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Predictivity of International Physical Activity Questionnaire Short Form for 5-Year Incident Disability Among Japanese Older Adults

in Journal of Physical Activity and Health

Background: This study aimed to examine whether physical activity measured using the International Physical Activity Questionnaire Short Form (IPAQ-SF) can predict incident disability in Japanese older adults. Methods: Community-dwelling older adults participated in a prospective cohort survey. The time spent in moderate- to vigorous-intensity physical activity was assessed at the survey baseline using the IPAQ-SF. The participants were categorized into those who spent ≥150 minutes per week (physically active) or <150 minutes per week (physically inactive) in moderate- to vigorous-intensity physical activity. Incident disability was monitored through Long-Term Care Insurance certification during a follow-up lasting 5 years. Results: Among the 4387 analyzable participants (mean age = 75.8 y, 53.5% female), the IPAQ-SF grouped 1577 (35.9%) and 2810 (64.1%) participants as those who were physically active and inactive, respectively. A log-rank test showed a significantly higher incidence of disability among the inactive group of participants (P < .001). The Cox proportional hazards model showed that physically inactive participants had a higher risk of incident disability than the physically active ones did, even after adjusting for covariates (hazard ratio, 1.24; 95% CI, 1.07–1.45, P < .001). Conclusions: Older adults identified as physically inactive using the IPAQ-SF had a greater risk of developing disabilities than those identified as physically active. The IPAQ-SF seems to be appropriate to estimate the incidence risk of disability.

The promotion of physical activity (PA) is important for public health. The World Health Organization (WHO) recommends performing ≥150 minutes per week of moderate- to vigorous-intensity PA (MVPA).1 In older adults, PA contributes to the prevention of disability caused by chronic diseases or functional decline24; therefore, evaluating PA helps estimate the disability risk and health care needs among this population. PA has been recorded using objective monitors or self-reported measures.5 Although objective monitors such as accelerometers and pedometers allow for an objective data collection through monitoring of body movement, self-reported measures, such as questionnaires, allow for a large data collection with higher feasibility than objective monitors.

The International Physical Activity Questionnaire Short Form (IPAQ-SF) is suited to facilitate large population studies on PA among adults.6 The IPAQ-SF assesses PA through 3 domains: walking, moderate-intensity PA, and vigorous-intensity PA. Although the validity of IPAQ-SF was confirmed even among older adults,7 there existed a tendency to overestimate the time spent in all intensities of PA. Furthermore, there was a 40% to 46% agreement between the IPAQ-SF and objective measurement in terms of identifying those whose PA met the WHO-recommended level.8 Nevertheless, the IPAQ-SF was useful for examining the association of PA with quality of life,9 metabolic syndrome,10 sarcopenia,11 and mental health12 in older adults. However, there is a scarcity of studies examining whether meeting the WHO’s PA recommendation, as identified by the IPAQ-SF, is associated with health issues in older persons. Therefore, this study aimed to use the IPAQ-SF to assess whether meeting WHO’s PA recommendation could predict disability incidence among Japanese older adults. The findings may help evaluate disability risk by physically inactive for older adults in clinical settings.

Methods

Participants

This study used prospective cohort study data from the National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes (NCGG-SGS). As described in previously published literature,13,14 NCGG-SGS is a community-based cohort study aiming to establish a screening system for preventing geriatric syndromes. Under the NCGG-SGS, community-dwelling older people in the Midori ward of Nagoya city, Japan, aged ≥70 years were recruited from July to December 2013. An invitation letter was sent to the 24,271 Midori ward residents who had no long-term care needs or support; of these, 5257 participated in the health examinations. The participants’ eligibility was determined by their ability to understand instructions provided during the health examination. All participants were tracked monthly for any new incident of disability for 5 years through the Japanese public Long-Term Care Insurance (LTCI) system, managed by the municipal government.

The flow chart of the participants’ data inclusion process is shown in Figure 1. Participants were excluded if they had received an LTCI certification of disability before the health examination and after receiving the study invitation (n = 21); a self-reported basic activities of daily living disability (n = 7); a medical history that included stroke, dementia, or Parkinson’s disease (n = 386); a general cognitive impairment (Mini-Mental State Examination score < 21; n = 146)15; died or moved to another city during the follow-up period (n = 162); or missing data for all the variables (n = 148). In total, 4387 participants were included in the analysis. All participants provided written informed consent. This study was conducted according to the guidelines proposed in the Declaration of Helsinki. The study protocol was reviewed and approved by the research ethics committee of the National Center for Geriatrics and Gerontology.

