functional declines associated with ageing. The trainability of older individuals is evidenced by their ability to adapt and respond to both endurance and strength training. Reductions in risk

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factors associated with disease improve health status and contribute to an increase in life expectancy. Additional benefits from regular exercise include improved bone health, postural stability thereby reducing the risk of falling and associated injuries and fractures and increased flexibility and range of motion. Regular exercise can also provide a number of psychological benefits related to preserved cognitive function, alleviation of depression symptoms and behaviour and an improved concept of personal control and self-efficacy. 2.3.1 Factors influencing physical activity In the Toronto Model, Bouchard et al. (1990)2 defined social environment as the combination of social, cultural, political, and economic conditions. This social environment affects participation in physical activity, health-related fitness, and health status. Social networks, e.g. members of the family, other relatives, friends, social clubs, church organizations, and other groups, may have a negative influence on attitudes toward physical activity. Other environmental factors (such as pollution, poverty, and lack of education), over which the individual may have little or no influence, can affect also the decrease of fitness and health. Personal attributes e.g. age, gender, socioeconomic status, personality characteristics, and motivation, shape the lifestyle pattern of a person, including the attitude toward physical activity. It seems reasonable to assume that also for older people of different gender, ethnical and cultural backgrounds differences in physical and leisure time physical activity may be found. In the next paragraphs we will elaborate on these issues. 2.3.2 The relation between physical activity and ethnicity and culture It seems important in the context of this study to weigh the influence of ethnical and cultural differences on physical activity. Kumar11 in a guest editorial for the Journal of Aging and Physical Activity (1998) stated that there is considerable diversity in the specific type of activities engaged in by older persons in India. In this ethnically rather homogeneous group the cultural contexts in which these activities take place vary considerably. There is a growing appreciation for the importance of healthful lifestyles and preventive medicine in preserving health and effective functioning in old age. There are differences between persons of different ethnicity with respect to physical fitness. This has been studied by Nakanishi and Nethery (1998)12. They stated that environmental and cultural aspects are known to influence particular characteristics of an ethnic group and, as such, are partially responsible for distinguishing an ethnic group from others. They compared non-athlete young Japanese and American males on a variety of physiological and fitness characteristics in order to locate and quantify the magnitude of any physiological and fitness difference between the two ethnical groups. Aerobic capacity based upon bicycle ergometer, resting heart rate, and resting blood pressure, vertical jump, grip strength, and flexibility as measured by sit-and-reach, and trunk-and-neck extension tests were obtained for young Japanese and American males. Within the limitation of this study it was concluded that the Japanese had a higher lower extremity power and better flexibility in the trunk-and-neck extension compared with the American.

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The functional fitness scores of American and Italian older adults on the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) test battery for sedentary adults over 60 years old were studied by Capranica et al. (2001)13. Between American and Italian men, no statistically significant difference was found for coordination and endurance. American men scored better on flexibility and strength, whereas Italian men scored better on body mass index and agility. Between American and Italian women, no statistically significant difference was found for BMI and agility. American women scored better on flexibility and strength. Fitzgerald et al. (1994)14 examined self-reported activity, measured fitness status, exercise knowledge, and exercise beliefs of African American and White females in good health between the ages of 50 and 80 years enrolled in a health promotion project. Examination of fitness status by ethnicity indicated a higher level of fitness among White females. Ethnic differences were found on 2 of 6 exercise belief items and 2 of 3 exercises knowledge questions. A multiple regression analysis found that activity level was predicted by the knowledge question concerning heart rate during exercise necessary to maintain fitness, the belief concerning the difficulty ‘to stick to a regular schedule of physical activity,’ and ‘to find the time to exercise on a regular basis.’ This study suggests that health promotion efforts need to determine exercise attitudes and beliefs of older women, provide basic exercise knowledge, and include fitness programmes designed specifically for older women. 2.3.3 The relation between physical activity and gender Besides physical differences between men and women other factors can play an important role in participation in physical activity. Several authors have studied the correlations between the different aspects which possible can affect physical activity and gender. The majority of the studies however, has been done in women. Ainsworth et al. (2003)15 stated that little is known about the correlates of physical activity among African-American women living in the south-eastern United States. They assessed the relationship of personal, social, cultural, environmental, and policy variables with physical activity among women in ethnic minority groups. Approximately one third of the women met current recommendations for moderate or vigorous physical activity, 49.4% were insufficiently active, and 16.5% were inactive. Meeting the recommendations or engaging in insufficient activity (versus inactive) was related to attaining higher educational levels, being married or with a partner; being in excellent or very good health, having greater self-efficacy, seeing people exercise in the neighbourhood, having more favourable ratings of women who exercise (social issues score), having lower social role strain, and reporting the presence of sidewalks or lighter traffic in the neighbourhood. Multiple factors influence physical activity. Therefore they recommended to use multilevel approaches that incorporate the personal, social environmental, and physical environmental factors related to participation in physical activity in interventions to increase physical activity.

