A Systematic Approach to Evidence-Based Design for Measurable Health and Wellness Outcomes: Curating and Translating Evidence to Practice

OBJECTIVES

Evaluating evidence from peer-review literature for use in evidence-based design is often challenging for the design disciplines, requiring access to the peer-reviewed literature, expertise in evaluating methods and findings, and translating the results into actionable design and operational recommendations.

PURPOSE

The purpose of this methods paper is to elucidate the process for systematic evaluation of research to translate evidence into practical application to improve design for occupant health and wellness.

BACKGROUND

Researchers have found strong connections in environmental design influence on health and wellness that have proven to be substantiative in the effort to improve health and well-being. Design has the capacity to encourage healthy choices and decisions within the built environment. Translation of evidence into applied design solutions may improve public health.

METHODS

A protocol is presented that culminates in the translation of evidence into design recommendations focused on improving occupant health. The protocol includes preparation for the literature search and review, search strategy, study selection, data analysis, and development of the literature review.

RESULTS

After evaluation of the evidence is completed, there were several positive findings in the example that stakeholders could utilize to improve the health of building occupants with programs and design to support nutrition, physical activity, and circadian entrainment.

CONCLUSIONS

There are a variety of software tools and processes to utilize in the curation of evidence to improve the built environment with relevant design recommendations and operational considerations affecting the personal, social, and economic health of our society.

The influence of resistance training on adipokines in post-menopausal women: A brief review

The onset of menopause elicits changes in body composition that negatively influence adipokine levels. Consequently, various health risk factors (e.g., cardiovascular disease, osteoporosis, physical inactivity, obesity, arterial hypertension, hypercholesterolemia, sarcopenia) are influenced by adipokines due to changes in body composition after menopause. Thus, improvements in body composition are considered the primary influencer of adipokines. Though several therapeutic interventions (e.g., medication, diet, meditation, exercise) are employed to target changes in body composition, resistance training appears to be more effective in positively improving body composition through changes in lean-muscle mass/fat-mass ratio. However, due to the lack of research, very little is known about adipokines' anti/inflammatory response in postmenopausal women after completing resistance training. Most resistance training studies in postmenopausal women have focused on leptin, adiponectin, and resistin, with limited research assessing other adipokines that are important in metabolic regulation and inflammatory processes. Additionally, the consistency of resistance training protocols as an intervention is not standardized or fully recognized. Therefore, the focus of this review is to establish a more comprehensive understanding of the benefits of resistance training on influencing adipokine levels based on changes to total body composition in postmenopausal women.

The Benefits of Utilizing Total Body Composition as a Predictor of Cardiorespiratory Fitness Based on Age: A Pilot Study

Maximal oxygen consumption (VO2max) has been associated with body fat percentage (%BF) or fat free mass. However, most analyses do not consider total body composition (TBC) as defined by %BF, fat free mass index (FFMI—a height-adjusted measure of muscle mass), visceral adipose tissue, and bone mineral content (BMC). The aim of this study was to determine if TBC predicts cardiorespiratory fitness in healthy adults and if a relationship exists in young and older adults. Sixty healthy individuals (age group 1 (AG1, ≤35 years), n = 35; age group 2 (AG2, >35 years), n = 25) were screened in a cross-sectional study and retrospectively examined. All participants completed a full body DEXA scan and a standardized multistage treadmill test to determine VO2max. A multiple linear regression analysis was performed to examine the relationship between TBC and VO2max. The multiple regression model showed an overall significant effect for TBC (p < 0.001, R2 = 0.282). When analyzed by age group, the regression model of TBC was not significant in young adults (AG1, p = 0.319, R2 = 0.141), but significant in older adults (AG2, p < 0.001, R2 = 0.683). Significant predictors of VO2max in the older cohort were %BF (β = −0.748, p = 0.001) and BMC (β = 0.014, p = 0.002). Total body composition predicted VO2max in a small cohort of healthy adults. This study highlights the importance of TBC for cardiovascular health, especially in mid-to later-life individuals.

Efficacy of L-Leucine Supplementation Coupled with a Calorie-Restricted Diet to Promote Weight Loss in Mid-Life Women

OBJECTIVE

This study evaluated the effect of leucine supplementation coupled with a calorie-restricted diet over a 12-week period in mid-life overweight and obese women on body composition and resting metabolic rate (RMR).

METHOD

This study was a randomized, single-blind, placebo-controlled trial in which 34 women were randomly assigned to either 10 g leucine (LEU) or placebo daily, while following a calorie-restricted diet A dual energy x-ray absorptiometry (DXA) analysis, metabolic rate assessment via a BodyGem® and anthropometrics were performed at baseline and after the 12-week study to determine changes in fat mass, lean mass and RMR. Main variables were analyzed using 2 (condition) by 2 (time) mixed design ANOVAs with repeated measures. Odds ratio was calculated by counting the number of individuals gaining or maintaining lean mass (p ≤ .05).