Figure 1
Figure 1

—Process flow for data inclusion. BADL indicates basic activities of daily living; LTCI, Long-Term Care Insurance; MMSE, Mini–Mental State Examination; NCGG-SGS, National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes.

Citation: Journal of Physical Activity and Health 18, 10; 10.1123/jpah.2021-0247

Assessment

Disability

This study identified disability using an LTCI certification that indicated whether a patient required care or support. The LTCI system in Japan has been described elsewhere.16 Briefly, a trained local government official visits the individual’s home and administers a questionnaire regarding the patient’s current physical and mental status. The assessment is composed of 73 items in 7 dimensions, including paralysis and limitation of joint movement and activities of daily living (ADL)/instrumental ADL and use of medical procedures (12 items). The applicant’s standardized scores from the questionnaire are calculated for the 7 dimensions described above, and the estimated time taken for 9 categories of care (grooming/bathing, eating, toileting, transferring, eating, assistance with instrumental ADL, behavioral problems, rehabilitation, and medical services) are recorded. Thereafter, the subjects are assigned a care-needs level based on the total estimated care minutes per day, and the Nursing Care Needs Certification Board reviews and confirms the care need level. “Support Level 1 or 2” indicates a need for assistance to support ADL, whereas “Care Level 1 through 5” indicates a need for continuous care. This study defined incident disability as the occasion of a participant being certified to need continuous care according to the LTCI classification regardless of their care level.

Physical Activity

The Japanese version of the IPAQ-SF evaluated the usual 7 days’ PA within each item (ie, vigorous intensity, moderate intensity, and walking) to estimate the time spent engaged in ≥10 minutes of PA per week. No difference has been recorded between the reliability and validity of the short and long forms; the short form has been recommended for feasibility.6 Although the official IPAQ guidelines17 assigned the PA intensity of 3.3, 4.0, and 8.0 metabolic equivalents (METs) for walking, moderate PA, and vigorous PA, respectively, we used the modified IPAQ-SF, which was validated in Japanese older adults and assigned 2.5, 3.0, and 5.3 METs for walking, moderate PA, and vigorous PA, respectively.7 The sum of moderate- and vigorous-intensity PA duration was used to calculate ≥3.0 METs of MVPA time. Then, the participants were categorized into two groups, namely, physically active (with ≥150 min/wk of MVPA) and physically inactive (with <150 min/wk of MVPA) according to WHO’s PA recommendation.1

Covariates

Besides collated data on their sociodemographic characteristics (age, sex, and education years), the participants were asked whether they had any chronic diseases (diabetes mellitus, heart and cardiovascular diseases, and respiratory diseases) and chronic pain in any part of the body lasting at least 2 months during a face-to-face interview. In addition, normal walking speed was measured on a 6.4-m walking path with 2.4 m of measurement space and 2 m of front and back space for acceleration and deceleration.

Statistical Analyses

The differences in the participants’ characteristics of the physically active and inactive groups were examined using an independent t test for continuous variables and χ2 tests for ordinal variables. The cumulative incidence of disability during the follow-up period was assessed for both groups using the Kaplan–Meier curve, and the differences were examined using the log-rank test. The associations between incident disability and meeting the recommended PA identified by the IPAQ-SF were examined using Cox proportional hazards regression models. The hazard ratio (HR) and 95% CI of incident disability were calculated using crude and adjusted models, with the physically active group as reference. To rule out reverse causality (ie, functional decline causing physical inactivity), lagged analyses were conducted to exclude participants who developed incident disability within 12 or 24 months. All analyses were performed using SPSS (version 25; IBM, Armonk, NY). The significance level was set at P < .05 in all analyses.

Results

The characteristics of all participants (N = 4387; age, 75.8 [4.2] y; 53.5% female) are summarized in Table 1. Through the IPAQ-SF, we classified 1577 (35.9%) and 2810 (64.1%) participants into physically active and inactive groups, respectively. The incident disability was 237 (15.0%) and 642 (22.8%) in the physically active and inactive groups, respectively (P < .001).

