Physical and Leisure Activity, Body Composition, and Life Satisfaction in HIV-Positive Hispanics in Puerto Rico

JANAC Vol. 15, No. 4, July/August 2004 ARTICLE 10.1177/1055329003261966 Ramírez-Marrero et al. / Physical and Leisure Activity

Physical and Leisure Activity, Body Composition, and Life Satisfaction in HIV-Positive Hispanics in Puerto Rico Farah A. Ramírez-Marrero, PhD Barbara A. Smith, RN, PhD, FAAN Nelson Meléndez-Brau, EdD Jorge L. Santana-Bagur, MD

Hispanics represent 13% of the U.S. population but account for 19% of the new AIDS cases reported in 2000. The antiretroviral drug therapy used for the treatment of HIV/AIDS may cause lipodystrophy and insulin resistance, among other effects. Physical and leisure activities reduce these effects and improve the emotional and physical well-being of HIV-positive persons. This study describes physical and leisure activities, life satisfaction, depression, and body composition of HIV-positive Hispanics in Puerto Rico and compares body composition, CD4 counts, depression, leisure time, and life satisfaction of participants classified as physically active or inactive. Sixty-eight individuals were evaluated using questionnaires and biophysical measurements. Descriptive statistics and independent t tests were used for data analysis. Physically active participants had higher life satisfaction scores and healthier body composition as compared to those physically inactive. Health professionals must encourage the promotion of a physically active lifestyle among HIV-positive Hispanics. Key words: HIV, Hispanics, physical activity, leisure activity, body composition, life satisfaction

The World Health Organization (2000) indicated that Haiti, the Dominican Republic, and Puerto Rico are the three Caribbean countries with the highest esti-

mated number of people infected with HIV. Puerto Rico is ranked third among the states and territories of the Unites States with the highest annual incidence of reported AIDS cases, with 32.3 per 100,000 inhabitants (Centers for Disease Control and Prevention, 2003). In 2002, the number of persons reported with AIDS in Puerto Rico was 28,419 (Commonwealth of Puerto Rico Department of Health, 2003), 86% were between the ages of 20 to 49, and 50% were injection drug users. In the continental United States, Hispanic women have shown higher risk behaviors associated with HIV infection, and Hispanics in general have been disproportionately affected by the HIV/AIDS epidemic (Centers for Disease Control and Prevention, 2000; Grella, Annon & Anglin, 1995). Farah A. Ramírez-Marrero, PhD, is an associate professor at the University of Puerto Rico, Río Piedras Campus, Center for HIV/AIDS Education and Research, San Juan, Puerto Rico. Barbara A. Smith, RN, PhD, FAAN, is professor and Marie L. O’Koren Endowed Chair at the University of Alabama at Birmingham, School of Nursing. Nelson Meléndez-Brau, EdD, is a professor at the University of Puerto Rico, Río Piedras Campus, Department of Physical Education and Recreation, San Juan, Puerto Rico. Jorge L. Santana-Bagur, MD, is an associate professor in the Department of Medicine and director of the AIDS Clinical Trial Unit at the University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 15, No. 4, July/August 2004, 68-77 DOI: 10.1177/1055329003261966 Copyright © 2004 Association of Nurses in AIDS Care

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The decline in HIV-related mortality and morbidity observed in the United States has been associated with the availability of the new highly active antiretroviral therapy (HAART). This aggressive therapy has been successful in reducing viral load, increasing CD4 lymphocytes, delaying the onset of AIDS, and increasing the survival rate of HIV-infected individuals. On the other hand, HAART is also related to the development of negative side effects such as gastrointestinal disorders, liver problems, lipodystrophy, insulin resistance, hyperglycemia, hypercholesterol, and decreased bone density. The decreases in lean body mass and increases in abdominal fat observed in HIV-positive persons on HAART increase their risk of developing chronic conditions such as hypertension, diabetes, and coronary artery disease. Beyond this, the combination of sedentariness and malnutrition have been related to loss of lean body mass and mortality in these persons (Gilquin & Marchandise, 1997; Macallan et al., 1995). Hispanics in the United States are among those who initiate early HAART after AIDS diagnosis (Hsu, Vittinghoff, Katz, & Schwarcz, 2001). Also, HIVinfected Hispanics tend to have a higher perception of pain symptoms and distress compared to other ethnic groups in the United States (Rotheram-Borus, 2000). Although pain symptoms are not related to health status and health care, pain is associated with changes in illness status. Moreover, Hispanics identify the “support from others” as one important factor affecting their adherence to antiretroviral medication regimes (Kemppainen, Levine, Mistal, & Schmidgall, 2001). An additional health behavior characteristic among Hispanics is their higher prevalence of physical inactivity, particularly among women, compared to Blacks and Whites (U.S. Department of Health and Human Services, 1996). These are examples of cultural factors that are important to enhance the ability of advanced practice nurses and other health care professionals to develop meaningful interventions for HIV-positive Hispanics. It is well known that in addition to the use of prescribed medications, positive thoughts and emotions can influence immune status and overall health. In support of these relationships, Solomon (1994) and Leipart (1992, pp. 1-6) identified several traits and characteristics in HIV long-term survivors including (a) having a commitment, purpose, or meaning in life; (b) having a sense of social and communal responsibil-

