University of Groningen

Physical activity and cardiometabolic healthByambasukh, Oyuntugs

DOI:10.33612/diss.112903501

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CHAPTERSummary

Nederlandse samenvatting

Mongolian-language summary

Acknowledgements

About the author

Abbreviations

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SUMMARY The epidemic proportions of non-communicable diseases and health outcomes, such as type 2 diabetes, ischemic heart disease, heart attacks, and stroke, continue to be major health concern worldwide. One of the underlying reasons for this epidemic is the prevalence of obesity, which nearly tripled between 1975 and 2016. Obesity is considered a major cause of non-communicable diseases. Obesity, and abdominal obesity in particular, is associated with other cardiometabolic risk factors and with an underlying condition of insulin resistance. Lifestyle factors best known to influence non-communicable disease include diet, physical activity, and others. The health-related roles of daily-life physical activities, which encompass a variety of domains (e.g., occupational and non-occupational), could differ. However, existing studies have mostly focused on leisure-time PA or on exercise and sports, but only a few studies have considered a wider spectrum of physical activities performed in daily life and results are mixed. Furthermore, it is not clear from the clinical guidelines whether an individual can reach the recommended level of moderate-to-vigorous physical activity (MVPA) through all of the different domains of daily-life activities, notably those related to leisure, commuting, and occupational MVPA. The main objective of this thesis is to examine the associations between daily life MVPA and several cardiometabolic risk factors. A particular focus of this investigation is on ascertaining whether these associations depend on domains of daily-life MVPA, whether potential health benefits may change over the life course, and to study this in the context of chronic diseases. Should “domain” of MVPA be taken into account in order to improve PA related cardiometabolic health care management?

In this thesis, we found that the potential benefits of daily-life MVPA are contingent on the non-occupational or occupational domains of PA. A higher level of non-occupational daily-life MVPA is associated with a lower risk of cardiometabolic risk factors and adverse health outcomes, such as NAFLD (Chapter 2), hypertension (Chapter 3) and a gain in body weight (Chapter 4), as well as with long-term outcomes (post-transplant diabetes mellitus, cardiovascular, and all-cause mortality) in renal transplant recipients (Chapter 5). Notably, commuting MVPA could offer health benefits in addition to those associated with leisure-time MVPA (Chapters 3&4), and thus it could be considered an option for reaching the recommended level of MVPA (Chapters 2-5). By contrast, a higher level of occupational MVPA is not directly associated with cardiometabolic risk factors in the same way that MVPA relating to leisure or commuting is (Chapters 2-4). Even in renal transplant recipients, where being at work may be indicative of a relatively good health, individuals who were much more active in terms of their occupational MVPA may not

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obtain any additional benefits for health. Therefore, in clinical guidelines on cardiometabolic health, differentiation of MVPA into non-occupational or occupational may be an important attribute, of similar relevance as intensity and duration. Moreover, it is important to be aware that occupational MVPA should not be considered as a substitute for leisure-time MVPA. What are important considerations related to occupational MVPA?

In light of the finding that occupational MVPA is not related to a reduction in cardiometabolic risk, we predicted that total MVPA would also show no added advantage over non-occupational MVPA in terms of the resulting benefits. Indeed this was the case. For instance, for the associations of MVPA with NAFLD (chapter 2) and blood pressure (chapter 3), dose-dependency disappeared at more active levels when occupational MVPA was included to calculate total MVPA. Conversely, when non-occupational MVPA categories, excluding occupational MVPA, were used, PA was associated dose dependently with the NAFLD risk and with blood pressure. This aspect should also be accounted for when interpreting results obtained using accelerometers, which do not distinguish the different types and domains of PA. Finally, occupational MVPA should be critically assessed within an assessment of healthy daily-life PA.

At the same time, it has been suggested that sedentariness is the ‘new smoking’, thus indicating that sedentary occupations are not healthy. In their landmark study, Morris et al. (1953) found that there was a significant difference in the cardiovascular risk of ‘double decker bus drivers’ versus ‘conductors who repeatedly walk up and down the bus stairs frequently’, thereby indicating that a physically active occupation is healthier than a sedentary one. Nevertheless, there is a growing body of evidence indicating that occupational MVPA may have no clear benefit on health. The mechanism that evidently prevents occupational PA from generating health benefits is unclear. Therefore, different types and intensities of occupational MVPA should be evaluated more closely and in more detail to determine whether or not it can be considered beneficial for health. Is moderate-to-vigorous commuting (active transportation) PA an option to improve the cardiometabolic health care management?

In previous studies, whereas some have shown that active modes of transportation (active commuting) are beneficial for reducing cardiometabolic risks, others have not found this association. The inconsistency in these findings may be partly attributable to the ways in which PA was defined in these studies. Most studies did not distinguish between the levels of intensity of the commuting activity. In this thesis, we focused only on MVPA, such as cycling or intense or brisk walking during commuting and we found inverse associations of commuting MVPA with

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cardiometabolic risk factors (chapters 2–5). Especially, the Netherlands provides an exceptional model for demonstrating how commuting MVPA can benefit cardiometabolic health because cycling is a frequently used mode of transportation. Accordingly, active commuting through cycling could be improved in many countries, globally, which could help to reduce the global burden of cardiometabolic risk. Is there a need to consider sex-specific approaches in the cardiometabolic health care management?

A question raised in this thesis was whether sex-specific approaches are needed for managing cardiometabolic risk, given that men and women may differ in metabolism and lifestyle habits. Therefore, all associations tested in this thesis were considered separately for men and women. The findings presented in chapter 4 reveal a stronger association of MVPA with the prevention of weight gain in women than in men. Moreover, we found that the selection of obesity measures for assessing women’s cardiovascular risk should be more specific, including, for example, the total body fat percentage determined as a result of conducting bioelectrical impedance analysis. Thus, obesity-related and sex-specific approaches should be considered in combination to determine ways of improving cardiometabolic risk management. Can benefits of MVPA be linked to health over the life course in age-related cardiometabolic health care management?

MVPA was found to be inversely associated with the risk of NAFLD (chapter 2), hypertension (chapter 3), and cardiovascular mortality and diabetes (chapter 5) in individuals of all ages. However, the associations were stronger in older adults compared with younger adults. By contrast, the association of PA with lower body weight gain was stronger in younger adults compared with older adults (chapter 4). From a life course perspective, all of these associations can be linked, given that a higher BMI in early adult life is considered a predictor of future cardiovascular diseases in later life. Furthermore, in view of the concept of healthy aging, we found that older individuals who are able to remain active despite their age are also likely to remain relatively healthy (Chapters 2-5). Our overall conclusion is that a physically active lifestyle may be important at any age, but for different relevant health outcomes. Does the individuals’ health background matter for the benefit of MVPA?

