nutrients

Article
Are Older Adults without a Healthy Diet Less
Physically Active and More Sedentary?
Ming-Chun Hsueh 1,2 , Ru Rutherford 3 , Yi-Hsuan Huang 3 , Hung-Yu Chang Chien 3 ,
Chia-Hui Chang 3 , Jong-Hwan Park 4, * and Yung Liao 3
1 Department of Physical Education, National Taiwan Normal University, 162, Heping East Road Section 1,
Taipei 106, Taiwan; boxeo@ntnu.edu.tw
2 Institute of Sports Pedagogy, University of Taipei, No. 101, Sec. 2, Jhongcheng Rd., Shilin Dist., Taipei 11153,
Taiwan
3 Department of Health Promotion and Health Education, National Taiwan Normal University, 162, Heping
East Road Section 1, Taipei 106, Taiwan; bluenstop@gmail.com (R.R.); vincent6403@gmail.com (Y.-H.H.);
eric840617@gmail.com (H.-Y.C.C.); aj820927@gmail.com (C.-H.C.); liaoyung@ntnu.edu.tw (Y.L.)
4 Health Convergence Medicine Research Group, Biomedical Research Institute, Pusan National University
Hospital, 179, Gudeok-Ro, Seo-Gu, Busan 49241, Korea
* Correspondence: jpark@pnuh.co.kr; Tel.: +82-10-6228-1485; Fax: +82-52-240-7071




Received: 4 April 2019; Accepted: 10 May 2019; Published: 20 May 2019


Abstract: Few studies on older populations consider several energy balance-related behaviors together.
This cross-sectional study compared subjectively and objectively measured physical activity (PA)
and sedentary behavior (SB) patterns between older adults with and without a healthy diet. We
recruited 127 community-dwelling older Taiwanese adults (69.9 ± 5.0 years); data were collected
during April and September 2018. Objectively measured total PA, moderate-to-vigorous PA, light
PA, step count, total sedentary time, duration of sedentary bouts, number of sedentary bouts, and
number of sedentary breaks were assessed using activity monitors. Subjectively measured PA and
SB were measured using the International Physical Activity Questionnaire and Sedentary Behavior
Questionnaire for Older Adults. Chi-square tests and independent sample t-tests were performed.
For subjective measures, older adults without a healthy diet spent significantly less total leisure time
on PA and more leisure sitting time than those with a healthy diet. For objective measures, older
adults without a healthy diet spent less time on light PA and had a higher total sedentary time,
duration of sedentary bouts, times of sedentary bouts, and times of sedentary breaks than those with
a healthy diet. Regardless of the use of objective or subjective measurements, older adults without a
healthy diet engaged in a more inactive and sedentary lifestyle. These findings have implications for
health promotion practitioners in designing tailored interventions.

Keywords: accelerometer; questionnaire; physical activity; sedentary bouts; sedentary break; elderly

1. Introduction
Energy balance-related behaviors (EBRBs) are behaviors that may influence the energy balance and
include dietary behavior, sedentary behavior (SB), and physical activity [1,2]. Healthy dietary behavior,
physical activity (PA), and reduced sedentary time decrease the risks of mortality, non-communicable
diseases, and geriatric syndrome in older adults [3–5]. Despite the fact that dietary behavior, physical
activity, and sedentary behavior play significant roles in older adults’ health, only a few studies on the
elderly population have considered these three EBRBs together [6]. In particular, for older adults, it
is important to further compare physical activity and sedentary behavior patterns of those with and
without a healthy diet, because physical activity and sedentary behavior may play important roles