ity; and (c) engaging in exercise and physical activities. Other researchers have also reported positive relationships between life satisfaction, health behaviors, leisure activities, and exercise training. Kibler & Smith (2000) and Caroleo (1999) determined that therapeutic recreation programs, including a variety of leisure-time activities, are important to reduce levels of stress and isolation and to improve the psychological well-being and health of HIV-positive individuals. Kalichman, Kelly, Morgan, and Rompa (1997) found that gay and bisexual men who engaged in highrisk sexual practices were also more dissatisfied with life compared to those who practiced only safe sex. Kalichman et al. argued that individuals who are satisfied with their lives, and hold a positive expectancy for their futures, are more likely to practice healthier behaviors. Moreover, Stringer, Berezovskaya, O’Brien, Beck, and Casaburi (1998) reported that only the HIVpositive individuals in their two exercise groups (moderate and heavy intensity) significantly improved in response to questions related to quality of life, hope, and desire to continue living when compared to the control group. Physical activity and exercise are two interrelated and synonymously used terms, but they are also terms with particular characteristics. Physical activity is defined as body movements caused by the activation of skeletal muscles with the resulting increase in energy expenditure above resting levels (Caspersen, Powell, & Christenson, 1985). Exercise is defined as physical activity that is planned, structured, and repetitive. Both physical activity and exercise have been positively related to physical fitness. Good levels of physical fitness contribute to health and well-being by improving the ability to perform daily activities with vigor and alertness, reducing levels of fatigue, and providing extra energy for enjoying leisure-time activities and meeting unexpected emergencies (U.S. Department of Health and Human Services, 1996). Leisure-time activities are those performed during free time or activities that are unrelated to work. These can be categorized into competitive sports, recreational activities, and exercise training. Research studies support that exercise and physical activity are not only safe for HIV-positive persons but also beneficial to their health by improving the body’s ability to fight the infection (Eichner & Calabrese, 1994; LaPerriere et al., 1994; Yarasheski &

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Roubenoff, 2001). Exercise and physical activity can benefit HIV-positive individuals by reducing the centralized obesity and peripheral wasting associated with HAART (Evans, Roubenoff, & Shevitz, 1998; Roubenoff et al., 1999b; Smith et al., 2001). Also, progressive resistance and strength training and the use of anabolic steroids have helped to further increase lean body mass and strength in HIV-positive persons treated with HAART (Roubenoff et al., 1999a; Roubenoff & Wilson, 2001; Sattler et al., 1999). The improvements in physical conditioning with regular physical activity and exercise represent higher levels of energy available for daily activities, including leisure pursuits. Several research studies also indicate that exercise reduces the levels of depression in HIV-positive individuals and helps to improve their quality of life (LaPerriere et al., 1990; LaPerriere et al., 1991; Neidig et al., in press; Roubenoff, 2000). One possible explanation for these findings may be the direct positive relationship between physical activity and exercise and physical and emotional well-being. Exercise may enhance the immune status by reducing negative affective states and by the modulation of levels of endogenous opiates and stress hormones. Declines in the rates of depression and distress have also been reported with the use of HAART in most but not all HIVpositive persons (Rabkin, Ferrando, Lin, Sewell, & McElhiney, 2000). Fernández, Gómez, Velásquez, Miniño, and Hunter (1997) reported the behavioral and psychological characteristics of 58 HIV-positive Hispanic adults receiving clinical treatment in Puerto Rico. A cutoff score of 15 was used to indicate depression using the Beck Depression Inventory (Beck & Steer, 1993). The mean Beck Depression Inventory score was 17.9 ± 13.7, indicating that the sample was clinically depressed. Women had significantly higher scores compared to men (25.6 ± 15.0 vs. 14.4 ± 11.7, respectively). Also, better educated individuals (> 12th grade) had lower depression scores compared to those who were less educated (≤ 12th grade) (mean Beck Depression Inventory score = 9.4 ± 6.9 vs. 22.8 ± 15.0). The study did not report differences in the level of education between males and females or the use of HAART or physical activity and exercise among the participants.