Although the benefits of PA could be gained more easily when there is more room for health improvements, which is the case in older adults, its effects could potentially be outweighed by other, more important clinical factors (e.g., comorbidities and the use of medication). Therefore, we attempted to study the

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associations of PA with health in specific groups such as renal transplant recipients (chapter 5). Our results indicated that the associations of PA did not disappear in the context of this specific group with a chronic health condition. Rather, a higher MVPA was strongly associated with a lower risk to develop long-term adverse health outcomes such as post-transplant diabetes and CV mortality in younger and older adults, with this association being especially strong in older adult patients. Conclusions

In light of the findings of this thesis, we can conclude that the potential benefits of daily-life MVPA differ with age, and also with non-occupational or occupational domains of PA. Furthermore, we suggest that a physically active lifestyle at any adult age, even for individuals with chronic health conditions, could be beneficial for cardiometabolic health.

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SAMENVATTING Welvaartsziekten zoals diabetes type 2, ischemische hartziekte, hartaanvallen en beroertes nemen epidemische proporties aan en vormen wereldwijd een groot gezondheidsprobleem. Eén van de onderliggende redenen voor deze epidemie is de toename van obesitas. Het wereldwijde vóórkomen van obesitas is tussen 1975 en 2016 bijna verdrievoudigd. Obesitas wordt beschouwd als een belangrijke oorzaak van welvaartsziekten. Obesitas, en met name een grote buikomvang, wordt geassocieerd met insuline resistentie en cardio-metabole risicofactoren. Obesitas hangt samen met leefstijlfactoren waarvan bekend is dat ze welvaartsziekten beïnvloeden. Dit zijn onder andere voeding en lichamelijke activiteit. Lichamelijke activiteit is gerelateerd aan gezondheid, maar die relatie kan mogelijk verschillen per domein van lichamelijke activiteit (bijvoorbeeld beroepsmatig of niet-beroepsmatig). Eerdere studies hebben zich vooral gericht op lichaamsbeweging in de vrije tijd of op sport, maar slechts enkele onderzoeken hebben een breder spectrum van lichamelijke activiteiten in het dagelijks leven bestudeerd, bovendien zonder consistente bevindingen voort te brengen. Verder is het niet duidelijk uit de beweegrichtlijnen of een persoon het aanbevolen niveau van matige tot intensieve lichamelijke activiteit kan bereiken via alle verschillende domeinen van dagelijkse activiteiten, met name die met betrekking tot vrije tijd, woon-werkverkeer en beroepsmatige arbeid. Het hoofddoel van dit proefschrift is om de associaties tussen lichamelijke activiteit in de verschillende domeinen te relateren aan meerdere cardio-metabole risicofactoren. Een bijzondere focus ligt op het vaststellen of deze associaties afhankelijk zijn van domeinen van het dagelijkse leven, of potentiële gezondheidsvoordelen tijdens de levensloop kunnen veranderen, en om dit te bestuderen in de context van chronische ziekten.

Moeten we rekening houden met het 'domein' van lichamelijke activiteit om de cardio-metabole gezondheidswinst te behalen?

In dit proefschrift hebben we vastgesteld dat de potentiële voordelen van matig-tot-intensieve lichamelijke activiteit in het dagelijkse leven afhangen van de domeinen van lichamelijke activiteit, hetzij beroepsmatig of niet- beroepsmatig. Een hogere mate van niet-beroepsmatig matig-intensief bewegen wordt geassocieerd met een lager risico op cardio-metabole risicofactoren. Het gaat dan om een lagere kans op een vette lever (hoofdstuk 2) of hypertensie (hoofdstuk 3) en minder toename van het lichaamsgewicht (hoofdstuk 4). Ook bij mensen met een niertransplantatie was een hogere mate van matig-intensief bewegen gerelateerd aan betere lange termijn uitkomsten, zoals minder kans op post-transplantatie diabetes mellitus en vroegtijdige (cardiovasculaire) sterfte (hoofdstuk 5).

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Naast bewegen in de vrije tijd kan met name matig-intensief woon-werkverkeer gezondheidsvoordelen bieden (hoofdstukken 3 en 4). Daarmee kan het worden beschouwd als een optie om het aanbevolen niveau van matig-intensief bewegen te halen (hoofdstukken 2-5). Meer matig-intensief bewegen in een beroepsmatige context is daarentegen niet direct geassocieerd met minder kans op cardio-metabole risicofactoren (hoofdstukken 2-4). Zelfs bij mensen met een niertransplantatie, waar werken een indicatie kan zijn van een relatief goede gezondheid, hadden personen die beroepsmatig veel actiever waren geen betere gezondheid. Daarom is het in de beweegrichtlijnen mogelijk van belang om onderscheid te maken tussen matig-intensief bewegen in de vrije tijd, voor woon-werkverkeer of voor werk. Zo beschouwd lijkt matig-intensief bewegen op het werk geen vervanging voor matig-intensief bewegen voor woon-werkverkeer of in de vrije tijd.

Wat zijn belangrijke overwegingen met betrekking tot werkgerelateerde matig-intensieve lichamelijke activiteit?

Aangezien werkgerelateerd bewegen niet samenhangt met een lager cardio-metabool risico, stellen we voor dat het opnemen van werkgerelateerd bewegen bij totaal matig-intensief bewegen geen bijkomend voordeel heeft ten opzichte van bewegen op basis van vrije tijd en woon-werkverkeer alleen. Dit was inderdaad zichtbaar in de data. Bij de verbanden tussen bewegen en vette lever (hoofdstuk 2) en bloeddruk (hoofdstuk 3) verdween bijvoorbeeld de dosisafhankelijkheid als werkgerelateerd bewegen werd meegeteld bij de totale hoeveelheid dagelijkse activiteit. Omgekeerd, als werkgerelateerd bewegen niet werd meegeteld, was er een duidelijke dosis-respons-relatie tussen de totale hoeveelheid matig-intensief bewegen en het risico op een vette lever en met de bloeddruk. Dit heeft mogelijk implicaties voor studies die bewegen meten met versnellingsmeters. Bij het interpreteren van resultaten die zijn verkregen met behulp van versnellingsmeters moet hier mogelijk rekening mee worden gehouden, omdat uit de accelerometrie data niet makkelijk kan worden afgeleid of het matig-intensief bewegen werkgerelateerd was of niet. Door vermenging met werkgerelateerde inspanning wordt het effect van bewegen in de vrije tijd mogelijk gemaskeerd.

