Posters 3

The Arm-in-Arm Gait Training Trial (AAGaTT) research project aims to evaluate the effectiveness of a paired gait training program for older adults at risk of falling. This program involves pairing an older adult who has recently experienced a fall with a younger partner who acts as a ‘walking coach’. The study examines the impact of this approach on various aspects of the older adults’ lives and their perceptions of the experience. Analysis of interviews conducted after the 4-week program reveals several positive aspects of the interaction between older adults and their younger partners. Firstly, the presence of a younger companion is valued by older adults, who appreciate the reassuring and reassuring aspect of having a partner in good health by their side. In addition, the social aspect of this interaction is emphasized, with pleasant, shared moments and enriching exchanges about life and experiences. The benefits of the training program are also highlighted. Participants report an increase in self-esteem as they realize their ability to achieve things they thought were beyond their reach. Moreover, the program brings a degree of discipline to the lives of older adults, giving them a regularity and structure that they value. Finally, on a physical level, participants report an improvement in their walking ability as a result of the program. In conclusion, the initial findings of the AAGaTT study suggest that walking with a younger partner can have a positive impact on the lives of older adults, both socially and physically and psychologically. These findings underscore the importance of intergenerational interactions in maintaining the health and well-being of older adults and highlight the potential of pair walking training programs in this context.

RESEARCH ABSTRACT Background: Physical inactivity is one of the leading risk factors for non-communicable diseases worldwide. Purpose: This article evaluates three decades (1990-1999; 2000-2009; 2010-2019) of progress in physical activity and health research in China. Methods: A systematic review was conducted by the Global Observatory for Physical Activity GoPA! for Pubmed, SCOPUS, and ISI Web of Knowledge ‘physical activity and health’ publications between 1950 and 2019. For this study, we focused on the 610 Chinese publications identified. We assessed the evolution in the number of publications and classified them into five areas (1. Prevalence, measurement, and trends; 2. Correlates and determinants; 3. Health consequences; 4. Interventions; and 5. policy). Results: The average number of “physical activity and health publications” increased from one per year in the 90s to 7.6 per year in the 2000s, and to 47 per year in the 2010s. Most publications focused on the correlates and determinants (38.7%) and the health consequences of physical activity (35.9%). Physical activity policy accounted for 2.3% of the publications. In the 90’s, only 11 articles were identified, of which seven were on the health consequences of physical activity. Although the absolute number of articles increased from 11 to 520 articles in the 2010s, the proportion of articles on the health consequences of physical activity decreased from 63.6% in the 1990s to 35.2% in the 2010s. Conclusion: China has 17.7% of the world’s population and 2.6% of the scientific publications on ‘physical activity and health’ identified in a worldwide systematic review. Despite a slow start, China’s research on physical activity and health has grown rapidly since 2000. Practical Implications: This study highlights China’s progress in physical activity and health research, offering valuable insights for public health improvement and future policy-making. Funding: No funding information provided.

Background: The goal of developing new meeting places in local communities is that the places are being used by the residents to support active living and wellbeing. To achieve this, knowledge about different users’ needs and preferences is essential. Purpose: To develop a digital needs assessment tool that could be utilized by stakeholders involved in the planning of new meeting places. Method: The needs assessment tool was developed through a consensus-based process with researchers and practitioners, which involved several steps. First, a group of experienced practitioners identified factors that promote residents’ use of meeting places. Second, the researchers conducted a review of international literature on the topic. Then, expert knowledge and research knowledge on identified factors were integrated, systematized, and grouped. Lastly, a survey was carried out among stakeholders from relevant networks. The stakeholders rated the importance of each factor and could add new suggestions. The results from the survey were used to reach consensus on factors of more and less importance to promote use of meeting places. Results: From science and practice combined, a total of 118 factors were identified. These factors covered the social, physical, and natural environment of the meeting place, as well as organizational aspects. Some factors were important across all age groups. However, most of the factors (99) were age-specific needs and preferences of children, adolescents, adults, and elderly. Conclusion: A diversity of factors promoting use of meeting places were identified, most of them age-related, emphasizing the importance of planning with the intended target group in mind. Practical implications: Combining local expert knowledge with international evidence ensures that the tool is applicable in a national context. The tool enhances the municipal planners’ ability to plan for the intended user group, ensuring that meeting places in local communities are used. Funding: Norwegian Research Council.