The purpose of this study was to describe physical and leisure-time activity, body composition, life satisfaction, and depression in HIV-positive Hispanic men and women living in Puerto Rico. A second purpose was to compare body composition, leisure time, CD4 counts, life satisfaction, and depression of those individuals classified as physically active or inactive. The authors suggest that their findings could influence public health policies related to HIV treatment in Hispanics and provide data to support sensitive interventions by advanced practice nurses and other health care professionals.

Method Design A descriptive study was conducted to examine the psychological (i.e., life satisfaction, depression), behavioral (i.e., physical and leisure-time activity), and biophysical characteristics (i.e., body composition, CD4 counts) in a group of HIV-positive men and women living in Puerto Rico and to evaluate differences by gender and level of physical activity on selected psychological and biophysical parameters. All participants were interviewed at the AIDS Clinical Trial Unit at the University of Puerto Rico, Medical Sciences Campus, when they attended their regularly scheduled appointments. The AIDS Clinical Trial Unit staff provided the CD4 count data for each individual within a window of 1.5 months from the date of the interview. Participants A group of 68 HIV-seropositive men (n = 43) and women (n = 25) were recruited from the AIDS Clinical Trial Unit (mean age = 40.4 ± 8.0 years, weight = 76.0 ± 17.3 kg, height = 168.1 ± 10.4 cm, CD4 = 311.1 ± 222.2 cells/mm3). Some individuals had a CD4 count below 200 cells/mm3, but none presented clinical symptoms or had an AIDS-defining illness. All of the study’s participants were on HAART. Prior to participation, each individual signed a consent form approved by the human investigation review board at the University of Puerto Rico, Medical Sciences Campus.

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Procedures Four separate questionnaires were used to evaluate the psychological characteristics (Life Satisfaction Index and Beck Depression Inventory) and behavioral characteristics (Leisure Activity Inventory and SevenDay Physical Activity Recall) of the participants in the study. Biophysical parameters included measurements of body composition and CD4 counts. The Leisure Activity Inventory (Meléndez, 1991) was used to assess leisure-time activities among participants. This instrument contains a list of 29 commonly practiced leisure activities in Puerto Rico (Cronbach’s alpha = .81). Individuals were interviewed and the frequency of participation for each activity was recorded using a 4-point scale (i.e., never = 0, rarely = 1, occasionally = 2, and frequently = 3). The inventory yields an overall score, which is the sum of the responses to each particular activity. The score could range between 0 and 87. Life satisfaction was measured using the Life Satisfaction Index Z developed by Havighurst (Neugarten, Havighurst, & Tobin, 1961) and adapted and validated in Spanish by Meléndez (1999). The instrument contains 18 statements, 11 expressing satisfaction and 7 expressing dissatisfaction with life (Cronbach’s alpha = .70). Participants were asked if they agreed, disagreed, or were unsure about each statement. Each response was weighted and an overall score was obtained to describe the individual’s relative level of life satisfaction. The score could range between 0 and 36. Depression was assessed using the Spanish version of the Beck Depression Inventory (Fernández et al., 1997). The instrument consists of 21 items describing cognitive, affective, behavioral, and somatic symptoms of depression (Cronbach’s alpha = .93). Participants recorded each item according to four levels of severity (i.e., 0 to 3). An overall score was obtained from the sum of the responses to each item. The score could range between 0 and 29. A cutoff score of 15 was used to indicate depression (Beck & Steer, 1993). The Seven-Day Physical Activity Recall was used to measure the time spent in moderate, hard, and very hard intensity leisure and occupational activities during the previous 7 days (American College of Sports Medicine, 1997). The researchers guided each participant through the day-by-day recall process to determine the duration and intensity of the physical activi-

