The effects of step-count monitoring interventions on physical activity: systematic review and meta-analysis of community-based randomised controlled trials in adults

New principles, the benefits, and practices for fostering a physically active lifestyle

The modern environment has led to an increased risk and incidence of sedentary lifestyles. When physical activity (PA) becomes insufficient, pathophysiological pathways are invoked and the future risk for chronic diseases and premature mortality increases. As a consequence, since the 1970s governmental agencies and medical societies have published guidelines to promote PA. The 2018 Guidelines for Physical Activity for Americans contain important updated guidelines, but many of these guidelines are not yet sufficiently known by the public or health providers. In addition, to make use of these guidelines, they need to be integrated with optimal behavioral interventions. Accordingly, this narrative review critically assesses five tenets that stem from the 2018 Guidelines and illustrates how these tenets can be integrated with tools and techniques for motivating individuals to initiate and maintain a more physically active lifestyle. The first tenet indicates that there is no lower threshold of PA that must be obtained before health benefits begin to accrue. Second, it is no longer required that PA be obtained in bouts of 10 min or more to "count". Bouts of lesser duration also count. Pending further study, new accelerometry data suggest that vigorous intermittent PA of just 1-2 min may also benefit health, such as that acquired by stair climbing or carrying heavy groceries. This has led to a new concept of promoting "lifestyle physical activity". Third, excessive sitting is health damaging if it is not accompanied by sufficient daily life PA or accrues over long uninterrupted bouts. Fourth, it is essential to incorporate resistance exercises for optimal health and to promote successful aging. Fifth, a wealth of new evidence indicates that PA strongly protects and promotes all aspects of brain health and may improve cognition even after a single bout of exercise.

mHealth intervention delivered in general practice to increase physical activity and reduce sedentary behaviour of patients with prediabetes and type 2 diabetes (ENERGISED): rationale and study protocol for a pragmatic randomised controlled trial

BACKGROUND

The growing number of patients with type 2 diabetes and prediabetes is a major public health concern. Physical activity is a cornerstone of diabetes management and may prevent its onset in prediabetes patients. Despite this, many patients with (pre)diabetes remain physically inactive. Primary care physicians are well-situated to deliver interventions to increase their patients' physical activity levels. However, effective and sustainable physical activity interventions for (pre)diabetes patients that can be translated into routine primary care are lacking.

METHODS

We describe the rationale and protocol for a 12-month pragmatic, multicentre, randomised, controlled trial assessing the effectiveness of an mHealth intervention delivered in general practice to increase physical activity and reduce sedentary behaviour of patients with prediabetes and type 2 diabetes (ENERGISED). Twenty-one general practices will recruit 340 patients with (pre)diabetes during routine health check-ups. Patients allocated to the active control arm will receive a Fitbit activity tracker to self-monitor their daily steps and try to achieve the recommended step goal. Patients allocated to the intervention arm will additionally receive the mHealth intervention, including the delivery of several text messages per week, with some of them delivered just in time, based on data continuously collected by the Fitbit tracker. The trial consists of two phases, each lasting six months: the lead-in phase, when the mHealth intervention will be supported with human phone counselling, and the maintenance phase, when the intervention will be fully automated. The primary outcome, average ambulatory activity (steps/day) measured by a wrist-worn accelerometer, will be assessed at the end of the maintenance phase at 12 months.

DISCUSSION

The trial has several strengths, such as the choice of active control to isolate the net effect of the intervention beyond simple self-monitoring with an activity tracker, broad eligibility criteria allowing for the inclusion of patients without a smartphone, procedures to minimise selection bias, and involvement of a relatively large number of general practices. These design choices contribute to the trial's pragmatic character and ensure that the intervention, if effective, can be translated into routine primary care practice, allowing important public health benefits.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05351359, 28/04/2022).

Wearable Activity Trackers Objectively Measure Incidental Physical Activity in Older Adults Undergoing Aortic Valve Replacement

BACKGROUND

For older adults with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR), recovery of physical function is important, yet few studies objectively measure it in real-world environments. This exploratory study explored the acceptability and feasibility of using wearable trackers to measure incidental physical activity (PA) in AS patients before and after AVR.

METHODS

Fifteen adults with severe AS wore an activity tracker at baseline, and ten at one month follow-up. Functional capacity (six-minute walk test, 6MWT) and HRQoL (SF 12) were also assessed.