Background: Despite numerous health benefits and extensive promotion efforts, 35% of Australian adults did not meet the WHO physical activity (PA) guidelines in 2022. To meet the WHO goal of reducing physical inactivity by 15% by 2030, a multi-sectoral system approach is urgently needed. Purpose: We report the process and findings from a co-designed systems mapping project to present environmental, social, and policy determinants of PA for children and adults in the context of urban New South Wales (NSW), Australia. Methods: A qualitative participatory group concept mapping workshop was held in May 2023 with 19 researchers and stakeholders working in education, transportation, urban planning, community, health, and sport and recreation. Initial maps were developed and refined using further online feedback from the participants. Interviews were conducted with additional policy makers from relevant sectors to further refine the maps. Results: Two systems maps were co-created, identifying over 100 variables influencing PA and their interconnections. Five domains emerged from the adults’ map – social and community, policy, built environment and transportation, healthcare, and workplace; four for the children’s map – family, school, transportation, and community and environment. The maps share similarities such as regarding potential drivers within the transportation, community and built environment sectors; however, the children’s map has an additional focus on the school setting and the adults’ map on workplace and healthcare settings. Interviews with policy makers provided further unique insights into understanding and intervening in the PA system for children and adults. Conclusions: This co-designed participatory systems mapping process, supplemented by stakeholders interviews, provided a unique opportunity to bring together stakeholders across sectors to understand the complexity within the PA system and begin to identify leverage points for tackling the systemic drivers of physical inactivity in NSW. Funding: Australia National Health and Medical Research Council, NSW Ministry of Health

Background: While research has shown the cognitive benefits of combining cognitive activity (CA) with physical activity (PA), these findings have predominantly been observed in controlled settings. To bridge the gap between research and real-life, we developed a cognitively enriched walking program for older adults. We conducted a randomized controlled trial complemented by a mixed-methods process evaluation to evaluate the program. Purpose: Provide insights into the process evaluation of the cognitively enriched walking program conducted in a real-world setting. Methods: Cognitively healthy adults aged 65+ years were randomly assigned to: 1) a cognitively enriched walking program (PA+CA, n = 52); 2) a walking program (PA only, n = 49); or 3) a passive control condition (n = 47). Both walking programs consisted of two supervised 60-minute group-based walking sessions per week, lasting six months in total. A mixed-method process evaluation, based on the framework of Saunders et al. (2005), was conducted to evaluate the PA+CA and PA-only conditions, focusing on fidelity, dose delivered, dose received, reach, recruitment and context of the intervention. After the intervention, participants and coaches completed a process evaluation questionnaire and participated in a semi-structured interview to thoroughly document the intervention process. Results: At baseline, 148 participants were included with a mean age of 69.9 (4.2) years. The questionnaire was completed by 7 coaches (n = 3 PA+CA and n = 4 PA only), and by 35 and 32 participants of the PA+CA and PA only condition, respectively. The results of this study are currently being analysed and will be presented during the symposium. Conclusions: The results will give insight into the process of this real-life cognitively enriched walking program. Practical implications: Findings will inform future programs to promote cognitive functioning by simultaneously focusing on PA and CA for older adults in real-life settings. Funding: Research Foundation Flanders.

Background: Obesity, as defined by the WHO, has reached pandemic levels globally, affecting about one-third of the world’s population. This multifactorial condition results from an imbalance between caloric intake and expenditure, exacerbated by genetic, epigenetic, social, and environmental factors. While bariatric surgery is the most effective long-term treatment for severe obesity, post-surgery weight regain remains a significant issue due to lack of professional support and accessible exercise facilities. Purpose: The B-FIT project aims to develop a new referral and intervention model to improve physical activity (PA) and reduce sedentary behaviour (SB) among individuals undergoing bariatric surgery. This model seeks to prevent post-surgical weight regain and promote long-term healthy habits through supervised interventions and behaviour change techniques. Methods: A randomized controlled trial will be conducted with a long-term follow-up (10 years) to evaluate the impact of PA and reduced SB (accelerometery) on weight control (body mass index and waist circumference), metabolic outcomes (HbA1c), and quality of life (SF-12) before and after bariatric surgery. Participants in the intervention group will be referred from the Hospital Sant Joan de Déu to the University of Vic-Central University of Catalonia for tailored exercise programs and behaviour modification support, starting 8 months pre-surgery and continuing 12 months post-surgery. The control group will follow the current hospital care protocol, which includes nutrition and PA advice without supervision pre- and post-surgery. Discussion: Preliminary findings indicate that incorporating structured PA programs is crucial for sustaining weight loss and improving overall health post-surgery. Challenges such as accessibility to exercise facilities and professional support highlight the need for integrated care models like B-FIT. Practical implications: The B-FIT model could serve as a blueprint for other healthcare institutions aiming to integrate PA programs into their obesity treatment protocols, potentially reducing healthcare costs associated with obesity-related comorbidities.