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Eyler et al. (2002)16 did a study among ethnic minority and low-income populations, who have the highest rates of cardiovascular disease and the lowest rates of leisure-time physical activity, on the physical activity programmes as performed by focus groups with White, African American, Latina, and American Indian women aged 20-50 years. Family priorities were a main barrier to physical activity in all the groups. Having multiple roles as wife, mother, daughter, and as an active community member was mentioned as time-consuming and difficult, leaving little time or energy for exercise. Cultural barriers, which varied among the groups, included acculturation issues, lack of community support, and lack of past experience with exercise. Physical activity interventions suggested involved work programmes, family-friendly programmes, increased social support, and the availability of safer places to exercise such as parks, well-lit walking trails, and recreation centers. Many of the barriers were common to all groups (e.g., family priority) while some were unique (e.g., lack of community support). Assessing and addressing the issues raised should be considered when planning physical activity interventions for these populations. Perceived benefits and barriers to physical activity among older Latina women were studied by Juarbe et al. (2002)17. They stated that evidence of the benefits of physical activity in the health of aging women continues to grow, but questions remain about the factors that influence these women’s ability to engage in this behaviour. A qualitative design was used to describe the social and culture-specific perceived benefits and barriers to physical activity among Latina women, ages 40 to 79. Analysis of these women’s responses revealed that perceived benefits (health promotion, physical fitness, and improved roles) and barriers (time constraints of women’s roles, personal health, internal and external factors) function as competing elements that may explain physical inactivity. Health care providers should emphasize overcoming barriers and promote perceived benefits as clinical interventions that may pose the greatest potential to increase physical activity among aging Latina women. Wilmore (2001)18 summarized the literature on the influence of age, sex, and health status on the changes in systolic (SBP) and diastolic blood pressure (DBP), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C), consequent to exercise training. The results indicated that age has little or no influence on the changes in SBP, DBP, TG, and HDL-C in response to exercise training. Females appeared to have an attenuated response to exercise training compared with males with respect to SBP, DBP, and HDL-C but the data for TG are equivocal. Finally, there appeared to be more favourable changes in resting SBP and DBP, TG, and HDL-C in unhealthy subjects (hypertensive and post-MI patients) when compared with healthy subjects. 2.3.4 The relation between physical activity and social environment There is little information available on physical activity patterns in the elderly in developing countries. Developing countries are now in transition and move toward Western style patterns of physical activity and social structure.

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The study performed by Henry et al. (2001)19 is unique in that it compared the physical activity levels in two contrasting communities: a residential home and a rural community of elderly subjects in Thailand. The men in the rural community were slightly lighter and leaner than those in the residential community, but the differences were not significant. However, the women were significantly heavier and more obese in the residential home than in the rural community. This is consistent with the higher levels of physical activity in the rural community. There was considerable variation in physical activity in this population. This study of physical activity patterns in elderly subjects in a developing country highlights the variation in activity between both communities. The opportunities for the elderly living in the residential home to have active lifestyles are limited. This may at least in part be due to the influence of the nursing home staff. Gerritsen et al. (2004)20 stated that nursing home staff can effectively contribute to optimizing the quality of life (QOL) of nursing home residents but first and foremost it has to be clear what exactly QOL is and how it can be enhanced. It is important to recognize the concept of quality of life in modern world. To identify a framework that provides tools for optimizing QOL and can form the basis for the development of guidelines for its enhancement it should meet three basic criteria: 1. it should be based on assumption about comprehensive QOL of human beings in general; 2. it should clearly describe the contribution of each dimension to QOL and identify relationships between the dimensions; 3. it should take individual preferences into account. The implications of this framework in understanding the QOL of nursing home residents need to be defined. If they are neglected and left unchanged it is likely that this will result in increased morbidity of the residents in their final years of life. Measurements of functional ability, balance, strength, flexibility, life satisfaction, and physical activity were compared by Schroeder et al. (1998)21 among groups of older adults (age 75-85 years). Subjects performed the Physical Performance Test (PPT), timed ‘Up and Go’, 1 repetition maximum (1RM) leg press and extensions, the Modified Sit and Reach, the Physical Activity Questionnaire for the Elderly and the Satisfaction With Life Scale. No difference was found among the groups for life satisfaction. Individuals living in a nursing facility had poorer PPT scores, dynamic balance, leg extension strength, leg press strength, flexibility, and physical activity than individuals living in assisted-care facilities and the community. Assisted-care individuals had significantly lower PPT scores and leg strength than communityliving individuals. The decline of ADL performance and physical activity may be due to loss of strength, balance, and flexibility, all associated with a loss of independence. 2.3.5 The relation between physical activity and education level In their study Bungum and Morrow (2000)22 stated that little is known why people initiate or maintain physical activity patterns. It has been shown that those persons who had 12 or more years of education and had discussed physical activity with a