RESULTS

Both groups lost a significant amount of weight due to both fat and lean mass loss, but there was no significant difference between groups, with RMR remaining unchanged over the course of the study and not significantly different between groups. The loss in lean mass was noticeably less, though not statistically significant (p = 0.644) for the women in the LEU group, with 38% vs. 6%, gaining or retaining lean mass during the intervention relative to the placebo.

CONCLUSIONS

Our findings demonstrate that a greater proportion of mid-life overweight or obese women taking LEU supplements gained or maintained lean mass during intentional weight loss, though it did not reach a level of statistical significance.

Healthy Behaviors through Behavioral Design-Obesity Prevention

Evidence for behavior modification for improved health outcomes was evaluated for nutrition, physical activity (PA), and indoor environmental quality (IEQ). The databases searched included LISTA, PubMed, and Web of Science, with articles rated using an a priori baseline score of 70/100 to establish inclusion. The initial search produced 52,847 articles, 63 of which were included in the qualitative synthesis. Thirteen articles met inclusion for nutrition: cafeteria interventions, single interventions, and vending interventions. Seventeen articles on physical activity were included: stair use, walking, and adjustable desks. For IEQ, 33 articles met inclusion: circadian disruption, view and natural light, and artificial light. A narrative synthesis was used to find meaningful connections across interventions with evidence contributing to health improvements. Commonalities throughout the nutrition studies included choice architecture, increasing the availability of healthy food items, and point-of-purchase food labeling. Interventions that promoted PA included stair use, sit/stand furniture, workplace exercise facilities and walking. Exposure to natural light and views of natural elements were found to increase PA and improve sleep quality. Overexposure to artificial light may cause circadian disruption, suppressing melatonin and increasing risks of cancers. Overall, design that encourages healthy behaviors may lower risks associated with chronic disease.

Stressful Life Changes and Their Relationship to Nutrition-Related Health Outcomes Among US Army Soldiers

Stressful life changes may tax people's adaptive capacity. We sought to determine if and when experiences of stressful life changes were associated with increased odds of adverse nutrition-related health outcomes among US Army soldiers relative to those who did not experience the same stressful life change. An additional aim was to determine which stressful life changes had the greatest association with these outcomes and if there were gender differences in the magnitude of the associations. Stressful life changes studied included: changes in marital status, combat deployment or return from deployment, relocation, adding a child, change in rank, change in occupation, and development of a physical limitation to duty. Using longitudinal data from the Stanford Military Data Repository, which represents all active-duty soldiers aged 17-62 between 2011 and 2014 (n = 827,126), we employed an event history analysis to examine associations between stressful life changes and a subsequent diagnosis of hyperlipidemia, substantial weight gain, and weight-related separation from the Army. Marriage was associated with an increase in the odds of substantial weight gain 3 months later for both men and women. Developing a physical duty limitation was associated with an increase in the odds of a hyperlipidemia diagnosis 2 months later for both men and women, as was substantial weight gain 2 months later. Stressful life changes were also associated with increased odds of nutrition-related health outcomes, although we found gender differences in the magnitude of the associations. Findings could be used to mitigate the effects of stress on health by health professionals.

Stressful Life Changes Affect Nutrition-Related Health Outcomes Among US Army Soldiers (P18-070-19)

Objectives

This prospective cohort study aimed to determine if experiencing stressful life changes were associated with an earlier onset of adverse nutrition-related health outcomes among US Army Soldiers. An additional aim was to determine which stressful life changes were most associated with these outcomes and if there were gender differences in the magnitude of the associations.

Methods

Stressful life changes were changes in marital status, combat deployment or returning from deployment, relocation, adding a child, change in rank, change in occupation, or development of a physical limitation to duty. Nutrition-related health outcomes were hyperlipidemia diagnosis, substantial weight gain, or weight-related separation from the Army. Using longitudinal data from the Stanford Military Data Repository representing all active-duty Soldiers who were age 17–62 between 2011 and 2014 (n = 827,126), event history analysis was used to model the association of stressful life changes with nutrition-related outcomes.

Results

Marriage was found to raise the odds of substantial weight gain three months later by 1.24 times (95% CI: 1.16, 1.32) for men and 1.68 times (95% CI: 1.51, 1.89) for women. Developing a physical duty limitation raised the odds of hyperlipidemia two months later by 1.42 times (95% CI: 1.15, 0.75) for men and 1.83 times (95% CI: 1.01, 3.32) for women and the odds of substantial weight gain two months later by 3.16 times (95% CI: 2.89, 3.44) in men and 1.69 times (95% CI: 1.36, 2.08) in women.

Conclusions

Differences in the magnitude of associations show stressful life changes affect male and female Soldiers differently. Identifying times after stressful life changes when the risk of developing an undesirable health outcome is highest offers new possibilities for proactively addressing health. Findings could guide the timing of interventions to mitigate the effects of stress on health in military and civilian populations.

Funding Sources

None. Disclaimer: Authors’ views do not reflect official DoD or Army policy.