Background: In an era where sedentary lifestyles are increasingly prevalent, incorporating regular physical activity into daily routines is crucial. The Walking for Fitness program at the University of the Philippines Los Baños encourages students to embrace walking as part of their fitness routine. The success of such a program is not solely dependent on the participants’ commitment but also on the quality of the environment in which they walk.

Purpose: Through structured activities and reflective practices, the program seeks to promote a culture of health and wellness on campus. This paper identifies the specific challenges faced by participants due to the lack of designated open spaces within the university, assesses the impact of environmental factors on participant satisfaction, and explores the potential benefits of university-provided open spaces in enhancing the program’s overall effectiveness.

Methods: Stratified random sampling

Results: The feedback from students reveals that while the program has many positive aspects, the challenges posed by the current walking environment—uneven sidewalks, poorly lit paths, and the presence of stray dogs—have hindered their overall experience and motivation. Central to this discussion is the urgent need for the university to provide open spaces that will ensure the program remains relevant, engaging, and beneficial for all who partake in it.

Conclusion: These spaces would not only address the current challenges but also foster a more supportive environment for physical activity, contributing to the holistic development of the university community.

Practical Implications: The study could influence university policies regarding the allocation of resources toward campus facilities. It might prompt the administration to prioritize the development and maintenance of open spaces, ensuring that physical activity is supported and encouraged as part of the university’s commitment to student and staff well-being.

Funding: University of the Philippines

Background: Type 2 diabetes mellitus (T2DM) is a chronic disease which contributes to an increased disease burden worldwide. To reduce adverse events and complications, effective diabetes self-management is required. Research has shown that the self-management and glycaemic control of people with lower educational levels is often less managed than those of higher educated people. This implies that patients from lower educational groups require additional care for their diabetes self-management. Purpose: The purpose of this study is to assess the (cost-)effectiveness of a diabetes self-management program ‘Powerful Together With Diabetes’ (PTWD), which is specifically developed for patients from lower educational groups living with T2DM. Methods: The PTWD program is focused on attaining basic knowledge and skills for effective diabetes self-management. In a previous study (the DISC study), lower-educated participants enjoyed the PTWD program as well as improved their T2DM-related behaviours. The design of the study is an effectiveness-implementation hybrid type 2 trial. We will conduct mixed methods effectiveness, process and economic evaluations. To investigate the (cost-)effectiveness, a two-arm quasi-experimental trial will be conducted with a parallel a mixed method process evaluation. Study participants are patients from lower educational groups living with T2DM between 35 and 70 years old. Data will be collected with questionnaires, physical activity trackers and registration data from general practitioner registries. The primary outcome of the study is change in haemoglobin A1c (HbA1c) levels from baseline to 12 months. The secondary outcomes are use of primary and secondary care, medication use, blood biomarkers, health behaviours (e.g. physical activity), anthropometrics, and quality of life. To see if the results are maintained, we will measure the outcomes 24 months after baseline. Practical implications: this study contributes to the evidence of interventions specifically designed for this population and to help lower educated diabetes patients Funding: Funded by ZonMw, grant number 555003202