Naast zorgen om werkgerelateerd bewegen is zitten wel gesuggereerd als het ‘nieuwe roken’, wat aangeeft dat ook werkgerelateerde zittende bezigheden niet gezond zijn. Een bekende studie van Morris et al. uit 1953 liet zien dat er een significant verschil was in het cardiovasculaire risico van ‘buschauffeurs van dubbeldeksbussen’ versus ‘conducteurs die herhaaldelijk de bustrap op en af lopen’, wat aangeeft dat een fysiek actieve bezigheid gezonder is dan een zittende. Desondanks is er een groeiend aantal aanwijzingen dat matig-intensieve activiteiten op het werk geen duidelijk gezondheidsvoordeel opleveren. Het is niet duidelijk of de soort lichamelijke activiteit die bij het werk hoort niet gunstig is, of dat er andere

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omstandigheden zijn op het werk die een eventueel gezondheidsvoordeel tegenwerken. Daarom moeten verschillende soorten en intensiteiten van werkgerelateerd bewegen nader en gedetailleerder worden geëvalueerd om te bepalen of en wanneer het als gunstig of ongunstig voor de gezondheid kan worden beschouwd.

Is matig-intensief bewegen in het kader van woon-werkverkeer een goede optie om het cardio-metabole risico te verminderen?

In eerdere studies hebben sommigen aangetoond dat actieve vervoerswijzen (actief woon-werkverkeer) gunstig zijn voor het verminderen van cardiometabolische risico's, terwijl anderen deze associatie niet hebben gevonden. Deze inconsistentie kan gedeeltelijk te wijten zijn aan de manier waarop bewegen in deze studies werd gedefinieerd. In de meeste onderzoeken werd geen onderscheid gemaakt tussen de intensiteitsniveaus van de activiteit ‘woon-werkverkeer’. In dit proefschrift hebben we ons alleen gericht op de matig-intensieve categorie van bewegen, zoals fietsen of stevig wandelen. We vonden dat meer actief woon-werkverkeer gerelateerd was aan een lager cardiometabool risico (hoofdstukken 2-5).

Nederland biedt een uitzonderlijk model om te bestuderen hoe actief woon-werkverkeer de cardiometabole gezondheid ten goede kan komen, omdat fietsen een veelgebruikte manier van transport is. Fietsen voor woon-werkverkeer zou in veel landen kunnen worden gestimuleerd, wat wereldwijd zou kunnen helpen om het cardiometabool risico te verminderen.

Is het nodig om sekse-specifieke benaderingen te overwegen bij het verbeteren van de cardiometabole gezondheid?

Een vraag die in dit proefschrift aan de orde werd gesteld, was of sekse-specifieke benaderingen nodig zijn om cardiometabool risico te schatten, aangezien mannen en vrouwen kunnen verschillen in metabolisme en levensstijl. Daarom werden alle in dit proefschrift geteste associaties afzonderlijk beschouwd voor mannen en vrouwen. De bevindingen in hoofdstuk 4 onthullen een sterkere associatie bij vrouwen dan bij mannen van matig-intensief bewegen met het voorkómen van gewichtstoename. Bovendien vonden we dat de keuze voor obesitas-maten voor het beoordelen van het cardiovasculaire risico specifieker zou kunnen zijn voor vrouwen en mannen, bijvoorbeeld door het totale lichaamsvetpercentage te meten met bio-elektrische impedantieanalyse. Obesitas-gerelateerde en sekse-specifieke benaderingen moeten in samenhang worden overwogen om de inschatting van het cardiovasculair risico te verbeteren voor vrouwen. Biedt het voordelen om de potentiële gezondheidswinst van bewegen te bezien vanuit levensloopperspectief?

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Meer matig-intensief bewegen was gerelateerd aan een lager risico op vette lever (hoofdstuk 2) en hoge bloeddruk (hoofdstuk 3) en cardiovasculaire sterfte en transplantatiediabetes (hoofdstuk 5) in alle leeftijdscategorieën. De associaties waren echter sterker bij oudere volwassenen dan bij jongere volwassenen. Meer matig-intensief bewegen was geassocieerd met een lagere toename in lichaamsgewicht gedurende de 4 jaar dat deelnemers van de Lifelines studie zijn gevolgd. Deze associatie was daarentegen sterker bij jongere volwassenen dan bij oudere volwassenen (hoofdstuk 4). Vanuit een levensloopperspectief kunnen al deze associaties worden gekoppeld, aangezien een hogere BMI in het vroege volwassen leven wordt beschouwd als een voorspeller voor toekomstige hart- en vaatziekten in het latere leven. Bovendien vonden we, passend in het concept van gezond ouder worden, dat ouderen die ondanks hun leeftijd actief kunnen blijven, waarschijnlijk ook relatief gezond blijven (hoofdstukken 2-5). Onze algemene conclusie is dat een fysiek actieve levensstijl op elke leeftijd belangrijk kan zijn, maar voor verschillende relevante gezondheidsuitkomsten.

Is de gezondheidsachtergrond van het individu belangrijk voor de potentiële effecten van bewegen?

Hoewel aan de ene kant de voordelen van bewegen gemakkelijker kunnen worden bereikt wanneer er meer ruimte is voor verbetering van de gezondheid, wat het geval is bij oudere volwassenen, kunnen de effecten aan de andere kant mogelijk niet opwegen tegen andere, overheersende klinische factoren (bijv. comorbiditeit en het gebruik van medicijnen). Daarom is het ook interessant om te kijken naar de associaties tussen bewegen en gezondheid in specifieke groepen, zoals mensen met een niertransplantatie (hoofdstuk 5). Onze resultaten gaven aan dat de associaties tussen bewegen en gezondheid niet verdwenen in deze specifieke groep met een chronische gezondheidstoestand. Integendeel, een hogere mate van matig-intensief bewegen werd sterk geassocieerd met een lager risico op het ontwikkelen van nadelige gezondheidsuitkomsten op lange termijn zoals diabetes na transplantatie en cardiovasculaire mortaliteit, waarbij deze associatie vooral sterk was bij de oudere patiënten.

Conclusies

Gezien de bevindingen in dit proefschrift kunnen we concluderen dat de potentiële voordelen van matig-intensief bewegen in het dagelijks leven afhangen van de leeftijd, en ook met het domein van bewegen, hetzij werkgerelateerd, voor woon-werkverkeer of vrije tijd. Verder suggereren wij dat een fysiek actieve levensstijl op elke volwassen leeftijd, en ook voor personen met chronische gezondheidsproblemen, gunstig is voor de cardiometabole gezondheid.