RESULTS

At baseline, AS participants (n = 15, 53.3% female, mean age 82.3 ± 7.0 years) wore the tracker for four consecutive days more than 85% of the total prescribed time, this improved at follow-up. Before AVR, participants demonstrated a wide range of incidental PA (step count median 3437 per day), and functional capacity (6MWT median 272 m). Post-AVR, participants with the lowest incidental PA, functional capacity, and HRQoL at baseline had the greatest improvements within each measure; however, improvements in one measure did not translate to improvements in another.

CONCLUSION

The majority of older AS participants wore the activity trackers for the required time period before and after AVR, and the data attained were useful for understanding AS patients' physical function.

Dose-response relations between the frequency of two types of momentary feedback prompts and daily physical activity

OBJECTIVE

Self-monitoring and behavioral feedback are widely used to help people monitor progress toward daily physical activity goals. Little information exists about the optimal dosing parameters for these techniques or if they are interchangeable in digital physical activity interventions. This study used a within-person experimental design to evaluate associations between the frequency of two different prompt types (one for each technique) and daily physical activity.

METHOD

Insufficiently active young adults were assigned monthly physical activity goals and wore smartwatches with activity trackers for 3 months. They received zero to six randomly selected and timed watch-based prompts each day, with individual prompts either providing behavioral feedback or prompting the participant to self-monitor.

RESULTS

Physical activity increased significantly over the 3-month period (step counts d = 1.03; moderate-to-vigorous physical activity duration d = 0.99). Mixed linear models revealed that daily step counts were positively associated with the frequency of daily self-monitoring prompts up to approximately three prompts/day (d = 0.22) after which additional prompts provided minimal or reduced benefit. Daily step counts were not associated with the frequency of behavioral feedback prompts. Daily moderate-to-vigorous physical activity was not associated with the frequency of either prompt.

CONCLUSIONS

Self-monitoring and behavioral feedback are not interchangeable behavior change techniques in digital physical activity interventions, and only self-monitoring prompts show signs of a dose-response association with physical activity volume. Activity trackers, such as smartwatches and mobile apps, should provide an option to replace behavioral feedback prompts with self-monitoring prompts to promote physical activity among insufficiently active young adults. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Exercise, diet, and sleep habits of nurses working full-time during the COVID-19 pandemic: An observational study

BACKGROUND

Healthy diet, exercise, and sleep practices may mitigate stress and prevent illness. However, lifestyle behaviors of acute care nurses working during stressful COVID-19 surges are unclear.

PURPOSE

To quantify sleep, diet, and exercise practices of 12-hour acute care nurses working day or night shift during COVID-19-related surges.

METHODS

Nurses across 10 hospitals in the United States wore wrist actigraphs and pedometers to quantify sleep and steps and completed electronic diaries documenting diet over 7-days.

FINDINGS

Participant average sleep quantity did not meet national recommendations; night shift nurses (n = 23) slept significantly less before on-duty days when compared to day shift nurses (n = 34). Proportionally more night shift nurses did not meet daily step recommendations. Diet quality was low on average among participants.

DISCUSSION

Nurses, especially those on night shift, may require resources to support healthy sleep hygiene, physical activity practices, and diet quality to mitigate stressful work environments.

Short-term outcomes of physical activity counseling in in-patients with Major Depressive Disorder: Results from the PACINPAT randomized controlled trial

Introduction

A physical activity counseling intervention based on a motivation-volition model was developed and delivered to in-patients with Major Depressive Disorders with the aim of increasing lifestyle physical activity. The aim of this study is to evaluate the short-term outcomes of this intervention.

Methods

A multi-center randomized controlled trial was conducted in four Swiss psychiatric clinics. Adults who were initially insufficiently physically active and were diagnosed with Major Depressive Disorder according to ICD-10 were recruited. The sample consisted of 113 participants in the intervention group (M age = 42 years, 56% women) and 107 in the control group (M age = 40 years, 49% women). Motivation and volition determinants of physical activity were assessed with questionnaires. Implicit attitudes were assessed with an Implicit Association Test. Physical activity was self-reported and measured with hip-worn accelerometers over 7 consecutive days starting on the day following the data collection.

Results

According to accelerometer measures, step count decreased on average 1,323 steps less per day (95% CI = -2,215 to -431, p < 0.01) over time in the intervention group compared to the control group. A trend was recognized indicating that moderate-to-vigorous physical activity decreased on average 8.37 min less per day (95% CI = -16.98 to 0.23, p < 0.06) over time in the intervention group compared to the control group. The initial phase of the intervention does not seem to have affected motivational and volitional determinants of and implicit attitudes toward physical activity.