Background: Free-form dance (FFD) has been studied as a physical activity (PA) mode for improving health; however, the intensity of FFD has yet to be characterized, which limits present understanding of the PA dose associated with participating in FFD. Purpose: To quantify the absolute and relative intensities of solo, FFD among active, community-dwelling adults. Methods: Participants [N=48; female 79%(38); age—18-83 years; dance training experience—0-56 years], engaged in multiple 5-minute FFD bouts at respectively self-determined moderate and vigorous intensities, with and without music. Absolute (indirect calorimetry) and relative intensities (ratings of perceived exertion via Borg scale; heart rate) were measured during FFD. The significance level was established a priori at α=0.05. Results: Linear mixed effects models showed the mean absolute intensity of self-determined moderate intensity dancing without music was 5.6(0.24) metabolic equivalents (METs). On average, the presence of music (β=0.6) and the intention to dance at a vigorous intensity (β=1.1) were positively associated with METs. METs were inversely associated with age (β=-0.05) and BMI (β=-0.10). The mean relative intensity of self-determined moderate-to-vigorous intensity dancing, with and without music, was 76%(1.59) of the age-predicted maximal heart rate; 74%(1.59) of the heart rate reserve (HRR); and 13(0.34) on the Borg scale. By measure of %HRR, all adults reached at least a moderate intensity across all bouts. Conclusions: Adults modulated the PA intensity of FFD at will between self-determined moderate and vigorous intensity bouts. The presence of music was positively associated with intensity during FFD. Adults reached at least a moderate PA intensity during FFD with or without music as measured by HRR. Practical Implications: The intention to engage in FFD at a moderate-to-vigorous intensity, with or without music, provides a sufficient stimulus for community-dwelling adults to reach moderate-to-vigorous PA intensities while dancing solo. Funding: National Endowment for the Arts Award #1879058-38-C-21

Background: National data shows that 7% of people in Nepal are insufficiently active, while the rate is 43.1% for individuals in semi-urban areas. These individuals engage in less leisure-time physical activity (PA) and exhibit high levels of sedentary behaviour, despite moderate to vigorous PA (MVPA) being beneficial for health. The true extent of insufficient PA might be higher due to potential under-reporting in the subjective assessments used in these surveys. Purpose: We aim to evaluate movement behaviour and sleeping patterns using accelerometer. Methods: We conducted a cross-sectional descriptive study to investigate the prevalence of insufficient physical activity in the semi-urban areas of Pokhara Metropolitan City, Nepal. We systematically recruited 436 adults aged 18 to 69 from the study site using random sampling. To measure movement behaviour, we used the wrist-worn Axivity AX3 accelerometer, set at 100 Hz with a dynamic range of ±8g. Results: Out of 436 participants, 425 have valid data. Male participants constituted about one-third of the population (30.8%). The mean (SD) minutes of MVPA per day was 29.0 (31.2), with males averaging higher at 37.8 minutes compared to females at 25.0 minutes. More than half of the participants (56.9%) did not meet the WHO recommendation of at least 150 minutes of MVPA per week. The mean reported duration of sleep was 6.6 hours per day, while the actual sleep duration was only 5.6 hours per day, resulting in a sleep efficiency of just 79.9%. Conclusions: Objectively measured physical activity in this population was surprisingly lower than the national average. Additionally, sleep efficiency was also below normal. Practical Implications: This study highlights the practical use of objective measures of physical activity in community settings in low- and middle-income countries like Nepal. Funding: This study is part of PhD project and partially funded by university grant.

The Multifunctional Gymnastics Program of the Social Service of Commerce of São Paulo promotes access to its gyms with a proposal to develop physical capacities and motor skills in an integral way for students with different physical conditions over the age of 12. The physical sports activity programs aim to encourage the regular practice of physical activity in a democratic way, providing access in different regions of the state and creating opportunities for workers, their families and also benefiting populations with lower economic conditions. A little over a year ago, access was created so that users can freely visit 13 units in the São Paulo metropolitan region, so that they can optimize their time, get to know new possibilities for practice and also carry out activities near their home or work while maintaining regular exercise and using an exercise app. The unit in this survey has 1603 students, 744 of whom are elderly, and 76% of whom are female, which indicates that we offer opportunities for female care and empowerment through our activities We observed that with this access our maximum attendance per hour rose from 67 people to 98 individuals, and the evening hours saw an increase in people doing activity after work, but there was still no increase in the average number of workouts per week. The use of the app, which allows educators at all units to guide students and prescribe exercises, was well accepted by the students and demonstrates that new technologies increase access to regular physical activity.In addition, proposals for new collective training models have also led to more students from other units coming to our space.We conclude that the creation of strategies involving technology, access and diversity of activities significantly encourages attendance and permanence in our program.