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ТОВЧ ХУРААНГУЙ Чихрийн шижин, зүрх судасны эмгэг, тархинд цус харвалт, шигдээс зэрэг халдварт бус өвчин (ХБӨ), тэдгээрийн хүндрэлүүдийн тархалт төдийлөн буурахгүй, харин ч өссөөр дэлхийн хэмжээний эрүүл мэнд, нийгэм эдийн засгийн томоохон тулгамдсан асуудлуудын нэг болоод байна. Идэвхитэй хөдөлгөөн нь эдгээр бүлэг өвчнөөс урьдчилан сэргийлэх, тэдгээрийн эмчилгээ, хяналтанд чухал үүрэгтэй нь нотлогдсоор байна. ХБӨ-ний урьдчилан сэргийлэлт, хяналт, эмчилгээний эмнэлзүйн удирдамжуудад “Дундаас дээш ачаалал шаардсан (MET1 > 4.0) дасгал хөдөлгөөнийг долоо хоногт 150 минутаас дээш хугацаагаар хийх”-ийг зөвлөмж болгосон байдаг ч ямар төрлийн хөдөлгөөний (ажлын болон ажлын бус цагаар хийх) тусламжтайгаар энэхүү зөвлөмжийг биелүүлэх нь тодорхойгүй байна. Мөн ажлын бус цагаар хийх хөдөлгөөнүүд, тэр дундаа амралт чөлөөт цагаар хийх хөдөлгөөний ач холбогдол харьцангуй өргөн судлагдсан харин бусад төрлийн хөдөлгөөний талаарх судалгааны ажлууд харьцангуй бага хийгдсэн байна. Иймд бид, дундаас дээш ачаалал шаардсан өдөр тутмын амьдрал - ахуйн хөдөлгөөнүүдийн талаар судалгааны ажил хийсэн. Тухайлбал, дундаас дээш ачаалал шаардсан 3 төрлийн бүлэг хөдөлгөөнийг сонгон авч судалсан. Үүнд:

1. Гэр - ажил, сургуулийн хооронд хийх ачаалал шаардсан хөдөлгөөн (унадаг дугуйгаар явах, хурдан алхалт);

2. Амралт, чөлөөт цагаар хийх идэвхитэй дасгал хөдөлгөөн болон бүх төрлийн спортоор хичээллэх;

3. Ажлын байран дахь ачаалал шаардсан хөдөлгөөн. Бидний хийсэн судалгааны үр дүнгээр таргалалттай холбоот - элэгний

өөхжилт (Бүлэг 2), артерийн даралт ихсэлт (Бүлэг 3), таргалалт (Бүлэг 4), чихрийн шижин, зүрх судасны эмгэгүүд (Бүлэг 5)-ийн эрсдлийг бууруулахад амралт, чөлөөт цагаар хийх идэвхитэй дасгал хөдөлгөөн нь хамгийн чухал нөлөөтэй болох нь батлагдсан. Мөн дундаас дээш ачаалал шаардсан хөдөлгөөнийг ажил - гэр, сургуулийн хооронд тогтмол хийх нь дээрх эмгэгүүдийн эрсдлийг бууруулах нөлөөтэй (Бүлэг 2-5) болох нь ажиглагдсан ба амралт чөлөөт цагаар хийх хөдөлгөөний хамт тогтмол хийж байх нь эрүүл мэндэд илүү ач холбогдолтой болох нь батлагдсан (Бүлэг 3-4). Харин ажлын байран дахь ачаалал шаардсан хөдөлгөөн нь дээрх эмгэгүүдийн эрсдлийг бууруулахад ямар нэгэн нөлөөгүй болох нь бидний судалгаануудад ажиглагдсан (Бүлэг 2-5). Тухайлбал биеийн жин бууруулахад бүх төрлийн энергийн

1 1 Хөдөлгөөний ачаалалыг хэмжих нэгж ба 1 нэгж нь тайван байх үеийн энерги зарцуулалттай тэнцэнэ.

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зарцуулалт нь чухал ач холбогдолтой байж болох ч ажлын байран дахь ачаалал шаардсан хөдөлгөөн нь биеийн жин нэмэгдэхээс сэргийлэх нөлөөгүй байв (Бүлэг 4). Дундаас дээш ачаалал шаардсан бүх төрлийн хөдөлгөөн нь эрүүл мэндэд адил нөлөө үзүүлдэггүй болох нь дээрх судалгаануудаар ажиглагдсан тул үр дүнг бататгах зорилгоор удаан хугацааны архаг өвчний улмаас бөөр шилжүүлэн суулгах хагалгаа хийгдсэн хүмүүсийг мэс ажилбараас хойш 5-6 жилийн дараа судалгаанд хамруулан 6-8 жилийн турш дагаж судалхад (Бүлэг 5), ажлын байран дахь ачаалал шаардсан хөдөлгөөн эрүүл мэндэд эерэг нөлөө үзүүлдэггүй нь тогтоогдсон.

Ажлын байран дахь ачаалал шаардсан хөдөлгөөн ихээр хийхэд хүрдэг ажил мэргэжлийн хүмүүс нь нийгэм-эдийн засгийн байдал, хоололт, амьдарлын хэв маяг, орчин зэрэг олон зүйлсээр ялгаатай, эдгээр нь төөрөгдүүлэх хүчин зүйлс байж болзошгүй ч бидний хийсэн хэд хэдэн статистик шинжилгээнүүдэд адил үр дүн үзүүлсэн. Тухайлбал дээр дурдсан бөөр шилжүүлэн суулгасан хүмүүсийн 20% нь ажил дээр ачаалал шаардсан хөдөлгөөнийг тогтмол хийдэг, тэднийг бусад өвчтнүүдтэй харьцуулахад эрүүл мэндийн үзүүлэлтийн хувьд харьцангуй өндөр хэдий ч бидний судалгааны үр дүнгээр ажил дээрх хөдөлгөөн төдийлөн ач холбогдолтой болох нь батлагдаагүй (Бүлэг 5). Иймд ХБӨ-ний эмнэлзүйн удирдамжуудад дундаас дээш ачаалал шаардсан хөдөлгөөний төрлүүдийн талаар тусгайлан зөвлөмж болгох, ялангуяа, амралт чөлөөт цагаар хийх дасгал хөдөлгөөн эсвэл гэр - ажил, сургуулийн хооронд хийх идэвхитэй хөдөлгөөнийг ажлын байран дахь ачаалал шаардсан хөдөлгөөнөөр орлуулах нь эрүүл мэндийн ач холбогдолгүй болохыг тусгаж байх шаардлагатай юм.

Дээр өгүүлснээр ажлын байран дахь ачаалал шаардсан хөдөлгөөн нь эрүүл мэндэд төдийлөн ач холбогдолгүй тул хөдөлгөөний талаарх судалгаа хийж буй судлаачид, ялангуяа хөдөлгөөн хэмжигч аппарат (хөдөлгөөн хэмжигч нь хөдөлгөөний төрлийг ялгах боломжгүй байдаг) ашигласан тохиолдолд хөдөлгөөн хэмжигчийн үр дүнг тооцохдоо энэ төрлийн хөдөлгөөн бүртгэгдсэн эсэхийг нягталж байх шаардлагатай. Мөн түүнчлэн ажлын байран дахь ачаалал шаардсан хөдөлгөөн ба ХБӨ-ний эрсдлийн хоорондын хамаарлыг шалтгаан - эмгэг жамын үүднээс судлаачид цаашид нарийвчлан судлан тогтоох шаардлагатай байна. Идэвхитэй хөдөлгөөний үр дүнд хүйс, нас, урьд өвчилсөн байдлын нөлөө

Хүйс: Хүйсийн хувьд хөдөлгөөний ач холбогдлын ялгаа элэгний өөхжилт (Бүлэг 2), артерийн даралт ихсэлт (Бүлэг 3), чихрийн шижин, ЗСӨ-ний эмгэгүүд, бүх төрлийн шалтгаант нас баралт (Бүлэг 5)-ын эрсдлийг бууруулах нөлөө ажиглагдаагүй. Харин биеийн жин нэмэгдэхээс сэргийлэх (Бүлэг 4)-д эмэгтэйчүүдэд хөдөлгөөний ач холбогдол харьцангуй өндөр, хүчтэй нөлөөтэй байв.