Trajectories of body mass index among active-duty U.S. Army soldiers, 2011-2014

Establishing the shape and determinants of trajectories of body mass index (BMI) among Soldiers is critical given the importance of weight management to military service requirements. To establish the shape and determinants of BMI trajectories among Soldiers, we aimed to (1) model the overall BMI trajectory of Soldiers, (2) find the most common trajectory groups among Soldiers, (3) investigate the relationship between BMI trajectories and sociodemographic and military-specific characteristics, and (4) determine if there were Soldiers with large fluctuations in BMI. The study population included all US Army Soldiers on active-duty between 2011 and 2014 who were age 17–62 (n = 827,126). With longitudinal data from the Stanford Military Data Repository, we used group-based trajectory modeling to identify the BMI trajectories of Soldiers and multinomial logistic regression to estimate associations between Soldier characteristics and trajectory membership. Four distinct BMI trajectory groups were found: increasing, decreasing, constant, and inconstant. The constant, increasing, and decreasing trajectories were similar in shape and percentage between men and women. The constant trajectory had the fewest Soldiers who exceeded weight standards or had duty limitations. The increasing trajectory was associated with marriage and fewer service years. The decreasing trajectory was associated with more service years and higher educational attainment. The inconstant trajectory differed in shape between men and women. Over 6% of men and 12% of women had fluctuations in BMI indicative of weight cycling. Understanding the characteristics associated with BMI trends may assist the Army in targeting resources aimed to improve Soldier health and combat readiness.

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Four BMI trajectory groups were found: increasing, decreasing, constant, inconstant.

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The constant trajectory had the fewest Soldiers who exceeded weight standards.

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The increasing trajectory was associated with marriage and fewer service years.

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The decreasing trajectory was associated with more service years and education.

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6% of men and 12% of women had fluctuations in BMI indicative of weight cycling.

Prevalence of metabolic disease and correlation to body composition and cardiovascular fitness in adults undergoing fitness assessments

The purpose of this descriptive study was to assess the prevalence of metabolic syndrome (MetS), prediabetes and type 2 diabetes (T2DM) in participants who voluntarily participated in a fitness assessment, and to examine associations with routine nutrition intake and overall body composition. One hundred and six participants were recruited. Anthropometric measurements were taken with blood analyses completed for fasting glucose, glycosylated hemoglobin (HbA1c) and lipid panel. A 24-hour diet recall and a dietary screening survey was used to assess nutrient intake, in a sub-set of 36 participants. Statistical analyses utilized partial Spearmans' rank correlations, risk ratios, and Kendall's Tau correlations, with significance level at p < 0.05. Twenty five percent of this sample had ≥ three risk factors for MetS, with elevated fasting glucose and blood pressure being the most prevalent. Twenty percent of the participants had HbA1c levels elevated at the prediabetes range, with no previous diagnosis. Four percent of participants had HbA1c levels elevated at the T2DM range. Two nutrients of interest were correlated to BMI status. Percent kcal from carbohydrate (τ -0.207, p<0.05) had a negative correlation with BMI status and percent kcal from fat intake had a positive correlation (τ 0.217, p<0.05). Findings from this small sample of adults indicate the need for routine assessment of: clustering of MetS risk factors, risk of prediabetes and T2DM and treatment of same. Many participants would benefit from increasing their participation in physical activity, weight loss in regard to overall health improvement, and education to improve diet quality.

Serum vitamin D and body composition in adults undergoing fitness assessments: A correlation study

The purpose of this descriptive study was to assess serum levels of 25(OH) vitamin D₃ (25(OH)D) in participants who voluntarily participated in a fitness assessment and correlate this with muscular strength, weekly exercise, overall body composition, and dietary intake of vitamin D and calcium. Thirty-six participants were recruited. Anthropometric measurements and handgrip strength were taken with blood analyses completed utilizing 25-hydroxyvitamin D assay. A dietary screening survey was used to assess calcium and vitamin D intake. All data collection was completed at time of assessment appointment. Statistical analyses completed utilized Pearson’s and Kendall’s Tau correlation, with level of significance set at p < 0.05. Twenty-two percent of our sample were 25(OH)D deficient and 33% 25(OH)D insufficient, with 16% consuming adequate vitamin D and 5% consuming adequate calcium. Eight of the females and one male had below average DXA assessments for bone health. Vitamin D intake was significantly correlated with serum 25(OH)D levels (τ = 0.29, p<0.01). In females there was an inverse relationship between 25(OH)D and weight (r = -0.45, p<0.05). Thirty-one percent of participants had higher than desirable waist circumference and were 25(OH)D insufficient or deficient. This sample had a high rate of 25(OH)D insufficiency and deficiency, with most not consuming adequate amounts of calcium and vitamin D. Normalizing serum 25(OH)D through food and supplements has the potential to positively impact several parameters of an individual’s health including weight status, visceral adiposity and waist circumference, and bone health.