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physician were more apt to have commenced exercise regiments. Some differences across race and gender have been reported and authors mention studies completed in the late 1970s, requesting information from Americans on the factors likely to motivate individuals to increase their physical activity in order to identify selfreported reasons for increasing physical activity behaviour and to describe differences in rationale for increased physical activity by ethnic group and gender. Frequently cited reasons were physician advice (43%), family influences (13%), and increased availability of facilities (10%). Nearly one-fourth (23%) of respondents indicated that nothing would increase their physical activity behaviour. Knowledge of such information would be valuable to those designing and implanting physical activity interventions. Sai Chuen Hui and Morrow (2001)23 surveyed a random sample of Chinese adults through a citywide telephone interview. The respondents demonstrated poor awareness of the role of physical activity in disease prevention. Older adults possessed poorer knowledge of physical activity but higher activity levels than their younger counterparts did. Results indicated that the level and knowledge of physical activity was the lowest among other health behaviours. Age, educational level, and knowledge of appropriate exercise prescription to achieve health benefits were factors use to discriminate among sedentary, somewhat active, and physically active groups. The importance of intervention programmes to raise the physical activity level and knowledge of Chinese adults was demonstrated by this study.

2.4 Influence of physical activity on fitness, health and quality of life in elderly As has already been mentioned in Chapter 1, Bouchard et al. (1990)2 under the title ‘Physical activity, fitness and health’ stated, with respect to the incidence and prevalence of inactivity amongst older people and it effects on fitness and health, that habitual physical activity can influence fitness. This in turn may modify the level of habitual physical activity, which is a reciprocal process. In this paragraph we will elaborate on this and discuss the findings of other authors. 2.4.1 The influence of physical activity on perceived health and quality of life Takkinen et al. (2001)24 examined longitudinally the predictive value of physical activity for a sense of meaning in life and for self-rated health and functioning. The study was part of the Evergreen project in Jyväskyla, Finland. A representative sample of 198 elderly persons born between 1904 and 1913 was interviewed in 1988 and followed up in 1996. The interviews dealt with the intensity of physical activity, meaning in life, and self-rated health and functioning. Physical activity had a positive effect on both meaning in life and self-rated health and functioning. In their study to determine the effects on energy expenditure, health and fitness outcomes in sedentary older adults aged 55-65 after 6-month participation in the GALM programme, De Jong et al. (2006)25 found the intervention group showed

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significant increases in energy expenditure for recreational sports activities, other leisure-time physical activity, health indicators, and perceived and performancebased fitness. Chin A Paw et al. (2004)26 in their study found that in their combined training group a small but significant decline was seen in perceived health, Dementia Quality of Life and Vitality Plus Scale score compared to the control group. They concluded that neither strength training nor all-round, functional training of moderate intensity is effective in improving quality of life, vitality or depression of older people living in long-term care facilities. King et al. (2000)27 compared the effects of two physical activity programmes on measured and perceived physical functioning and other health-related quality of life outcomes in older adults. Although inactivity is an important contributor to impaired functioning and disability with age, little is known concerning how improvements in physical functioning and well-being in older adults vary with the type of physical activity undertaken. Community-based programmes focusing on moderate-intensity endurance and strengthening exercises or flexibility exercises can be delivered in a way that will result in improvement of functional and wellbeing outcomes. Mazzeo and Tanaka (2001)28 provided recommendations to promote the participation of elderly in physical activity programmes and mentioned the health benefits which include a significant reduction in risk of coronary heart disease, diabetes mellitus and insulin resistance, hypertension and obesity as well as improvements in bone density, muscle mass, arterial compliance and energy metabolism. The benefits associated with involvement in regular exercise can significantly improve the quality of life in elderly populations. The authors stated that it is noteworthy that the quality and quantity of exercise necessary to elicit important health benefits will differ from that needed to produce significant gains in fitness. It is important to inform elderly individuals of the health and functional benefits associated with regular physical activity as well as how safe and effective such programmes can be. Increased involvement in regular exercise as well as improved adherence and compliance to such programmes should be promoted. 2.4.2 The influence of physical activity on mental health Reijneveld et al. (2003)29 studied the mental health of elderly immigrants and the effect of a short health education and physical exercise programme. Participants in the intervention group showed an improvement in mental health; the oldest subgroup also in mental wellbeing. No improvements were seen in physical wellbeing and activity, nor in knowledge. They conclude that health education and physical exercise improve the mental state of deprived immigrants. A meta-analysis study conducted by Colcombe and Kramer (2003)30 examined the hypothesis that aerobic fitness training enhances the cognitive vitality of healthy but sedentary older adults. Eighteen intervention studies published between 1966 and 2001 were entered into the analysis. Fitness training was found to have some benefits for cognition. The magnitude of fitness effects on cognition depended on a number of programmatic