Nutrients 2019, 11, 1119; doi:10.3390/nu11051119 www.mdpi.com/journal/nutrients

Nutrients 2019, 11, 1119 2 of 8

in influencing functional ability [7,8]. This information is critical for designers of behavioral change
interventions and health-promotion practitioners in designing tailored interventions for older adults
without a healthy diet.
However, there is a major concern regarding the measurement methods in the existing studies [9–11].
Few studies have examined physical activity and sedentary behavior patterns using both subjective
and objective measures [9]. Using objective measures such as accelerometers can help to precisely
measure activity intensity (sedentary, light, moderate, and vigorous), activity patterns (long sedentary
bouts and break times), and step counts [10]. Despite the limitation of recall methods, using subjective
measures can reflect the awareness of participants’ physical activity and sedentary behaviors and
provide information on the types, frequency, and duration of PA, which are all important health
indicators [11]. Therefore, we used both objective and subjective measures to collect data on older
adults’ awareness of and actual physically active and sedentary lifestyles. In addition, although several
studies examined the association between physical activity and dietary behavior [12,13], few compared
the sedentary behavior patterns of older adults with and without a healthy dietary behavior [14]. We
hypothesized that older adults without a healthy diet may engage in less physical activity and more
sedentary time than those with a healthy diet. To fill these research gaps, this study aimed to compare
the patterns of physical activity and sedentary behavior between older adults with and without a
healthy diet using objective and subjective measures.

2. Materials and Methods

2.1. Participants
The present cross-sectional study was conducted in Taipei city, Taiwan, during April and September
2018. The inclusion criteria of this study were being community-dwelling older adults and aged
60 years or older. Those who were unable to walk independently (were using any walking assistance
devices) were excluded from the present study [15]. The participants were recruited through local
advertisements and announcement in the community. The participants contacted the study recruiters
if they were interested in participation. In total, 170 men and women aged over 60 years were
enrolled. First, every participant completed an informed consent form and questionnaire about
socio-demographic information, healthy behavior, health condition, physical activity, and sedentary
behavior. Furthermore, the participants wore an accelerometer on their waist for seven consecutive days.
A convenience-store gift certificate (worth 7 USD) was given after they completed the questionnaire
and wore the accelerometer for the purposes of this study. Incomplete questionnaire and accelerometer
data were excluded (n = 43). For the data analysis, 127 participants were included in the study.

2.2. Research Ethics

Our study was conducted following the Declaration of Helsinki of 1975 and its subsequent
revisions. Before participation in the study, each participant provided written informed consent. We
also obtained ethical approval from the Research Ethics Committee of the University (REC number:
201711HM003).

2.3. Subjectively Measured Physical Activity and Sedentary Behavior

2.3.1. Leisure-Time Physical Activity

We used the Taiwanese version of the International Physical Activity Questionnaire-Long Version
(IPAQ-LV) to measure leisure-time physical activity. The IPAQ-LV had acceptable validity (Intraclass
Correlation Coefficient [ICC] = 0.79) [16]. We collected data on the time spent on different types of
physical activity including physical activities of vigorous and moderate intensities and walking for the
previous seven days.
Nutrients 2019, 11, 1119 3 of 8

2.3.2. Leisure-Time Sedentary Behavior

Sedentary behavior was assessed using the 10-item Sedentary Behavior Questionnaire for Older
Adults, which was validated in previous studies [17]. The questionnaire covered various types
of sedentary behavior including TV viewing, computer using, reading, socializing, sitting in an
automobile, eating, working (or volunteering), napping, hobbies (e.g., chess), and other sedentary
behaviors (e.g., craft or class). Each item demonstrated reasonable test–retest reliability and validity
and assessed the overall sedentary time. The participants were asked to recall how much time they
spent on each sedentary behavior and how many days they performed these behaviors in the previous
seven days. In accordance with the measures of leisure-time physical activity, three items (eating,
napping, and working time) were excluded because eating and working are not leisure-time sedentary
behavior, and nap is not a waking behavior [17]. The remaining seven items were summed as the
variable total time spent on leisure-time sedentary behavior.