Background: Physical activity (PA) is known to positively affect health, particularly in people with chronic respiratory diseases such as Cystic fibrosis (CF), where it can attenuated deterioration in pulmonary function and reduce hospitalizations. However, youth with CF (YwCF) seem to be less active compared to healthy peers, so health benefits are missed. Given the major impact of parents in shaping children’s health behaviours and the established positive association between parent and child PA levels in the healthy population, understanding this association in CF could reveal potential intervention components to stimulate YwCF to be (more) active. Purpose: To investigate the association between parental support, parent PA and child PA levels among YwCF. Methods: YwCF between 6 and 17 years old and their parents were eligible to participate. Participants were asked to wear an ActiGraph GT3X-BT for 7 consecutive days. Raw accelerometer data were processed by GGIR package in R. Additionally, parental support was assessed through a questionnaire. Correlations and multiple linear regressions for MVPA and total PA were conducted in R. Results: In this study, 26 parent-child dyads are included (58% girls, 11.2 years, FEV1 88%; 77% mothers, 39 years). Parent MVPA and total PA are positively correlated with child MVPA and total PA (Rs=0.45,p=0.02; Rs=0.55,p=0.004). Furthermore, the regression models for MVPA and total PA were significant (AdjR2=0.24,p=0.09;AdjR2=0.36,p=0.03), with both parent MVPA (p=0.005) and total PA (p=0.002) as only positive significant predictors of child PA behaviour. No significant results were found for parental support. Conclusions and Practical implications: Preliminary results stipulate that in CF, similar to the healthy population, active parents are associated with active youth. These results inform the development process of future PA interventions in YwCF suggesting PA education of the parents and increasing parent PA levels as potential intervention components to explore. Funding: No funding.

Background Active travel has been associated with increased physical activity engagement and better fitness. However, there is limited evidence regarding the impact of active travel on weight management in children. Purpose This study assessed whether active travel is associated with changes in body mass index (BMI) z-score in children over 12 months. Methods This study is part of a large 3-arm cluster randomised trial (MapMe2). Height and body mass measurements for 619 children in Reception (4-5 years) and Year 6 (10-11 years) were collected at baseline and followed up after 12 months. Parents reported how their children travelled to school via paper or online questionnaire. Responses were categorised as ‘active’ (bike, walk, scooter) and ‘passive’ (car, bus, metro). We assessed physical activity using triaxial ActiGraph wGT3X-BT accelerometers. We conducted a subgroup analysis for each school year. Using mixed effects models, we examined the association between active/passive travel groups, physical activity, and change in BMI z-score. Results For children in Reception, greater sedentary time was associated with a significantly lower BMI z-score (β = -0.018, 95% CI: -0.033 to -0.002, p = 0.026). Year 6 children who engaged in more minutes of moderate-to-vigorous physical activity (MVPA) had a significant decrease in BMI z-score (β = -0.010, 95% CI: -0.016 to -0.003, p = 0.006). Active travel was not significantly associated with BMI z-score in both groups. Conclusions No direct association between active travel and BMI z-score was observed in Reception or Year 6 children. Higher MVPA in Year 6 was associated with lower BMI z-score. While active travel alone may not impact BMI z-scores, increasing MVPA could benefit weight management, especially in older children. Practical Implications Active travel may support weight management indirectly through increased MVPA. Further research is needed to clarify this relationship. Funding NIHR Public Health Research Programme (NIHR127745).

Background: Mindfulness may be associated with persistent participation in discrete physical activity (PA) modes; however, research is needed to better understand acute changes in mindfulness in relation to PA exposures. Purpose: To characterize acute changes in mindfulness in response to solo, free-form dancing among adults. Methods: Community-dwelling adults (N=42), 18-83 years old [mean(SD); age: 40(18); BMI: 24.6(4.5), years dance training: range 0-56], completed the Toronto Mindfulness Scale and Positive and Negative Affective Schedule after finishing three conditions in a lab: (1) clipping their own fingernails (baseline); (2) sitting, standing, and walking at three self-selected treadmill speeds; and (3) dancing solo with and without music at self-determined PA intensities. Total energy expenditure (TEE; kilocalories), was assessed continuously across conditions 2-3 using indirect calorimetry. For each state mindfulness construct (i.e., curiosity and decentering), linear mixed effects models were fit with the condition effect coded, controlling for age, log-transformed years of dance training, TEE, positive (PSA) and negative (NGA) affect, the baseline level of each respective state, and PSAxTEE interaction. The significance level was set at α=0.05. Results: Curiosity after dancing did not differ (ß=0.09,p>0.05) from the mean level of curiosity over time [ß=14.4(0.59)], adjusting for age (ß=-0.08,p=0.04), baseline curiosity (ß=0.34, p=0.002), TEE (ß=-0.03,p=0.048), PSA (ß=0.29,p0.05). Decentering after dancing was higher (ß=1.03,p=0.005) than the mean level of decentering over time [ß=16.7(0.38)], adjusting for dance training (ß=0.63,p=0.047), PSA (ß=0.23,p<0.001), NGA (ß=-0.28,p=0.015), baseline decentering (ß=0.67,p0.05). Conclusions: Dancing was positively associated with decentering. Changes in curiosity were not detected in response to dancing; however, a differential relationship was observed between TEE and curiosity depending upon concurrent experiences of PSA. Practical implications: Free-form dance requires no instruction nor prior training; participation in free-form dancing is associated with higher state mindfulness. Funding: National Endowment for the Arts #1879058-38-C