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and methodological factors, which included the length of the fitness-training intervention, the type of the intervention, the duration of training sessions, and the gender of the study participants. These results concur with recent neuroscientific and psychological data that indicate cognitive and neural plasticity is maintained throughout the life span. Whereas previous studies of younger, healthy individuals have demonstrated an inverse relationship between physical activity and depression, the study of Moore et al. (1999)31 addressed the relation between self-reported physical activity and symptoms of depression in 146 men and women aged 50 years and older with major depressive disorder (MDD). A multiple regression analysis indicated that lower levels of physical activity were associated with more severe depressive symptoms after adjusting for age and gender. Physical activity changes resulting from an intervention that encouraged senior 62-91 years of age to increase their physical activity by participating in physical activity classes and programmes of their choice were studied by Stewart et al. (1997)32. Enrollees were encouraged to adopt activities tailored to their preferences, physical abilities, health status, income, and transportation resources. The intervention group was more active for all comparison months of the intervention period and also showed improvements in self-esteem. Those who adopted and maintained a new physical activity over the six-month intervention period experienced improvements in anxiety, depression, and overall psychological well-being relative to those who did not. An intervention promoting increased physical activity through the use of existing community resources may help increase physical activity in older adults. 2.4.3 The influence of physical activity on lifestyle and active behaviour Chin A Paw et al. (2001)33 described the design and preliminary evaluation of a 17-week, twice-weekly, comprehensive, progressive exercise programme for frail elderly adults in order to maintain or improve mobility and performance of daily activities essential for independent functioning. Strength, speed, endurance, flexibility, and coordination were trained in the context of motor behavior such as games and daily activities. The acceptability of the exercise programme was evaluated in a population frail older adults (mean age 77.6 years). Seventy-three percent reported wanting to continue participating if possible – although most only once a week. At follow-up (1-1.5 years afterwards) 30% were still participating in an exercise programme. Widespread implementation of this programme could increase physical activity among frail older adults. Conn et al. (2003)34 reviewed randomized, controlled trials that attempted to increase physical activity behaviour by aging adults. RCT’s reporting endurance physical activity or exercise behavioural outcomes for at least five subjects were included. Seventeen RCT’s with 6391 subjects were reviewed and a wide variety of intervention strategies were reported. The most common interventions were selfmonitoring, general health education, goal setting, supervised center-based exercise, problem solving, feedback, reinforcement, and relapse prevention education. Significant numbers of aging adults increased their physical activity in response to