2.4. Objectively Measured Physical Activity and Sedentary Behavior

In this study, we used ActiGraph, which is an activity monitor (wGT3X-BT) that counts the steps
and measures the time spent on total, light, moderate-to-vigorous physical activity, and sitting, as
well as sedentary patterns including the duration of a sedentary bout, times of sedentary bouts, and
sedentary breaks. We also used the ActiLife software (version 6.0, Pensacola, FL, USA) to analyze the
accelerometer data. Triaxial accelerometer models have demonstrated high intra-monitor reliability
and have been validated with acceptable criteria [18]. The accelerometer recorded data for seven days
(five weekdays and two weekend days). However, sleeping time was not calculated as sedentary
time but was classified as unfitted time. Non-wear time was defined as 60 min or more of continuous
unbroken 0 counts with a tolerance of up to 2 min of limited movement. Participants with at least
three valid days of accelerometer data and at least one weekend day were included in this study. A
period of 600 min (10 h) or more of monitor wear time was categorized as a valid day.
Accelerometer counts can distinguish sedentary behavior from physical activity. Here, ≤99
counts/min was regarded as sedentary time, and ≥100 counts/minute as physical activity. For
physical activity, light-intensity physical activity (LPA) was defined as PA between 100 and 2019
counts/min, and moderate-to-vigorous-intensity physical activity (MVPA) as greater than or equal to
2020 counts/min [19]. The MVPA bouts as periods of MVPA lasting at least 10 consecutive minutes
with a one-minute allowance below the MVPA threshold were included in the analysis [18]. In this
study, LPA, MVPA, total PA (LPA + MVPA), and daily step counts were included as exposure variables.
Following previous studies [20,21], total sedentary time, number and duration of ≥30 min sedentary
bouts were calculated for the analysis. The drop time of a sedentary bout was set at two minutes when
the data were analyzed.

2.5. Healthy Dietary Behavior

Participants were asked to report whether they had a healthy dietary behavior based on the
requirements of six key nutrient groups daily, according to the current Taiwanese dietary guidelines [22].
The six nutrient groups include the following: (1) miscellaneous, (2) milk and dairy product, (3)
vegetables, (4) fruits, (5) soybean/fish/meat/egg, and (6) nuts, seeds, oil, and fat. The healthy dietary
behavior was categorized as “yes” or “no” in the present study.

2.6. Statistical Analyses

All analyses were conducted using SPSS 22.0 for Windows (SPSS Inc., Chicago, IL, USA). General
characteristics were evaluated using a chi-square test, and independent sample t-tests were performed
to compare the differences of time spent in physical activity and sedentary behavior between older
adults with and without a healthy diet. For all analyses, the results are shown as means with standard
deviations (M ± SD). Finally, significance was set at p = 0.05.
Nutrients 2019, 11, 1119 4 of 8

3. Results
Table 1 provides the results for the 127 older adults with valid data for the analysis. The mean age
of those with or without a healthy diet was 69.8 ± 4.7 and 70.4 ± 5.3 years, respectively. Moreover, no
differences were evident between the groups for socio-demographic factors and health conditions.

Table 1. Characteristics of the participants.

Variables Healthy Diet (n = 94) No Healthy Diet (n = 33) p

Age, M ± SD 69.8 ± 4.9 70.4 ± 5.3 0.558
Gender (%) 0.291
Male 30.9% 21.2%
Female 69.1% 78.8%
BMI (kg/m2 ), M ± SD 24.2 ± 3.3 24.0 ± 3.6 0.752
Marital Status (%) 0.353
Married 63.8% 72.7%
Unmarried 36.2% 27.3%
Living status (%) 0.127
Living with others 91.5% 81.8%
Living alone 8.5% 18.2%
Education level (%) 0.110
University 25.5% 12.1%
Up to high school 74.5% 87.9%
Employment (%) 0.229
Yes 4.3% 0.0%
No 95.7% 100.0%
Self-rated health (%) 0.149
Good 34.8% 21.2%
Poor 65.2% 78.8%
Smoking habit (%) 0.872
Yes 5.3% 6.1%
No 94.7% 93.9%
Alcohol consumption (%) 0.071
Yes 5.3% 15.2%
No 94.7% 84.8%
Depression (%) 0.595
Yes 16.0% 12.1%
No 84.0% 87.9%
Diabetes (%) 0.153
Yes 16.0% 27.3%
No 84.0% 72.7%
Hypertension (%) 0.676
Yes 38.3% 42.4%
No 61.7% 57.6%
High blood lipid (%) 0.956
Yes 29.8% 30.3%
No 70.2% 69.7%
BMI: body mass index; M: mean; SD: standard deviation. The general characteristics were evaluated using a
chi-square analysis.