Conclusion

Physical activity counseling may be considered an important factor in the transition from in-patient treatment. Methods to optimize the intervention during this period could be further explored to fulfill the potential of this opportunity.

Clinical trial registration

https://www.isrctn.com/ISRCTN10469580, identifier ISRCTN10469580.

Acceptable, useful, and ineffective? Recent retirees’ experiences of a 12-month activity tracker-based physical activity intervention

Objective

Activity trackers appear cost-effective and acceptable intervention tools for promoting physical activity among older adults, particularly in the short-term. However, long-term studies focused on participants’ experiences continue to be scarce. This study evaluated participants’ experiences of a 12-month activity tracker-driven physical activity intervention.

Methods

Participants’ experiences were assessed qualitatively using open-ended questionnaire items ( n = 113) and semi-structured interviews conducted after the 12-month intervention ( n = 27). Quantitative items assessed the perceived ease-of-use and usefulness of the activity tracker during the intervention. Qualitative data was analyzed using thematic analysis and Wilcoxon signed-rank tests were used to examine changes in the perceived ease-of-use and usefulness over time.

Results

The 113 participants completing the 12-month intervention were on average 65.2 ( SD 1.0) years old and 81.4% women with 92.3% providing activity tracker data on at least 2 weeks per each intervention month. In the qualitative analysis, four main themes with 20 subthemes were identified: (a) burdens of participation, (b) affective attitudes of using the activity tracker, (c) perceived effects of using the activity tracker, and (d) no perceived behavioral effects. At 12 months, the participants found activity trackers mainly easy to use (mean 4.6, SD 0.6), reliable (mean 3.6, SD 1.2), motivating (mean 3.9, SD 1.0), and helpful in reducing sitting (mean 3.7, SD 1.0) with no changes observed during the intervention.

Conclusions

The participants’ experiences were highly varied suggesting that tailored intervention designs are likely to be required for effectively using activity trackers to promote long-term changes in daily activity among older adults.

Change in Daily Steps and Self-efficacy of Online Interactive Exercise Classes for Community-dwelling Older Adults in Japan: A Preliminary Study

Aims

This study aimed to (1) examine the feasibility of an online interactive exercise class for community-dwelling older adults and (2) preliminarily examine changes in physical activity and self-efficacy.

Methods

Participants were 25 community-dwelling older adults aged 65 years or older, but due to 5 dropouts, the final number of participants for analysis was 20 (mean age 76.9 ± 5.7 years). The intervention program was conducted for 40 minutes each session, twice a week for four consecutive weeks, using the LINE group call (LINE Corporation, Japan). An online questionnaire was used to assess participant characteristics, modified Fall Efficacy Scale score, modified Gait Efficacy Scale (m-GES) score, self-rated health, and daily steps, which were compared pre- and post-intervention using the Wilcoxon signed-rank sum and chi-square tests.

Results

The Wilcoxon signed-rank sum test showed significant improvement in the m-GES score and daily steps. The chi-square test showed that self-rated health was significantly greater in the maintenance/increase group.

Conclusions

Online interactive exercise classes are feasible for community-dwelling older individuals. These results also suggest the possibility of using telehealth to improve physical activity and self-efficacy.

Increasing physical activity in severe asthma: a systematic review and meta-analysis

INTRODUCTION

Physical inactivity is common in asthma and is recognised as an important modifiable risk for poor clinical outcomes such as impaired asthma control and health-related quality of life (HRQoL). Despite evidence supporting the role of physical activity in reducing the risk of these outcomes, little is known about optimal interventions for increasing physical activity in those with severe disease. This systematic review and meta-analysis evaluates the effectiveness of interventions in increasing physical activity in severe asthma.

METHODS

MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Embase, PubMed, Informit, SPORTDiscus and Cochrane databases were searched up to September 2021 for physical activity-based intervention studies that assessed physical activity outcomes (e.g. steps per day, time spent undertaking physical activity) in adults with severe asthma. Data on asthma-related (e.g. asthma control) and health-related outcomes (e.g. HRQoL) were assessed as secondary outcomes. The revised Cochrane Risk of Bias tool was used to assess risk of bias. Random-effects meta-analyses synthesised data where possible.