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Таргалалт ба ЗСӨ-ний хоорондын хамаарлыг таргалалтыг илрүүлэх ялгаатай аргуудыг сонгон судалгаа хийхэд эмэгтэйчүүдийн хувьд тодорхой ялгаатай болох нь ажиглагдсан. Тодруулбал, ЗСӨ-ний эрсдлийг үнэлэхэд эмэгтэйчүүдэд эрэгтэйчүүдээс ялгаатай арга, тухайлбал биеийн нийт өөхний нэмэгдэлтийг илрүүлэх арга нь илүү тохиромжтой байж болохыг илрүүлсэн (Бүлэг 6). ЗСӨ-ний эрсдлийг үнэлэхдээ таргалалтыг илрүүлэх бүх аргыг бус, тохиромжтой аргыг сонгох нь чухал болохыг 10 орчим жилийн хугацаанд дагаж судалсан судалгааны үр дүнгээр илрүүлсэн ба биеийн нийт өөхний хэмжээг тодорхойлох био-цахилгаан эсэргүүцэлт арга нь ЗСӨ-ний эрсдлийг үнэлэхэд, ялангуяа эмэгтэйчүүдэд хамгийн тохиромжтой арга болох нь ажиглагдсан. Иймд “хөдөлгөөн – таргалалт – ЗСӨ”-ний хоорондын хамаарал нь хүйсийн хувьд ялгаатай, эмэгтэйчүүдийн хувьд онцлог байж болох, цаашид судлгааны ажлыг үргэлжлүүлэх шаардлагатай гэсэн дүгнэлтэд хүрсэн болно.

Нас: Бидний судалгаануудын үр дүнгээр идэвхитэй хөдөлгөөний ач холбогдол нь насны бүлгүүдэд ялгаатай байж болох ч хөдөлгөөний ач тусыг бүх насанд хүрэгчид хүртэх боломжтой болох нь ажиглагдсан (Бүлэг 8, Зураг 4). Залуу насны хүмүүс, ялангуяа эмэгтэйчүүд (55-с доош насны) идэвхитэй хөдөлгөөн, дасгалыг тогтмол хийснээр илүүдэл жингээс урьдчилан сэргийлэх боломжтой болох нь илүү тодоор ажиглагдсан (Бүлэг 4) ба энэ нь цаашид ахимаг насанд (55-с дээш насны) илүүдэл жингээс үүдэлтэй ХБӨ-үүдээс сэргийлэх ач холбогдолтой байж болохыг Бүлэг 2-3 болон 5-6-д харуулсан болно. Мөн биеийн жин нэмэгдэлтээс сэргийлэх хөдөлгөөний нөлөө нь хоололт болон амьдралын бусад хэв маягаас үл хамаарсан хүчтэй нөлөө үзүүлж болохыг бидний хийсэн хэд хэдэн статистик шинжилгээнүүдийн үр дүнгүүд баталсан. Тодруулбал, биеийн жинг хасах эмчилгээнд дан хөдөлгөөний нөлөө хангалтгүй, зохистой хоололт голлох үүргийг гүйцэтгэдэг болохыг өмнө хийгдсэн судалгаанууд харуулсан бол биеийн жин нэмэгдэхээс урьдчилан сэргийлэхэд хөдөлгөөнийн нөлөө харьцангуй өндөр, бие даасан ач холбогдолтой байж болох нь бидний судалгаагаар батлагдсан (Бүлэг 4).

Дэлхий нийтээр “Эрүүл насжилт”-нд анхаарал ихээр хандуулах болсон өнөө үед, өдөр тутмын дасгал хөдөлгөөнийг тогтмол хийснээр эрүүл урт наслах боломжтой болохыг бидний судалгааны үр дүнгүүд харуулсан. Тухайлбал, элэгний өөхжилт (Бүлэг 2), артерийн даралт ихсэлт (Бүлэг 3), чихрийн шижин, ЗСӨ-ний эмгэгүүд, бүх төрлийн шалтгаант нас баралт (Бүлэг 5)-ын эрсдлийг бууруулахад “хөдөлгөөний нөлөө” ахимаг насныханд илүү тод ажиглагдсан.

Өмнө өвчилсөн өвчин: архаг эмгэгүүдээс шалтгаалан хөдөлгөөний нөлөө хэрхэн өөрчлөгдөж болохыг судлах зорилгоор бөөр шилжүүлэн суулгах мэс засалд орсон өвчтөнүүдэд хөдөлгөөний ач холбогдлыг судалсан (Бүлэг 5). Өвчний явц хүндэвтэр хүмүүс хөдөлгөөнийг ихээр хийх боломжгүй тул бид биеийн байдал харьцангуй тогтворжсон хүмүүсийг сонгон авч 6-8 жилийн

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хугацаанд дагаж судалхад хөдөлгөөн ихээр хийдэг бүлэг хүмүүст бөөр шилжүүлэн суулгасны дараах чихрийн шижин, ЗСӨ, эрт нас баралтын эрсдэл харьцангуй бага байсан (Бүлэг 5). Элэгний өөхжилтийн эрсдлийг эрүүл, чихрийн шижингийн урьдал байдалтай, чихрийн шижинтэй хүмүүст (Бүлэг 2), даралт ихсэлтийн эрсдлийг эрүүл, илүүдэл жинтэй, таргалалттай хүмүүст (Бүлэг 3) гэсэн бүлгүүдэд хуваан судалхад бүх насны, бүх бүлгийн хүмүүст хөдөлгөөний ач холбогдол статистик үнэн магадлалтай болох нь ажиглагдсан. Бид элэгний өөхжилттэй холбоот элэгний хатуурал үүсэх эрсдлийг идэвхитэй хөдөлгөөний тусламжтайгаар бууруулах боломжтой байж болохыг илрүүлсэн (Бүлэг 2). Дүгнэлт:

Энэхүү нэг сэдэвт бүтээлийн хүрээнд идэвхитэй дасгал хөдөлгөөний ач холбогдол нь түүний төрөл (ажлын болон ажлын бус цагаар хийх ачаалал шаардсан хөдөлгөөн)-өөс шууд хамааралтай болохыг илрүүлэн тогтоосон. ХБӨ-ний эрсдлийг бууруулахад ажлын бус цагаар хийх ачаалал шаардсан хөдөлгөөнүүд нь аль ч насны хүмүүс, түүнчлэн архаг эмгэгээр олон жил өвчилсөн хүмүүсийн хувьд ч ач холбогдолтойг зөвлөмж болгож байна.