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experimental interventions. The amount of increased activity rarely equaled accepted behaviour standards to achieve positive health outcomes. Further work is essential to identify successful strategies to increase activity by larger numbers of elders and to accelerate the increase in activity by those who change activity behaviours. They stated there is a vital need for rigorously designed studies to contribute to this science. Deforche and De Bourdeaudhuij (2000)35 reflected on the consensus on a programme of 30 minutes of moderate physical activity preferably on all days of the week while exercise implemented into daily activities is promoted whereas structured activity programmes lose importance. Activity levels of elderly people did not come up with current recommendations. Therefore strategies to enhance attendance of elderly in physical activities should be developed. Group programmes may be more effective in changing exercise behaviour of elderly than non-supervised physical activity. The purpose of this study was to investigate the differences in level of activity and psychosocial determinants of physical activity between seniors involved in an exercise class and seniors not engaged in any organized physical activity. Subjects involved in an exercise programme had higher levels of activity and reported more social influences and higher self-efficacy compared to the respondents practicing on an individual basis. No differences were found in perceived barriers or benefits. Exercising in a group programme gives the opportunity to accumulate some extra physical activity and positively affects the level of activity outside the programme. Stimulating elderly to join a structured activity programme in the company of family or friends in order to enhance supporting social influences and perceived competence could be an important intervention strategy. Pollard et al. (2000)36 investigated the prevalence and correlates of physical activity among older adults living independently in retirement communities. They found that only 15% of the older adults in this study were active at recommended levels. A stepwise multiple regression tested the association of 22 correlates with four measures of physical activity: energy expenditure levels, strength activity levels, endurance activity levels, and flexibility activity levels. Results indicated that belief in ability and positive attitude were factors related to physical activity. They stated that to promote activity among older adults these correlates may guide the development of effective interventions. Resnick and Spellbring (2000)37 explored the factors that influenced adherence to an exercise programme for elderly, and compared differences in motivation, efficacy expectations, health status, age, functional performance, and fall behaviour between adherers and non-adherers. Participants with an average age of 81 years of whom 14 did not adhere to walking, while 9 adhered showed that those adhering had fewer functional limitations due to their health, better functional performance, stronger self-efficacy expectations related to exercise, and fewer falls. Six major themes were identified that influenced adherence: a) beliefs about exercise; b) benefits of exercise; c) past experiences with exercise; d) goals; e) personality; and f) unpleasant sensations associated with exercise. Interventions that focus on teaching elderly about the benefits of exercise, establishing appropriate goals, and decreasing unpleasant and

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increasing pleasant sensations associated with exercise may be useful to improve adherence to a regular exercise programme. In a literature review conducted by Rhodes et al. (1999)38 it was found that education and exercise history correlate positively with regular exercise, while perceived physical frailty and poor health may provide the greatest barrier to exercise adoption and adherence in the elderly. Several identified constructs correlate with the regular exercise behaviour of elderly such as exercise attitude, perceived behavioural control/self-efficacy, perceived social support and perceived benefits/barriers to continued activity. Resnick (2001)39 tested a model of overall activity in elderly. It was hypothesized that (a) mental and physical health directly influences self-efficacy expectations; (b) mental and physical health, age, and self-efficacy expectations influence outcome expectations; and (c) all these variables directly or indirectly influence overall activity. A one-time interview was conducted with participants with the mean age of 86 years while the majority was Caucasian, women, and unmarried. The variables physical health, self-efficacy expectations, and outcome expectations directly influenced activity, and age and mental health indirectly influenced activity through self-efficacy and outcome expectations. Stevens et al. (2003)40 stated that a significant proportion of older adults in the Netherlands do not participate regularly in leisure-time physical activity. The Groningen Active Living Model (GALM) was developed to change this situation for the better. Prospective analyses revealed significant differences in several potentially mediating variables, although some of these differences were contrary to the hypothesis. They discriminated between adherers and non-adherers identified by several mediating variables expanding the generalizability of social cognitive theory-driven variables to a Dutch population. De Jong et al. (2006)25 as a follow up of the study of Stevens et al. studied the effects on energy expenditure, health and fitness outcomes in sedentary older adults aged 55-65 after 6-month participation in the GALM programme. They found significant increases in energy expenditure for recreational sports activities, other leisure-time physical activity, health indicators, and perceived and performance-based fitness in the intervention group. They concluded that the increases in energy expenditure for physical activity from the GALM programme look promising and are in line with the expected amounts necessary to improve health. However further research is needed to evaluate long-term effects of participation in the GALM programme.

2.5 Dose-response relation physical activity on fitness and health Physical activity should be incorporated as a permanent lifestyle item in everybody’s daily life. The more a person moves in daily life the less are the chances of this person to become prematurely impaired with regards to the performance of the activities of daily life. Studies to establish a dose response with regard to this have been performed by a number of authors.

Chapter 2 | How to Influence Health and Fitness in Elderly by Physical Activity: a Review of Literature

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Min Lee and Skerrit (2001)41 reviewed the dose-response relation between physical activity and all-cause mortality. The parameters examined of physical activity dose were: volume, intensity, duration, and frequency. There was clear evidence of an inverse linear dose-response relation between volume of physical activity and all-cause mortality rates in men and women, and in younger and older persons. Minimal adherence to current physical activity guidelines, which yield an energy expenditure of about 1000 kcal./wk. is associated with a significant 20-30% reduction in risk of all-cause mortality. Further reductions in risk were observed at higher volumes of energy expenditure. No answer could be given to the question whether a volume of