RESULTS

Four randomised controlled trials (all 12 weeks in duration) including 176 adults with moderate-to-severe asthma were included. An increase in physical activity was reported with a moderate-vigorous intensity aerobic and resistance training intervention (steps per day and time spent undertaking physical activity), and an unsupervised pedometer-based intervention (steps per day). Meta-analyses showed that physical activity interventions had an overall positive effect on steps per day (mean difference (MD) 1588, 95% CI 399-2778; p=0.009, I2=23), asthma control (MD -0.65, 95% CI -0.95--0.35; p<0.0001, I2=0%) and HRQoL (MD 0.56, 95% CI 0.10-1.01; p=0.02, I2=16%) compared to control.

CONCLUSION

While there is some evidence supporting the effectiveness of interventions in improving physical activity in adults with severe asthma, higher-quality, large-scale studies of longer duration are needed to determine the optimal intervention.

Beneficial effects of walking-based home program for improving cardio-respiratory performance and physical activity in sarcopenic older people: a randomized controlled trial

BACKGROUND

Sarcopenia is an age-related loss of muscle mass, decline in physical performance, and/or loss of muscle strength. Improving physical activity (PA) is associated with a reduced risk of sarcopenia. Additionally, the World Health Organization 2020 guidelines recommend 150 minutes/week of moderate-intensity or 75 minutes/week of vigorous PA plus resistance exercise twice a week. An increase in walking steps/day also enhances PA.

AIM

The study explored the benefits of a pedometer-based walking program plus a resistance exercise program in older adults with sarcopenia.

DESIGN

A randomized control trial.

SETTING

In community dwelling.

POPULATION

Older individuals with sarcopenia.

METHODS

Screening for sarcopenia was defined according to the Asian Working Group of Sarcopenia criteria in 2019, which is composed of the skeletal muscle mass index (SMI), muscle strength, and physical performance. Bioimpedance analysis, handgrip strength, and gait speed were measured for the SMI, muscle strength, and physical performance, respectively. to explore the effectiveness of a pedometer-based walking program plus TheraBand resistance exercise over 12 weeks. The intervention group was required to wear a pedometer and walk 7 500 steps/day for 5 days/week and perform the TheraBand resistance exercise twice a week, while the control group continued their routine daily activities. Respiratory muscle strength, functional capacity (i.e., 6-minute walk test), and PA were assessed before and after the 12-week program. To evaluate the benefits of the home-based walking program plus resistance exercise, two-way mixed ANOVAs were performed.

RESULTS

Sixty older individuals with sarcopenia aged ≥60 years were enrolled; however, a total of 57 older adults (28 in the invention group and 29 in the control group) completed the study. Inspiratory muscle strength, functional capacity, and PA increased between and within groups after the 12-week program (all P<0.05). Furthermore, muscle strength and physical performance improved in the intervention group after the 12-week program but not in the control group.

CONCLUSIONS

A pedometer-based intervention program with TheraBand resistance exercise could improve cardio-respiratory performance and PA among older Thai individuals with sarcopenia. Further study needs to consider type of exercise and dietary supplements.

CLINICAL REHABILITATION IMPACT

Increasing the number of steps walked per day may reduce the risk of developing sarcopenia in older people.

Understanding super engaged users in the 10,000 Steps online physical activity program: A qualitative study

Objective

Sustained engagement with Internet-based behavioural interventions is crucial to achieve successful behaviour change outcomes. As this has been problematic in many interventions, a lot of research has focused on participants with little or no engagement. However, few studies have attempted to understand users with continuous long-term engagement, the so called ‘super engaged users’, and why they keep on using programs when everybody else has long stopped. Therefore, the aim of this research was to qualitatively examine characteristics, usage profile and motivations of super engaged users in the 10,000 Steps program.

Methods

Twenty 10,000 Steps users (10 with more than 1 year of engagement, and 10 with more than 10 years of engagement) participated in semi-structured interviews, that were transcribed and thematically analysed.

Results

Participants were aged 60 years on average, with more than half being overweight/obese and/or suffering from chronic disease despite logging high step counts (219 million steps per participant on average) on the 10,000 Steps platform. Participants indicated that the reasons for sustained use were that engaging the program had become a habit, that the program kept them motivated, and that it was easy to use. Few participants had suggestions for improvement or expressed there were program elements they did not like. Uptake of program innovations (e.g., app-version, use of advanced activity tracker instead of pedometer) was modest among the super engaged users.

Conclusion

The findings from this study emphasise the need for digital health programs to incorporate features that will support the development of habits as soon as participants start to engage with the program. While a program’s usability, user-friendliness and acceptability are important to engage and retain new users, habit formation may be more important for sustained long-term engagement with the behaviour and the program.