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ACKNOWLEDGEMENTS First of all, I would like to thank the people who gave me the opportunity to study and live in the nice city of Groningen. Thank you, Prof. Tjalling Halbertsma, for taking the initial decision after our interview in Mongolia to give me the chance to advance to the next steps of the PhD enrolment. I also really appreciate Prof. Han Moshage for helping me through the next steps, especially for contacting my supervisors. I also would like to thank Prof. Ronald Stolk and Eva Corpeleijn for their decision after our Skype call to select me as their PhD student. For my supervisors Dear Eva, I am so happy that you were my main supervisor. I could never have imagined reaching this level without your support, guidance, and vision. With my different professional background, acquiring new skills, such as statistics, was a major challenge to me. Yet you guided my projects with patience, giving me all the time to fully understand each detail of the research process and allowing me to learn new skills by myself.

Your teaching went beyond the factual. You showed me that deadlines are important, but that the quality of the work produced is much more so. We never finished reports in a hurry, no matter how long data preparations and analyses took. You gave me all the time to improve them. This way, you were also educating me to become an independent researcher. The fact that you allowed me to use my home institution’s affiliation to the Mongolian National University of Medical Sciences in international meetings and manuscript submissions – for which I am very grateful – is more proof of this.

My final PhD year was very busy. Yet your door was open always to me and you were always very kind when I needed your help. Thank you so much for everything you have done for me. I also really appreciate you for giving me your Wednesdays.

Dear Prof. Stephan Bakker, during the last four years, your comments and suggestions on my studies were always valuable and insightful. Therefore, I am truly happy that you are officially named as my supervisor in my thesis. Although we only asked you to be my supervisor during the last year of my PhD – I would like to thank you for agreeing – from the start your guidance was like that of a supervisor. You have busy schedules, yet you always answered any question quickly, especially during the last steps of my PhD, which I appreciate a lot. For my paranymphs Dear Ewout and Petra, I would like to thank you for kindly agreeing to be my paranymphs. I take pleasure in expressing my thanks this way. Dear Ewout, for the

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past three years you’ve supported me in many ways, especially by helping me understand Dutch and western culture. Thank you so much for everything you have done for me. Dear Petra, I appreciate your help and support these last three years. Especially, many thanks for your help with processing the Lifelines data during my last year. I have seen your hard work and I expect your projects will yield a brilliant result. I wish you the best of luck. Dear Ewout and Petra, all your help as my paranymphs is very much appreciated. For my colleagues I would like to thank the members of Eva’s Unit of “Lifestyle Medicine in Obesity and Diabetes”, Petra, Riktje, Marloes, Louise, Coby and Maryse, for all your support and all the nice meetings. I also would like to extend my thanks to former members Leanne, Gerald, Anne, Congchao and Mulugeta. It was a great help to spend time with you guys at the beginning of my PhD. Thank you very much Riktje, your suggestions helped me to improve my chapter 7. I wish all of you, unit members, great success in your studies.

My sincere thanks to the PhD students on the “Fourth floor” for having a nice time with you guys: Nigus, Tesfa, Reinder, Katri, Du Jing, Ahmad, Omar, Carel-Peter, Tian, Elnaz …. My special thanks to my officemate Bale. You helped me during difficult times when I needed words of encouragement. It was always very nice to have a chat during our work breaks. Also, I met nice people because of you – your friends. Especially, Johanna, it was always very nice to meet you when you visited Bale in our office. I also would like to say my special thanks to Y. Chen, for your all help with learning statistical programs and many things more. It was great spending time with you in the UMCG gym.

Dear Prof. Marike Boezen, I appreciate that you supported me all the time as the head of the department. I also would like to express my thanks to all professors, teachers, and all staff members in the Department of Epidemiology for all your kindness and all your support: Roelian, Marijke, Aukje, Anita, Lisette, Gerben, Hans Burgerhof, Douwe, Behrooz, Truuske, Judith, Noha …. My special thanks to Aukje, our nice talks and all your help are much appreciated.

I would like to thank all the people who worked with me on my chapters - Harold Snieder, Michele Eisenga, Ron Gansevoort, Petra Vinke, Daan Kromhout, Gerjan Navis, Maryse Osté, António Gomes-Neto, Else van den Berg and Dorien Zelle. Your valuable comments and suggestions were great and improved my thesis. Especially, I would like to acknowledge Prof. Harold Snieder. Thank you so much for all your time and the nice talks we had.

Dear Anna, Ilse, Bas, Kim and other Lifelines project and data managers, my sincere thanks for your help with processing the Lifelines data.

***

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Dear Peer, Renze, Lauren and Hibma, thank you so much for your all support. I will follow your example and pay everything you’ve done for me forward to other people. I will keep your kindness always in my heart.

*** I would like to thank the members of the assessment committee, Prof. M. Visser, Prof. R. Dekker and Prof. U. Bultmann, for taking the time out of their busy schedule to read my manuscript.

*** I also would like to take this opportunity to express my thanks to my former colleagues, professors, mentors, teachers and friends. For my former professors, mentors, teachers and colleagues First and foremost, I would like to thank Prof. Kh. Altaisaikhan. I will never forget how you opened the doors of two great 'families' to me – the Mongolian National University of Medical Sciences (MNUMS) and the community of Mongolian endocrinologists. These doors were further opened by Prof. J. Suvd, [B. Gerel] and Dr. S. Sainbileg. I don’t think I can ever fully appreciate the efforts you put into teaching me - seeing patients, working with students and doing research. Your guidance and teaching helped to shape my professional career and personal life. I will forever be grateful for everything you have done for me. My special thanks to Prof. J. Suvd for being such an inspiration, visionary and guide in my life. You have a lot of ‘firsts’ in Mongolian medical sciences to your name. You are also the mentor of my mentors. I am unbelievably grateful I’ve gotten to know you. I also really appreciate that you took the time to review the Mongolian-language summary of the present thesis.

I first started at MNUMS as a physician at Erkhes University Hospital under the supervision of Dr. D. Byambasuren. Since that time, you have been mentoring me in my professional and personal life. Thank you for always being there for me as a mentor! Also, my special thanks to Dr. J. Munkhtsetseg for all your support and gave me the first inspiration to be a scientist.

When I started working as a member of the teaching staff at MNUMS, many people helped me. My special thanks to Prof. D. Amarsaikhan, Prof. N. Sumberzul, Dr. D. Otgonbayar, Prof. B. Oyungoo, Prof. S. Naranchimeg, Dr. B. Solongo and Dr. O. Bolormaa, for all your support and encouragement.