ties during the previous 7 days. During the interview, the total time sleeping, watching television, reading, or using a computer during the previous 7 days was also recorded. The instrument had a test-retest reliability of 0.60 and a validity correlation coefficient of .42 when compared with activity monitors in Hispanic adults (American College of Sports Medicine, 1997). The Compendium of Physical Activities (Ainsworth et al., 2000) was later used to estimate the average daily energy expenditure associated with physical activity based on the duration and intensity of the activities recorded. Measurements of body composition included height, weight, body mass index (BMI), seven skin folds, and five circumferences. Height and weight were measured using a standard Detecto scale. BMI was calculated by dividing each participant’s weight (kg) by height squared (m2). Skin folds were measured with a Lange caliper and included the following sites: biceps, triceps, subscapular, suprailiac, abdomen, thigh, and calf. Body circumferences were measured with a Gulick anthropometric measuring tape and included the following areas: neck, arm, hip, waist, and thigh. The relationships between total body composition and skin fold thicknesses (r = .7 to .9) and circumferences (r = .7) range from fair to good (Roche, Heymsfield, & Lohman, 1996). However, to minimize the source of measurement error, prediction equations were not included in this study. Data Analyses Descriptive statistics including medians, means, and standard deviations were used to describe the sample. Independent t tests (two tailed) were used to identify differences by gender in the variables of interest. Participants were divided by their estimated energy expenditure associated with physical activities. That is, a cutoff point of 300 kcal/day of physical activity– related energy expenditure was used to identify those physically active (≥ 300 kcal/day) from those not physically active (< 300 kcal/day). This energy expenditure represents the midpoint of the recommended physical activity energy expenditure for health (American College of Sports Medicine, 2000). An analysis of covariance was used to assess differences between the physically active and not physically active, using

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Table 1.

Leisure Activity and Psychological Variables by Gender (Mean ± Standard Deviation)

Variable Leisure Activity Inventory Life Satisfaction Index Beck Depression Inventory

All

Men

Women

43.4 ± 10.6 44.0 ± 11.9 42.0 ± 12.3 (43.0) (46.0) (40.0) 23.5 ± 7.9 24.8 ± 7.9 22.1 ± 8.0 (26.0) (26.0) (25.0) 11.3 ± 7.8 9.6 ± 6.9 13.7 ± 8.1** (10.0) (9.0) (11.0)

NOTE: Medians are shown in parentheses. **p = .03 (difference by gender).

age and gender as covariates when appropriate. The SAS JMP(r) Statistics and Graphics Guide (Version 3.1) and the SAS/IML User’s Guide (Version 8) were used for the statistical analysis. An alpha of .05 was set a priori to identify statistical significance.

Results The demographic characteristics of the participants were similar to other demographic reports of HIVpositive individuals in Puerto Rico. Males accounted for 63% (42) of the participants, 79% (54) were from 30 to 50 years of age, 62% (42) had an education level beyond 12th grade, and 72% (49) reported sexual contact as the means of infection. The level of education was higher than previously reported among HIVpositive individuals in Puerto Rico. A relatively large proportion of participants reported living alone (51%) and being unemployed (24%). Even though being unemployed and living alone could influence psychological well-being and perception of health status, most of the participants (74%) reported their overall health as good or excellent. Leisure activity. The responses to the Leisure Activities Inventory (see Table 1) yielded a median score of 43.0 (M = 43.4, SD = 10.6), with no gender differences observed. The scores recorded in this study ranged from 8 to 72. The three leisure activities with the highest ranking were home-based activities involving no physical effort (i.e., listening to music or radio, watching TV, and reading for pleasure). Exercise was ranked 14th and sports participation was ranked 27th out of a list of 29 different leisure activities provided.