Adherence and retention to the self-managed community-based Step Into Health program in Qatar (2012-2019)

Purpose

Investigate adherence and retention to the "Step Into Health (SIH)" initiative (www.stepintohealth.qa [website access only available from within the State of Qatar]), a Qatari self-managed community-based health program, from 2012 to 2019.

Methods

Participants (16,711; 16-80 years; 37% females, 34% Qatari) used a pedometer or smartphone application (app) to measure step count. Absolute adherence (ADH) and retention (RET) were calculated, with ADH (%) the ratio between number of days data and SIH enrollment length (RET). Linear Mixed Models identified differences in ADH between RET groups, main effects (i.e., sex, device, age, BMI, nationality) and interaction effects for ADH (RET entered as a covariate).

Results

Average ADH and RET to SIH (irrespective of sex, age, device and BMI) was 50% (±31%), and 16% (±20%), respectively, with ADH differing significantly between RET groups (F = 460.2, p < 0.001). RET (as a covariate) revealed a significant main effect for device (F = 12.00, p < 0.001) and age (F = 4.31, p = 0.001) on ADH observed. There was a significant association between RET and sex (p < 0.001), device (p < 0.001), and age groups 16-25 y (p < 0.001), and 26-35 y (p < 0.001). There were no significant main effects for sex or BMI on ADH, and no interaction effects (p ≥ 0.21) observed.

Conclusions

Follow-up data (e.g., interviews, focus groups, etc.) determining why differences in ADH and RET are observed appears prudent. To convert those that lapsed and/or abandoned SIH/PA into committed long-term PA adherers. This would be a first step to develop targeted public health promotions and initiatives to enhance health outcomes at a population level.

Do physical activity interventions combining self-monitoring with other components provide an additional benefit compared with self-monitoring alone? A systematic review and meta-analysis

Objective

To determine the net effect of different physical activity intervention components on step counts in addition to self-monitoring.

Design

A systematic review with meta-analysis and meta-regression.

Data sources

Five databases (PubMed, Scopus, Web of Science, ProQuest and Discus) were searched from inception to May 2022. The database search was complemented with backward and forward citation searches and search of the references from relevant systematic reviews.

Eligibility criteria

Randomised controlled trials comparing an intervention using self-monitoring (active control arm) with an intervention comprising the same treatment PLUS any additional component (intervention arm).

Data extraction and synthesis

The effect measures were mean differences in daily step count. Meta-analyses were performed using random-effects models, and effect moderators were explored using univariate and multivariate meta-regression models.

Results

Eighty-five studies with 12 057 participants were identified, with 75 studies included in the meta-analysis at postintervention and 24 at follow-up. At postintervention, the mean difference between the intervention and active control arms was 926 steps/day (95% CI 651 to 1201). At a follow-up, the mean difference was 413 steps/day (95% CI 210 to 615). Interventions with a prescribed goal and involving human counselling, particularly via phone/video calls, were associated with a greater mean difference in the daily step count than interventions with added print materials, websites, smartphone apps or incentives.

Conclusion

Physical activity interventions that combine self-monitoring with other components provide an additional modest yet sustained increase in step count compared with self-monitoring alone. Some forms of counselling, particularly remote phone/video counselling, outperformed other intervention components, such as websites and smartphone apps.

PROSPERO registered number

CRD42020199482.

Feasibility, acceptability, and fidelity of Physical Activity Routines After Stroke (PARAS): a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community-dwelling adult stroke survivors

BACKGROUND

Low levels of habitual physical activity and high levels of sedentary behaviour are commonly observed post-stroke. We aimed to assess the feasibility, acceptability and fidelity of a multifaceted, theory- and evidence-informed supported self-management intervention targeting physical activity and sedentary behaviour after stroke: Physical Activity Routines After Stroke (PARAS).

METHODS

Adult stroke survivors and healthcare professionals were recruited from North East England stroke services. Stroke survivor physical activity and sedentary behaviour were targeted by a self-management behavioural intervention supported by healthcare professionals trained in intervention delivery. The main outcomes were protocol and intervention acceptability and feasibility and fidelity of intervention delivery.

RESULTS

Eleven healthcare professionals (9 physiotherapists; 2 occupational therapists) participated in the study. Stroke survivor recruitment was lower than anticipated (19 versus target of up to 35). The healthcare professional training programme was feasible, with fidelity assessment of delivery supporting this finding. Data completeness was acceptable according to a priori criteria (>60%), except for stroke survivor questionnaire return rate (59%) and interview uptake (52%). No serious adverse events occurred. Healthcare professionals and stroke survivors perceived intervention delivery to be feasible and acceptable with minor modifications highlighted including the potential for earlier delivery in the stroke pathway.