Table 1

Participants’ Characteristics

IPAQ-SF-identified PA level
Physically activeaPhysically inactiveb
VariablesOverall (N = 4387)n = 1577n = 2810Pa
Age, y75.8 (4.2)75.3 (3.9)76.1 (4.4)<.001
Female, n (%)2348 (53.5)723 (45.8)1625 (57.8)<.001
Education, y12.0 (2.6)12.2 (2.6)11.9 (2.6).004
Diabetes, n (%)555 (12.7)194 (12.3)361 (12.8).602
Cardiovascular disease, n (%)840 (19.1)274 (17.4)566 (20.1).025
Respiratory disease, n (%)772 (17.6)240 (15.2)532 (18.9).002
Chronic pain, n (%)1696 (38.7)560 (35.5)1136 (40.4).001
Gait speed <1.0 m/s, n (%)1431 (32.6)397 (25.2)1034 (36.8)<.001
Incident disability, n (%)879 (20.0)237 (15.0)642 (22.8)<.001

Abbreviations: IPAQ-SF, International Physical Activity Questionnaire Short Form; MVPA, moderate- to vigorous-intensity PA; PA, physical activity. Note: All values are reported as mean (SD) or n (%).

aParticipants who reported ≥150 minutes per week and <150 minutes per week of MVPA in the IPAQ-SF were grouped into “physically active” and “physically inactive” groups, respectively. bContinuous variables and category variables between groups were compared using independent t test and χ2 test, respectively.

The log-rank test showed a significant difference in the incidence of disability between physically active and inactive groups (P < .001; Figure 2). The physically inactive group showed a significantly higher risk of incident disability than the physically active group, even after being adjusted for covariates (HR = 1.24; 95% CI, 1.07–1.45, P < .001; Table 2). In the 12-month and 24-month lagged analyses, 126 and 300 participants, respectively, with incident disability were excluded. The association between the MVPA level and incident disability remained significant in both analyses (12-mo lag: HR = 1.26; 95% CI, 1.07–1.49, P = .005; and 24-mo lag: HR = 1.21; 95% CI, 1.00–1.45, P = .045) (Table 2).

Figure 2
Figure 2

—Kaplan–Meier curves for estimating nondisability rates according to the incidence of disability and physical activity level. A significant difference was observed in the log-rank test between the physically active group (≥150 min/wk of MVPA) and inactive group (<150 min/wk of MVPA) (P < .001). MVPA indicates moderate- to vigorous-intensity physical activity.

Citation: Journal of Physical Activity and Health 18, 10; 10.1123/jpah.2021-0247

Table 2

Association of Physical Activity Level Identified by IPAQ-SF With Incident Disability in the Cox Proportional Hazards Regression Model

Crude model

(N = 4387)
Adjusted model

(n = 4387)
12-mo lagb

(n = 4261, excluding 126)
24-mo lagc

(n = 4087, excluding 300)
HR (95% CI)PHR (95% CI)PHR (95% CI)PHR (95% CI)P
Physically inactive

(ref: physically active)a
1.60 (1.38–1.86)<.0011.24 (1.07–1.45).0051.26 (1.07–1.49).0051.21 (1.00–1.45).045
Age, y1.14 (1.13–1.16)<.0011.13 (1.12–1.15)<.0011.14 (1.12–1.16)<.001
Sex (ref: female)0.75 (0.65–0.86)<.0010.77 (0.66–0.89).0010.74 (0.62–0.89).001
Education, y1.01 (0.98–1.03).6701.00 (0.98–1.03).8041.00 (0.97–1.03).965
Diabetes (ref: no)1.20 (0.99–1.44).0611.22 (1.00–1.5).0491.08 (0.85–1.37).530
Cardiovascular disease (ref: no)1.27 (1.08–1.48).0031.24 (1.04–1.47).0141.38 (1.14–1.68).001
Respiratory disease (ref: no)1.15 (0.98–1.36).0931.20 (1.01–1.43).0431.16 (0.95–1.42).142
Chronic pain (ref: no)1.24 (1.08–1.41).0021.23 (1.06–1.42).0051.18 (1–1.39).053
Gait speed1.99 (1.72–2.29)<.0011.90 (1.63–2.22)<.0011.90 (1.59–2.26)<.001

Abbreviations: CI, confidence interval; HR, hazard ratio; IPAQ-SF, International Physical Activity Questionnaire Short Form; MVPA, moderate- to vigorous-intensity physical activity; ref, reference.

aParticipants who reported ≥150 minutes per week and <150 minutes per week of MVPA in the IPAQ-SF were grouped into “physically active” and “physically inactive” groups, respectively. bThis analysis was lagged for 12 months after baseline assessment. Incident disability within the 12-month period (n = 126) was excluded. cThis analysis was lagged for 24 months after baseline assessment. Incident disability within the 24-month period (n = 300) was excluded.