Table 2. CD4 Counts, Physical Activity, and Body Composition by Gender (Mean ± Standard Deviation) Variable 3

CD4 counts (cells/mm ) Physical activity (average daily)

Male

Female

All

342.9 ± 245.9 5.5 ± 2.9

256.4 ± 164.8 5.1 ± 2.8

311.1 ± 222.2 5.4 ± 2.8

1.2 ± 0.7 268.8 ± 192.9

1.2 ± 0.9 288.6 ± 240.2

TV watching (hr/day) Total daily physical activity 1.2 (hr/day) ± 1.0 Physical activity-related energy 300.2 expenditure (kcal/day) ± 265.3 Body composition Weight (kg) 77.5 ± 18.1 Height (cm) 172.6 ± 7.8 25.9 Body mass index (kg/m2) ± 5.3 Σ Trunk skin folds (mm) 53.3 ± 18.0 Σ Limb skin folds (mm) 42.9 ± 19.6 Σ Trunk circumference (cm) 225.8 ± 34.0 Σ Limb circumference (cm) 77.5 ± 7.5

73.4 ± 15.8 160.3 ± 9.7* 28.6 ± 5.8* 73.6 ± 19.2* 87.5 ± 26.1* 232.3 ± 31.6 84.7 ± 12.7*

76.0 ± 17.3 168.1 ± 10.4 26.9 ± 5.6 60.7 ± 20.8 59.3 ± 30.9 228.2 ± 33.0 80.1 ± 10.3

NOTE: Trunk skin folds = subscapular, suprailiac, abdomen; Limb skin folds = biceps, triceps, thigh, calf; Trunk circumferences = neck, hip, waist; Limb circumferences = arm, thigh. *p ≤ .05 (females significantly different from males).

Life satisfaction and depression. The Life Satisfaction Index (see Table 1) yielded a median score of 26.0 (M = 23.5, SD = 7.9), with no differences between men and women. The Beck Depression Inventory yielded a median score of 10.0 (M = 11.3, SD = 7.8), with females having a higher score compared to males. The proportion of individuals at or above the cutoff point of 15 was 33.8% (males = 9, females = 14). CD4 counts, physical activity, and body composition. No differences in CD4 counts were observed between men and women (see Table 2). The time engaged in physical activities and the estimated energy expenditure associated with physical activity reported by participants ranged from 0 to 3.9 hours (M = 1.2, SD = 0.9) and from 0 to 1,218 kcal (M = 288.6, SD = 240.2), respectively. No differences in physical activity were found between males and females.

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Most of the reported physical activities were occupational in nature (i.e., household or job related). From those individuals classified as physically active, 32% reported involvement in leisure-time physical activities, the most common being walking, jogging, and calisthenics. Participants reported an average of 5.4 hours of TV watching per day. The average BMI in the participants was 26.9 kg/ m2. BMI was higher in women (28.6 kg/m2) compared to men (25.9 kg/m2). Women also had a higher sum of trunk and limb skin folds and sum of limb circumferences compared to males. To estimate the percentage of body fat for the sample, bioelectrical impedance was obtained in a random subsample of 28 individuals (males = 18, females = 10) using the RJL System analyzer. The mean and standard deviation of body fat in the group of men was 18.2% ± 5.5% and in the group of women was 42.3% ± 8.7%. Group differences. To further evaluate the relationship between physical activity and other health-related variables, participants were divided into a physically active group (≥ 300 kcal/day) and physically inactive group (< 300 kcal/day) (see Table 3). The physically active group had lower body weight, lower BMI, lower limb and trunk skin folds, lower trunk circumference, and spent less time watching TV. They also had higher life satisfaction scores (M = 25.5, SD = 7.1 vs. M = 20.7, SD = 8.2) compared to the physically inactive group. No group differences were observed in the following variables: age, height, CD4 counts, leisure time, and depression.

Discussion The physical and leisure-time activities, life satisfaction, depression, CD4 counts, and body composition characteristics of HIV-positive Hispanics living in Puerto Rico were described in this study. Differences in leisure time, life satisfaction, depression, body composition, and CD4 counts by gender and physical activity level were also described. The leisure-time lifestyle in this group of participants was similar (median score = 43) compared to that reported in other population groups in Puerto Rico. Meléndez (1991, 1998, 1999) reported a median

Table 3.