I also would like to express my thanks to other people who supported and encouraged me when I was working at MNUMS - Academician Prof. Ts. Lkhagvasuren, Prof. G. Batbaatar, Prof. B. Amarsaikhan, Prof. R. Otgonbayar,

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Dr. R. Oyungerel, Prof. D. Davaadorj, Prof. N. Bira, Prof. D. Ichinnorov, Prof. D. Zulgerel, Dr. N. Ariuntsetseg, Dr. B. Burmaa, Prof. T. Ariunaa, Dr. J. Enkhtuya, Prof. G. Erdenetuya, Dr. D. Uranchimeg, Dr. Ya. Enkhtur, Dr. D. Myagmartseren, Ts. Naidansuren, P. Tugsjargal, Prof. D. Davaalkham, Dr. N. Khuderchuluun, Dr. Ya.Enkhjargal, Dr. E. Bayarmaa and S. Sukhjargal. I also want to extend my acknowledgement to Prof. J. Tsolmon, President of MNUMS, Prof. R. Otgonbayar, Dean of School of Medicine and Dr. S. Sainbileg, Head of Department of Endocrinology, for your recent encouragement. Finally, I want to thank all colleagues at the Department of Endocrinology - Dr. S. Sainbileg, Prof. J. Suvd, Prof. Kh. Altaisaikhan, Kh. Otgooloi, Dr. T. Bayasgalan, A. Altanzul, B. Oyunbileg and B. Ankhlan. I look forward to working with you again in the future.

I was lucky to work on big projects in Mongolia when I was a junior staff. I appreciate people from those projects who gave me the chance to learn from them. My special thanks to Prof. B. Munkhbat, and Dr. Sh. Oyunbileg (MCA-Mongolia Health Project), and Elena Maximenco (EPOS Health Management) for all your support. I also would like to acknowledge Monfa Trade Co., Ltd (D.Sc., Prof. D. Tsendeekhuu and A. Daribal), one of the leading pharmaceutical companies in Mongolia. Your recent support for printing my thesis was wonderful and I really appreciate it. I also would like to say my thanks to D. Angar (Novonordisk).

Also my special thanks to my teachers from before university: Oyuntsetseg and Oyunchimeg, [Narangerel] and Khaltarkhuu and B. Nergui (Б. Нэргүй). Dear Dolgorsuren, I appreciate your time for preparing me to enroll at the MNUMS.

Luckily, I had some experience with living abroad before coming to the Netherlands. My special thanks to my professors and mentors at Yonsei University: Bongsoo Cha, Yumie Rhee, Eunseok Kang, Dongyeob Sin, Yongho Lee and Cheolryong Ku. Dear Yumie Rhee, I really appreciate that your supervision gave me the tools I needed to face my future and helped to shape my professional career. For my friends Thank you very much, my dearest friends E. Guyenbaatar, B. Sodgerel, B. Batsolongo, B. Azjargal, B. Baigalimaa, B. Nyamchimeg, B. Bolorsukh and D. Tsegmid for taking care of my parents during my stay abroad. Dear my other friends Dr. Ch. Chinzorig, Dr. U. Munkhzaya, N. Bat-Erdende, Dr. O. Khaliun and Sh. Tungalagtamir, thank you for always being my best friends! For people I met in Groningen I am so happy that I met many nice people during my PhD. My special thanks to Willem and Ariunaa sister, for their nice hospitality. I also would like to express my thanks to Jambaperenlei, Delgersuren, Benderya, Uuriintuya, Myagmarchuluun, Enkhmaa, Otgontsetseg, Altantsooj, Tsogtsolmaa, Munkh-Erdene and Ariunaa, for

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their kindness and hospitality. It was also very nice to meet Enkhhuyag, Bolorchimeg, Margad-Erdene, Tuyaral, Namsraijav, Davaasuren, Khurelbaatar and Bolor in Groningen. For my friends in Groningen I would like to thank all my friends who were studying and living together in Groningen, V. Byambasuren, B. Enkh-Orchlon, N. Otgongerel, D. Turtushikh, Dulguun, L. Khosbayar, B. Saranchimeg, N. Altanzul, T. Ariuntuya and B. Batzorig, for their friendship and support in social life.

It was great to meet Byambaa, Orchlon and Otgoo in Groningen at the beginning of my PhD. Your company helped me through being far away from home. Thank you so much for everything you have done for me. Also, my special thanks to Kh. Khulan for your visits to us. They also helped me to shape my life away from my family and friends. I wish you guys great success in your professional career. It was also very nice to meet your families in Groningen. I also wish all the best to your families: E. Anir, Orkhon’s grandma (Янжмаа), Otgoo’s parents (Нямсамбуу, Лхагва) and Byambaa’s parents (Ванчин, Лхагва).

I am so glad I got to spend time with my best friend Khosoo in Groningen. You have been my lifelong paranymph. For the last 10 years, we have been working at the same university (MNUMS) and studying in Korea. Now we are studying at same university and we are going back to work again at the same university soon. I really appreciate that you constantly support me and forgive me and that you always stay by my side. Thank you very much for being my best friend. I am also so glad that I got to know my best friend’s wife Saraa, who is a very honest and responsible person, much better. I wish you, Khosoo, Saraa and your lovely kids (Tergel and Tenuun) all the best.

Thank you so much Turuu, Ariuka and Zulaa sister. I appreciate that you guys supported me a lot during my last year of PhD. I wish you guys and Khosoo the best of luck with finalizing your PhDs. I also wish your families the very best - Dulguun and Irmuunee, Zorigoo, Saruul and Sanchir, and Namuunaa. It was also very nice to meet you, Zorigoo, again in Groningen. I wish you all the best in your future career. I am so proud of Zulaa’s daughter O. Nomuunaa. You are talented and such a good girl. I wish you all the best in your future studies.

For my family My dear parents Byambasukh Vanchig (Ванчигийн Бямбасүх) and Oyuntulkhuur Lkhamsuren (Лхамсүрэнгийн Оюунтүлхүүр), I love you both a lot and thank God that He gave you to me. I really appreciate your effort and love in bringing me up to be a better individual. Without either of you, I’d be nowhere near the person I

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am today. I also would like to express my thanks to my grandmother Choisurenjav (Чойсүрэнжав), for her all love and affection.

My parents both worked in the national police force. After a career of over 40 years during which he rose to high rank, my father continues to share his knowledge. Growing up in a ‘police family’ has been a source of great pride to me ever since I was a kid. Therefore, I am so glad my brother Khos-Erdene Byambasukh continues the police tradition in our family. I am very proud of your talent in “Practical Shooting”. I wish you the best of luck in your future international competitions.

I also would like to express my thanks to my beloved sister Batchimeg Byambasukh and brother-in-law Battulga Namsrai. During my PhD, I was glad to I spend my all holidays – Mongolian national holidays, Christmas and others – with my sister and her family. Thank you so much for giving me a nice time – every holiday was different and special. Also, thank you so much for showing me the beautiful Austrian mountains - I almost travelled through all of Austria. Thank you so much for the nice hospitality and lovely foods - delicious home-made knödel and kimchi which no restaurant could have prepared better. Thank you for always supporting me and being there for me over the past four years.