Table 2 shows subjectively and objectively measured time of intensity-specific physical activity
and sedentary behavior patterns. For subjective measures, compared with those with a healthy diet,
older adults without a healthy diet spent significantly less time on total leisure-time PA (60.59 ± 65.61
Nutrients 2019, 11, 1119 5 of 8

versus 35.09 ± 41.67, t = 2.09, p = 0.039) and leisure-time walking (39.26 ± 45.06 versus 16.04 ± 23.52,
t = 3.75, p < 0.001). No differences were found for the leisure-time MVPA of the two groups (21.33
± 37.42 versus 19.05 ± 36.74, t = 0.30, p = 0.763). Also, older adults without a healthy diet spent
significantly more time than those with a healthy diet on leisure sitting time (7.47 ± 3.20 versus 8.83 ±
2.56, t = −2.20, p = 0.029). Regarding the objective measures of physical activity, the results showed
that older adults with a healthy diet had a significantly higher LPA than those without a healthy diet
(301.21 ± 74.94 versus 266.81 ± 89.42, t = 2.15, p = 0.033). In addition, older adults without a healthy
diet had significantly higher total sedentary time (9.87 ± 1.24 versus 10.56 ± 1.21, t = −2.76, p = 0.007),
sedentary bout duration (190.95 ± 73.91 versus 257.35 ± 115.24, t = −3.09, p = 0.004), sedentary bout
times (4.43 ± 1.54 versus 5.66 ± 2.30, t = −2.85, p = 0.007), and sedentary break times (4.25 ± 1.54 versus
5.47 ± 2.28, t = −2.84, p = 0.007) than older adults with a healthy diet.

Table 2. Subjectively and objectively measured physical activity and sedentary behavior patterns of
older adults with and without a healthy diet.

Healthy Diet No Healthy Diet

Variables (n = 94) (n = 33) t df p
M ± SD M ± SD
Total LTPA, min/week 60.59 ± 65.61 35.09 ± 41.67 2.09 125 0.039 *
Subjective Leisure-time walking, min/week 39.26 ± 45.06 16.04 ± 23.52 3.75 106.67 <0.001 *
Measurement Leisure-time MVPA, min/week 21.33 ± 37.42 19.05 ± 36.74 0.30 125 0.763
Leisure sitting time, h/day 7.47 ± 3.20 8.83 ± 2.56 −2.20 125 0.029 *
Total PA, min/day 326.29 ± 77.60 289.30 ± 95.66 2.00 47.62 0.051
LPA, min/day 301.21 ± 74.94 266.81 ± 89.42 2.15 125 0.033 *
MVPA, min/day 25.08 ± 24.49 22.49 ± 18.91 0.55 125 0.582
Objective Steps, counts/day 7730.47 ± 3372.53 6674.12 ± 3371.51 1.55 125 0.124
Measurement Total sedentary time, h/day 9.87 ± 1.24 10.56 ± 1.21 −2.76 125 0.007 *
Sedentary bout duration, min/day 190.95 ± 73.91 257.35 ± 115.24 −3.09 41.61 0.004 *
Sedentary bout times 4.43 ± 1.54 5.66 ± 2.30 −2.85 42.46 0.007 *
Sedentary break times 4.25 ± 1.54 5.47 ± 2.28 −2.84 42.61 0.007 *
* p < 0.05; LTPA: leisure-time physical activity; PA: physical activity; LPA: Light physical activity; MVPA:
Moderate-to-vigorous physical activity; M: mean; SD: standard deviation; df : degree of freedom. Independent
sample t-tests were performed to compare the differences of time spent in physical activity and sedentary behavior
between older adults with and without a healthy diet.