Age, CD4 Counts, TV Watching, Life Satisfaction, Leisure Time, Depression, and Body Composition by Physical Activity Group (Mean ± Standard Deviation)

Variable N Age (years) CD4 counts (cells/mm3) TV watching (hr/day) Life satisfaction (score) Leisure time (score) Beck Depression Inventory (score) Body composition Weight (kg) Height (cm) Body mass index (kg/m2) Σ Trunk skin folds (mm) Σ Limb skin folds (mm) Σ Trunk circumference (cm) Σ Limb circumference (cm)

Active Inactive (≥ 300 kcal/day) (< 300 kcal/day) 40 41.8 ± 8.1 322.0 ± 224.2 4.5 ± 2.4 25.5 ± 7.1 45.0 ± 10.8 10.6 ± 7.8

28 38.5 ± 7.6 295.5 ± 222.5 5.9 ± 2.9* 20.7 ± 8.2* 41.1 ± 9.9 12.4 ± 7.9

71.2 ± 14.1 168.3 ± 9.8 25.7 ± 4.9 61.8 ± 20.8 62.6 ± 29.3 218.7 ± 21.8

82.1 ± 19.1* 167.8 ± 11.3 29.4 ± 5.8* 75.0 ± 20.6* 68.9 ± 33.3* 241.7 ± 41.2*

79.7 ± 11.1

83.0 ± 8.8

NOTE: Trunk skin folds = subscapular, suprailiac, abdomen; Limb skin folds = biceps, triceps, thigh, calf; Trunk circumferences = neck, hip, waist; Limb circumferences = arm, thigh. *p ≤ .05 (active significantly different from not active).

score of 36.6 among 150 families randomly selected from different cities and towns in the island; 39.8 in a group of 360 retired elderly people in the San Juan metropolitan area; and 47.4 in a group of 551 undergraduate university students. Meléndez (1991) also reported that individuals with less intense and varied leisure activities were less satisfied with their lives. Although leisure activities requiring physical effort such as exercise and sports participation were included among the 29 most common leisure activities in Puerto Rico, the participants in this study seemed to prefer leisure activities that required little or no physical effort. Without the inclusion of leisure-time physical activities of at least moderate intensity, the potential cardiovascular, metabolic, and physical health benefits of leisure activities are limited. The Life Satisfaction Index mean score of 23.5 observed in this study is comparable to the score of 25.9 reported in a group of 360 retired elderly people surveyed in San Juan, Puerto Rico (Meléndez, 1991).

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The fact that participants’scores are closer to the upper limits of the instrument’s range (range = from 6 to 36) suggests that mental or emotional distress were not prevalent in this sample. Moreover, the average score on the Beck Depression Inventory (M = 11.3, SD = 7.8) suggested that depression is not widespread among the individuals in this study. These results differed from a previous study in which a cohort of Puerto Rican HIV/ AIDS patients had a score indicative of clinical depression (i.e., 17.9 ± 13.7) (Fernández et al., 1997). It is possible that employment and education status could have influenced the emotional state of study participants. The proportion of unemployed individuals in the Fernández (1997) study was higher (81% vs. 24%), and the educational level was lower (66% vs. 38% below 12th grade) than in this study. Another possible explanation for the differences in depression between Fernández et al. (1997) and this study could be related to the availability of HAART. In a recent study by Rabkin et al. (2000), a group of 173 gay and bisexual men were studied to determine the psychological effect of being on HAART. The investigators reported that during the first 2 years that HAART was made widely available, rates of depression declined. Unfortunately, drug therapy was not reported in the Fernández study. All individuals in the present study were on HAART. The minimum daily recommendation for a healthy lifestyle is 30 minutes of at least moderate intensity physical activity (U.S. Department of Health and Human Services, 1996). This amount of physical activity represents approximately 150 to 400 kcal of energy expenditure per day (American College of Sports Medicine, 2000). The participants in the present study reported an average of 1.2 hours of daily physical activity, with an average estimated energy expenditure of 291 kcal per day. This level of physical activity was higher than expected and in contradiction to the Leisure Activities Inventory data reflecting little or no physical effort. One possible explanation is that the individuals in this study overestimated physical activity. The high variability in the physical activity levels, the nature of the leisure activities reported in the present study, and the inherent inaccuracy of recall instruments to estimate daily physical activities (Montoye, Kemper, Saris, & Washurn, 1996) are three possible reasons to suspect that the amount and inten-