My talented and smart nephews Kh. Erdene-Bolor, B. Egshig-Undrakh and B. Dulbadrakh never fail to make me happy and proud. I wish them great success in their studies and future life. There aren’t enough words in the world to express my appreciation for my family. I love you forever and ever.

Oyuntugs Byambasukh

Groningen, Netherlands

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ABOUT THE AUTHOR Oyuntugs Byambasukh was born in 1984 in Ulaanbaatar, Mongolia. He completed his secondary school in Ulaanbaatar. Oyuntugs graduated as Medical Doctor (general practitioner) in 2008 from the Mongolian National University of Medical Sciences (MNUMS) and joined the university as a junior academic staff under supervision of Prof. Kh. Altaisaikhan. During this period (2008-2012), he obtained his master’s degree (MSc) and specialized as endocrinologist in the same university under supervision of Prof. J. Suvd. He has been a lecturer in the Department of Endocrinology at MNUMS since 2010.

In October, 2015, he joined University Medical Center of Groningen, University of Groningen for his PhD study under supervision of Associate Prof. E. Corpeleijn (Department of Epidemiology) and Prof. S.J.L Bakker (Department of Internal Medicine).

Currently, he will return to his former position as a lecturer at the department of Endocrinology, MNUMS.

His research interests are studies on obesity, diabetes and cardiovascular diseases with particular focuses on potential benefits of physical activity in understanding cardiometabolic health care management and predictive abilities of various obesity measures (especially in measurements of body composition) in the prediction of future outcomes such as diabetic complications and cardiovascular diseases.

linkedin.com/Oyuntugs Byambasukh Peer-reviewed publications Byambasukh, Oyuntugs, Dorien Zelle, and Eva Corpeleijn. "Physical Activity, Fatty Liver, and Glucose Metabolism Over the Life Course: The Lifelines Cohort." American Journal of Gastroenterology 114.6 (2019): 907-915. Byambasukh, Oyuntugs, Michele F. Eisenga, Ron T. Gansevoort, Stephan J.L. Bakker, Eva Corpeleijn. "Body fat estimates from bioelectrical impedance equations in cardiovascular risk assessment: The PREVEND cohort study." European journal of preventive cardiology 26.9 (2019): 905-916. Oyuntugs Byambasukh, Harold Snieder, Eva Corpeleijn. “The relation between leisure time, commuting and occupational physical activity with blood

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pressure in 125,402 adults: The Lifelines cohort”. Journal of The American Heart Association 2019;8:e014313

Press releases Press release in Website of University Medical Center Groningen (www.umcg.nl): Lichaamsvet als indicator Press release in Website of University Medical Center Groningen (www.umcg.nl): Lichaamsbeweging en leververvetting Presentations 2016 Oral presentation at NASO (Dutch Association for the Study of Obesity)

Scientific spring meeting, Utrecht, NL. Poster presentation at European Obesity summit, Gothenburg, Sweden.

2017 Oral presentation at 53rd Annual Meeting of EASD (European Association for the Study of Diabetes), Lisbon, Portugal. Oral presentation at Annual Dutch Diabetes Research Meeting 2017, Oosterbeek, NL.

2018 Poster presentation at European Obesity summit, Vienna, Austria. Oral presentation at Annual Dutch Diabetes Research Meeting 2018, Oosterbeek, NL.

2019 Poster presentation at EPI|LIFESTYLE Scientific Sessions (Epidemiology and Prevention | Lifestyle and Cardiometabolic Health), Houston, Texas, US Oral presentation at WEON (Netherlands Epidemiological Conference), Groningen, NL Guest presentation at the Ulaanbaatar International Congress of Endocrinology and Diabetes-2019, Ulaanbaatar, Mongolia

Training 2015 Epidemiology and Applied Statistics, GSMS, Groningen, NL. 2016 Energy metabolism and body composition in nutrition and health research,

Wageningen university, NL Publishing in English, GSMS, Groningen, NL. Presenting skills in English, GSMS, Groningen, NL. Project Management and GSMS Introduction, GSMS, Groningen, NL.

2017 Science Writing Course, GSMS, Groningen, NL. Applied longitudinal data analysis: Modeling change over time, GSMS, Groningen, NL. Fundamentals of Biobanking and cohort research, GSMS, Groningen, NL. Entrepreneurship and Valorization for medical sciences, GSMS, Groningen, NL. Multivariate analyses: How to handle three variables, GSMS, Groningen, NL.

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Introduction into R, GSMS, Groningen, NL. Incomplete information: Non-response, attribution and missing data, GSMS, Groningen, NL. Systematic reviews and meta-analysis, GSMS, Groningen, NL.

2018 Ethics of research and scientific integrity for researchers, GSMS, Groningen, NL. Advanced clinical epidemiology, GSMS, Groningen, NL.

2019 Phase II/III clinical trials, GSMS, Groningen, NL. Scholarships 2016 Travel grant, European Obesity summit 2016 2017 Travel grant, 53rd Annual Meeting of EASD 2018 Travel grant, European Obesity summit 2018 2019 Honorarium, Ulaanbaatar International Congress of Endocrinology and

Diabetes-2019

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ABBREVIATIONS ALP Alkaline phosphatase ALT Alanine aminotransferase AST Aspartate aminotransferase BF% Body fat percentage BIA Bioelectrical impedance analysis BMI Body mass index BP Blood pressure CI Confidence interval CLTPA Commuting-leisure-time physical activity CPA Commuting physical activity CVD Cardiovascular disease DBP Diastolic blood pressure DM Diabetes mellitus EASD European Association for the Study of Diabetes FLI Fatty liver index FPG Fasting plasma glucose FRS Framingham risk score GGT Gamma-glutamyltransferase HbA1c Hemoglobin A1C HDL-C High-density lipoprotein cholesterol HR Hazard ratio IDF International Diabetes Federation IGM Impaired glucose metabolism IR Insulin resistance LDL-C Low-density lipoprotein cholesterol LLDS Lifelines Diet Score LTPA leisure time physical activity MET Metabolic equivalent task MPA Moderate physical activity MVPA Moderate-to-vigorous physical activity NAFLD Non-Alcoholic fatty liver disease NASH Non-Alcoholic Steato Hepatitis NCD Non-Communicable disease NGM Normal glucose metabolism OPA Occupational physical activity OR Odds ratio PA Physical activity PREVEND Prevention of Renal and Vascular End-stage Disease

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Q Quartile RTR Renal transplant recipients SBP Systolic blood pressure SQUASH Short Questionnaire to Assess Health Enhancing Physical Activity T Tertile T2DM Type 2 diabetes mellitus TG Triglycerides TPA Total physical activity UAE Urinary albumin excretion VPA Vigorous physical activity