4. Discussions
This is the first study comparing the patterns of physical activity and sedentary behavior of older
adults with and without a healthy diet using accelerometers and questionnaire-based measures. The
main findings of this study are that older adults without a healthy diet tend to engage in more inactive
and sedentary lifestyles than those with a healthy diet, regardless objective or subjective measurements.
These findings may have great implications for behavioral change designers and health-promotion
practitioners and indicate an urgent need to design interventions or programs to promote physical
activity and reduce the sedentary behavior of older adults without a healthy diet.
An interesting finding when comparing the time spent on objectively measured physical activity
between older adults with and without a healthy dietary behavior was that the time spent on total
PA, MVPA, and daily step counts did not significantly differ between the two groups. However, the
healthy-diet group engaged in more LPA than the unhealthy-diet group. Given that many previous
studies emphasized the health benefits of engaging in LPA [23–25], our results may suggest that
encouraging older adults without a healthy diet to accumulate more LPA could be an effective strategy
to obtain optimal health benefits. In addition, when comparing the objectively measured sedentary
behavior patterns of the two groups, older adults without a healthy diet engaged in higher total
sedentary time, more prolonged sedentary bouts, and a longer duration of sedentary bouts than those
with a healthy diet. Possibly, older adults without a healthy diet were also more likely to have a
sedentary lifestyle. Since EBRBs contribute to negative impacts on older adults’ health [3–5], our
Nutrients 2019, 11, 1119 6 of 8

results using objective measures may highlight the importance of decreasing the total sedentary time
and 30 min sedentary bouts in older adults without a healthy diet.
Noteworthy is that when using subjective measures of leisure-time physical activity and sedentary
behavior, older adults with a healthy diet engaged in significantly more leisure-time physical activity
and less sedentary behavior. Questionnaire-measured physical activity and sedentary behavior were
also associated with health indicators in older adults [26,27]. A possible explanation for this result is
that older adults with a healthy diet may be more likely to perceive themselves as having a healthy
lifestyle. This may also suggest the importance of increasing the awareness of physical activity and
sedentary behavior levels among older adults without a healthy diet.
There are several limitations to this study that must be acknowledged. The cross-sectional study
design cannot make strong causal inferences of the association of PA and sedentary behavior with diet
quality. Possibly, if participants do not have a healthy diet, they may also have lower physical activity
and spend more time on sedentary behavior. Moreover, because of a potential selection bias, the results
of this study should be interpreted with caution; for instance, healthier older adults were more likely
to participate in this study than unhealthy ones. Therefore, our results could not be generalized to the
entire Taiwanese older population. The current study used a single question for health diet distribution
and did not examine specific dietary constituents. While leisure-time physical activity and leisure
sitting time are widely used and validated instruments [28,29], self-reported measurements may reflect
personal biases. Finally, several potential confounders such as the basal resting metabolic rate of the
participants and research duration (i.e., season’s influence) were not considered in the present study.
Future studies on this issue should control for these confounders in the analyses.
In conclusion, using objective or subjective measurements, we found that older adults without a
healthy diet tend to engage in more inactive and sedentary lifestyles than older adults with a healthy
diet. These findings support the hypothesis of the present study and have great implications for
designers of behavioral changes and health-promotion practitioners in planning tailored interventions.

Author Contributions: Conceptualization M.-C.H. and Y.L.; methodology R.R., H.-Y.C.C., and C.-H.C.; software
M.-C.H., R.R., and Y.-H.H.; formal analysis M.-C.H., R.R., and Y.-H.H.; investigation M.-C.H. and R.R.; resources
M.-C.H. and Y.L.; writing—original draft preparation M.-C.H., R.R., Y.-H.H., H.-Y.C.C., C.-H.C., J.-H.P., and Y.L.;
writing—review and editing M.-C.H., R.R., Y.-H.H., H.-Y.C.C., C.-H.C., J.-H.P., and Y.L.; supervision J.-H.P. and
Y.L.; project administration M.-C.H., J.-H.P., and Y.L.; funding acquisition M.-C.H., J.-H.P., and Y.L.
Funding: Ming-Chun Hsueh received a personal grant from the Ministry of Science and Technology of Taiwan
(MOST 106-2410-H-003 -144 -MY2). The Ministry of Science and Technology of Taiwan was not involved in the
study design, data collection, analysis, interpretation, and writing of the manuscript. This work was supported by
a Global Research Network program through the Ministry of Education of the Republic of Korea and National
Research Foundation of Korea (NRF-Project number: NRF-2017S1A2A2038558).
Acknowledgments: This work was supported by the “Higher Education Sprout Project” of the National Taiwan
Normal University and Ministry of Education, Taiwan, R.O.C.
Conflicts of Interest: The authors declare no conflict of interest.

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