sity of daily physical activities were overestimated by the participants. Although the interviewers used various probes to question the reported activities, some individuals insisted on reporting hours of continuous, high intensity, occupational physical activity. It is also possible that people with chronic health conditions, like those in this study, have more difficulties discriminating between physical activities of different intensities (i.e., light, moderate, heavy, or very heavy intensity). The reported amount of time spent watching TV also suggests a possible overreporting of physical activity levels in this study. Participants reported an average of 5.5 hours per day of sitting and watching TV. This amount of TV viewing is considered excessive and an indicator of a more sedentary lifestyle. Also, too much TV viewing has been strongly correlated with obesity and depression among children and adults (Crespo et al., 2001; Kivela, 1995). Of even greater concern was that some individuals in the present study reported from 10 to 12 hours of TV watching, particularly those incapacitated or unemployed. Many of the participants in this study, particularly women, were overweight and had a BMI indicative of increased risk of obesity (American College of Sports Medicine, 2000). This lends support to the theory that physical activity was overreported in this sample. That is, individuals with high levels of energy expenditure are less likely to be obese unless the daily energy intake surpasses the daily energy expenditure. Physical activity and resting metabolic rate are the two major components of daily energy expenditure in humans. One consistent observation among HIVpositive individuals is an increase in their resting metabolic rate (Macallan et al., 1995; Paton et al., 1996) and may account for the loss of lean body mass in this population. Because all the participants in this study received nutritional counseling as part of their treatment at the AIDS Clinical Trial Unit, it is not likely that energy intake was higher than energy expenditure. However, nutrient intake was not evaluated in this study. Future studies with HIV-positive persons must include measurements of nutrient and caloric intake. The lower BMI, skin folds and circumferences, and TV-watching time in the physically active group compared to the physically inactive group represent additional cardiovascular, metabolic, and behavioral

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health benefits and a possible protection against the secondary effects of HAART. The effect of exercise in controlling fat deposition and improving psychological parameters in HIV-positive individuals has been supported by previous research studies (Evans, et al., 1998; LaPerriere et al., 1990; Neidig et al., in press; Roubenoff et al., 1999b). Different than those studies, the present study suggests that physical activity also influences positively the health status of HIV-positive males and females in Puerto Rico. This study also found no effect of physical activity on the participants’ CD4 counts, which is congruent with other research reports that used exercise as the independent variable (LaPerriere et al., 1997; Smith et al., 2001; Stringer et al., 1998). In conclusion, physical activity can positively influence the general physical and emotional well-being of people living with HIV in Puerto Rico. These findings highlight the need of a clear medical consensus regarding the recommended levels of physical activity in this population (Paton et al., 1996; Stringer et al., 1998). Programs involving physical and recreational activities should be included in all clinical, social, and community interventions designed to improve the health and quality of life of HIV-positive individuals. Future studies must consider the use of validated and objective methods to measure physical activity in HIV-positive groups, such as step counters and accelerometers. The validity and reliability of questionnaires to assess physical activity range from acceptable to good depending on the individual’s ability to recall the amount and intensity of previous physical activities. Healthy people more accurately recall the hard and very hard intensity physical activities than the moderate intensity physical activities (American College of Sports Medicine, 1997). It is possible that people with chronic and debilitating conditions are more inclined to participate in physical activities that are light to moderate intensity. If people with illness perceive the amount and intensity of physical activities differently, it is likely that they will overreport their activity levels when the available paper and pencil instruments are used. The inclusion of nutritional evaluation is extremely important to interpret possible consequences of physical activity in body composition and other health-related variables.

Nursing Implications The findings of this study have several implications for practicing nurses. First, the findings underscore that physical activity is beneficial and not harmful to HIV-positive Hispanics and is consistent with many of the U.S. Department of Health and Human Services’ Healthy People 2010 objectives (http://www. healthypeople.gov/). Second, a sedentary lifestyle in HIV-positive individuals can lead to increases in obesity and its associated health problems. The prevalence of these health problems is already high among Hispanics compared to other minority groups. Third, further studies addressing culturally appropriate interventions by advanced practice nurses aimed at reducing the time spent in sedentary activities and increasing the time spent in moderate to vigorous physical activity are needed in this population.

Acknowledgments The authors wish to thank the staff of the AIDS Clinical Trial Unit at the University of Puerto Rico, Medical Sciences Campus, for their support. The authors also thank research assistants Jessica Resto and María del Carmen Quintana and the individuals who agreed to participate in this study. Funding was provided in part by the Research Center for Minority Institutions (NIH-RCMI G12RR03641-S), the Center for HIV/AIDS Education and Research, and the Institutional Fund for Research at the University of Puerto Rico, Río Piedras Campus.

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