Background: Disseminating and implementing physical activity programs often includes local adaptations according to setting resources and priorities. Adaptations can be based on program form (e.g., program structure) or function (e.g., underlying principles of change). Our objective is to describe the same core functions across four different programs delivered within the U.S. Cooperative Extension System (CES), the dissemination and implementation (D&I) science framework used to collect comprehensive data, and the team-based approach to decision making. Program Delivery or Policy Components: CES operates in every state and territory and represents an established D&I system to deliver health programs. In one state, the Physical Activity Leadership Team (PALT) consists of agents and researchers who select, adapt, and deliver physical activity programming. The PALT utilized core functioning behavior change principles including group-dynamics, social support, goal setting, self-monitoring, feedback, and education across four programs: (1) FitEx to improve physical activity and fruit/vegetable intake among adults; (2) Lifelong Improvements through Fitness Together to improve functional fitness for aging adults; (3) Flourishing in the Garden to improve fruit/vegetable intake, permaculture knowledge, and confidence in gardening among youth; and (4) Physical Activity in Cooperative Extension (PACE) to improve physical activity and public health competencies among agents. All of the programs are 8-9 weeks in duration and include varying levels of synchronous and asynchronous components. For example, PACE includes 9 1-hour live, virtual sessions and 9 hours of self-guided work to earn the microcredentialing. Evaluation: Ongoing evaluation is based on the RE-AIM framework to determine who participates (Reach); the impacts (Effectiveness); how many agents are trained and their personal characteristics (Adoption); needed ongoing training, adaptations, and technical assistance (Implementation); and agent intent to deliver in the future (Maintenance). Conclusions: D&I science can guide use of core program functions and adapt the delivery form to meet CES needs and priorities.

Background: Understanding age-related changes in physical activity (PA) patterns may be useful in the development of public health recommendations tailored to older adults. However, limited data are available on how intensity-specific PA changes with age. Purpose: This longitudinal study aimed to quantify changes in older adult’s PA measured by accelerometry over a 4-year period. Methods: Participants were 298 randomly selected older Japanese adults (48.0% men, 65–84 years at baseline, follow-up rate 56%) who provided valid accelerometer data (Active style Pro HJA-750C, Omron, Kyoto) for both baseline in 2017 and follow-up in 2021. Compositional data analysis was used to examine changes in sedentary behavior (SB), light-intensity PA (LPA) and moderate-to-vigorous PA (MVPA), taking into account the co-dependence of time use domains. Results: Mean daily time spent in SB, LPA and MVPA at baseline was 477, 347 and 57 minutes respectively. Overall, SB increased and PA decreased over the four-year period, with the largest relative change in MVPA regardless of gender (men: 6.6% to 5.4%, women: 6.0% to 4.9%). Mean time spent in MVPA decreased by approximately 10 minutes per day. The decline in LPA was less for women than for men. Conclusions: The decline in PA with age was significant, with MVPA decreasing by approximately 10 minutes per day over four years. On the other hand, LPA was relatively maintained in women, suggesting that this helps women maintain PA in the later years of life. Funding: Supported by grant from ‘the Policy Research Institute, Ministry of Agriculture, Forestry and Fisheries in Japan’ and ‘the Pfizer Health Research Foundation’, by JSPS KAKENHI Grant Number 16H03249, 17K19794, 18K10829, 19H03910, and 21K17551, and by the Health and Labor Sciences Research Grant 22FA1005 and 22FA2001.