Discussion

This study examined the predictivity of PA level identified using the IPAQ-SF for incident disability among community-dwelling older adults. Our findings showed that older adults categorized as physically inactive (performed <150 min/wk of MVPA) according to IPAQ-SF had a higher risk of incident disability than those categorized as physically active (performed <150 min/wk of MVPA). This association remained significant, even in the lagged analyses.

The prospective association between PA levels and incident disability found in our study was consistent with other studies that measured PA using accelerometers.24 Moreover, the lagged analyses’ results suggested that the prospective association was significant without reverse causality. This suggested that the IPAQ-SF can be used as an assessment tool to roughly predict the risk of incident disability by estimating the time per week of MVPA. The present study used questions concerning only moderate and vigorous intensity of PA from the IPAQ-SF that could be beneficial in clinical or research settings due to lower respondent burden. Previous studies that used the IPAQ-SF to determine PA levels in older adults followed the official IPAQ guidelines and used estimated METs × hour per week.17 They reported a cross-sectional association between PA and health-related outcomes, including quality of life, metabolic syndrome, sarcopenia, and mental health.912 To establish the predictivity of the IPAQ-SF for various health-related outcomes in older adults, more prospective studies are needed.

Using the MVPA duration recorded in the IPAQ-SF, we identified 35.9% of the participants who met the recommended PA levels. However, it is difficult to prove whether the proportion was valid because we did not measure MVPA objectively. In a study that measured PA using the IPAQ-SF and accelerometer in adults aged 50–87 years, the IPAQ-SF (PA included walking duration) identified 76.5% of the participants who met the recommended PA, whereas the accelerometer only identified 37.8% such participants.8 We used a modified IPAQ-SF that did not include walking duration with MVPA duration, and the results were comparable to those determined using accelerometers.8 A potential explanation could be that most walking activities among older adults may be below the threshold for moderate-intensity PA.18 In addition, a previous study18 among community-dwelling older adults showed that the amount of PA measured using a modified IPAQ-SF (which did not include walking duration with moderate-intensity PA), rather than the original IPAQ-SF (which included walking duration with moderate-intensity PA), yielded results closer to those measured using an accelerometer.7 Therefore, excluding walking duration from MVPA duration may be appropriate when assessing older adults’ MVPA using the IPAQ-SF.

A strength of this study is that it is the first to examine whether IPAQ-SF findings concerning PA levels can predict incident disability in older adults. Another is that it examined a large cohort. However, the study also has a few limitations. First, we did not compare the output of the IPAQ-SF with that of an accelerometer and, therefore, could not validate whether the estimated risks were comparable. IPAQ-SF-based PA might be an overestimation due to recall bias.19 Second, generalization of the study findings warrants caution because the participants were not representative of the older adult population and were recruited from a community nonrandomly. Although we did not restrict those who were sent invitation letters from participation and examine the differences between the participants and the others, those who can access the health examination facility by themselves or through family support might have participated in the health examination. Thus, the participants may have a health advantage over other members of the study population, who could not access the health examination. Third, we did not examine incident disability in detail and, therefore, could not determine which cause of disability was most predicted by the IPAQ-SF. Fourth, using the IPAQ-SF to calculate MVPA duration does not correspond to the current PA guidelines.1 Although the current PA guidelines recommend performing ≥150 minutes per week of MVPA, irrespective of each bout’s length,1 the IPAQ-SF does not enquire about MVPAs lasting <10 minutes. In the future, we should elucidate whether including MVPA lasting <10 minutes to the IPAQ-SF could impact its value in predicting incident disability among older adults. Finally, although the validity of the IPAQ-SF in the Japanese language is adequate, its reliability is questionable7; therefore, the findings may have low reproducibility.

Conclusions

In the Japanese community, physically inactive older adults identified using the IPAQ-SF showed a higher risk of incident disability than physically active ones did. Therefore, the IPAQ-SF can be an option to PA assessment tools such as accelerometers that objectively measure PA to roughly predict the risk of disability caused by physical inactivity.

Acknowledgments

The authors would like to thank the Midori ward office for helping with participant recruitment. This work was financially supported by the Strategic Basic Research Programs Redesigning Communities for Aged Society (RISTEX) of the Japan Science and Technology Agency (JST), Health and Labor Sciences Research Grants (grant number: H24-tyoujyu-ippan-004), and JSPS KAKENHI (grant number: JP20K19665). The funders played no role in the design, conduct, and reporting of this study.

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Kurita is with the Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan. Doi, Tsutsumimoto, Nakakubo, Ishii, Kiuchi, and Shimada are with the Department of Preventive Gerontology, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu, Aichi, Japan. Kiuchi is also with the Graduate School of Health Sciences, Kagoshima University, Kagoshima, Japan.

Kurita (kuritoshi@ncgg.go.jp) is corresponding author.
  • View in gallery

    —Process flow for data inclusion. BADL indicates basic activities of daily living; LTCI, Long-Term Care Insurance; MMSE, Mini–Mental State Examination; NCGG-SGS, National Center for Geriatrics and Gerontology-Study of Geriatric Syndromes.

  • View in gallery

    —Kaplan–Meier curves for estimating nondisability rates according to the incidence of disability and physical activity level. A significant difference was observed in the log-rank test between the physically active group (≥150 min/wk of MVPA) and inactive group (<150 min/wk of MVPA) (P < .001). MVPA indicates moderate- to vigorous-intensity physical activity.

  • 1.

    Bull FC, Al-Ansari SS, Biddle S, et al. World Health Organization 2020 guidelines on physical activity and sedentary behaviour. Br J Sports Med. 2020;54(24):14511462. PubMed ID: 33239350 doi:10.1136/bjsports-2020-102955

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Dunlop DD, Song J, Semanik PA, et al. Relation of physical activity time to incident disability in community dwelling adults with or at risk of knee arthritis: prospective cohort study. BMJ. 2014;348:g2472. PubMed ID: 24782514 doi:10.1136/bmj.g2472

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Fielding RA, Guralnik JM, King AC, et al. Dose of physical activity, physical functioning and disability risk in mobility-limited older adults: results from the LIFE study randomized trial. PLoS One. 2017;12(8):e0182155. PubMed ID: 28820909 doi:10.1371/journal.pone.0182155

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    Shah RC, Buchman AS, Leurgans S, et al. Association of total daily physical activity with disability in community-dwelling older persons: a prospective cohort study. BMC Geriatr. 2012;12(1):63. PubMed ID: 23072476 doi:10.1186/1471-2318-12-63

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5.

    Dowd KP, Szeklicki R, Minetto MA, et al. A systematic literature review of reviews on techniques for physical activity measurement in adults: a DEDIPAC study. Int J Behav Nutr Phys Act. 2018;15(1):15. PubMed ID: 29422051 doi:10.1186/s12966-017-0636-2

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Craig CL, Marshall AL, Sjöström M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35(8):13811395. PubMed ID: 12900694 doi:10.1249/01.MSS.0000078924.61453.FB

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Tomioka K, Iwamoto J, Saeki K, et al. Reliability and validity of the International Physical Activity Questionnaire (IPAQ) in elderly adults: the Fujiwara-kyo study. J Epidemiol. 2011;21(6):459465. PubMed ID: 21946625 doi:10.2188/jea.JE20110003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Grimm EK, Swartz AM, Hart T, et al. Comparison of the IPAQ-Short Form and accelerometry predictions of physical activity in older adults. J Aging Phys Act. 2012;20(1):6479. PubMed ID: 22190120 doi:10.1123/japa.20.1.64

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Guedes DP, Hatmann AC, Martini FA, et al. Quality of life and physical activity in a sample of Brazilian older adults. J Aging Health. 2012;24(2):212226. PubMed ID: 21750225 doi:10.1177/0898264311410693

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Choi M, Yeom HA, Jung D. Association between physical activity and metabolic syndrome in older adults in Korea: analysis of data from the Korean National Health and Nutrition Examination Survey IV. Nurs Health Sci. 2013;15(3):379386. PubMed ID: 23480329 doi:10.1111/nhs.12045

    • Crossref
    • PubMed
    • Search Google Scholar
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