CONCLUSIONS

The study protocol and intervention delivery were feasible and acceptable to stroke survivors and healthcare professionals with modifications required before large-scale evaluation.

TRIAL REGISTRATION

ISRCTN35516780 . Registered on October 24, 2018.

Feasibility and Acceptability of an Active Video Game-Based Physical Activity Support Group (Pink Warrior) for Survivors of Breast Cancer: Randomized Controlled Pilot Trial

BACKGROUND

Survivors of breast cancer with functional limitations have a 40% higher mortality rate than those without. Despite the known benefits of physical activity (PA), <40% of survivors of breast cancer meet the recommendations for PA. The combination of active video games (AVGs) and group-based PA counseling may hold potential for motivating PA adoption and improving physical function. However, this method has not been widely studied in survivors of breast cancer.

OBJECTIVE

We aimed to determine the feasibility and acceptability of a group AVG-based multicomponent PA intervention and estimate its effect size and variability on PA and physical function in female survivors of breast cancer in a clinic setting.

METHODS

Female survivors of breast cancer (N=60) were recruited through the clinic and randomly assigned to the intervention group (12 weekly sessions) or the control group (existing support group). The intervention group received game-based pedometers and participated in weekly group AVG sessions, PA behavioral coaching, and survivorship navigation discussions. A participant manual with weekly reflection worksheets was provided to reinforce the coaching lessons and promote self-led PA. The control group received conventional pedometers and participated in an existing breast cancer support group. Feasibility was assessed by enrollment rate (≥50%), retention rate (≥80%), group attendance rate (75% attending ≥9 sessions [intervention group]), and the number of technological issues and adverse events. Acceptability was measured by participants' attitudes (from strongly disagree=1 to strongly agree=5) toward the use of AVGs and the overall program. The outcomes included PA (accelerometers) and physical function (Short Physical Performance Battery and gait speed). Analysis of covariance was used to determine differences in PA and physical function between the groups. The Cohen d and its 95% CI determined the effect size and variability, respectively. All the analyses followed the intention-to-treat principle.

RESULTS

Participants were an average of 57.4 (SD 10.5) years old, 70% (42/60) White, and 58% (35/60) off treatment. The enrollment rate was 55.9% (66/118). Despite substantial long-term hurricane-related disruptions, we achieved an 80% (48/60) retention. The intervention group's attendance rate was 78% (14/18), whereas the control group's attendance rate was 53% (9/17). Of the 26 game-based pedometers, 3 (12%) were damaged or lost. No study-related adverse events occurred. Acceptability items were highly rated. Steps (β=1621.64; P=.01; d=0.72), Short Physical Performance Battery (β=.47; P=.01; d=0.25), and gait speed (β=.12; P=.004; d=0.48) had a significant intervention effect.

CONCLUSIONS

The intervention was feasible and acceptable in this population despite the occurrence of a natural disaster. Pilot results indicate that group AVG sessions, PA coaching, and survivorship navigation produced moderate effects on PA and physical functioning. AVGs with PA counseling can potentially be used in existing breast cancer support groups to encourage PA and improve physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02750241; https://clinicaltrials.gov/ct2/show/NCT02750241.

Effectiveness of wearable activity trackers to increase physical activity and improve health: a systematic review of systematic reviews and meta-analyses

Wearable activity trackers offer an appealing, low-cost tool to address physical inactivity. This systematic review of systematic reviews and meta-analyses (umbrella review) aimed to examine the effectiveness of activity trackers for improving physical activity and related physiological and psychosocial outcomes in clinical and non-clinical populations. Seven databases (Embase, MEDLINE, Ovid Emcare, Scopus, SPORTDiscus, the Cochrane Library, and Web of Science) were searched from database inception to April 8, 2021. Systematic reviews of primary studies using activity trackers as interventions and reporting physical activity, physiological, or psychosocial outcomes were eligible for inclusion. In total, 39 systematic reviews and meta-analyses were identified, reporting results from 163 992 participants spanning all age groups, from both healthy and clinical populations. Taken together, the meta-analyses suggested activity trackers improved physical activity (standardised mean difference [SMD] 0·3-0·6), body composition (SMD 0·7-2·0), and fitness (SMD 0·3), equating to approximately 1800 extra steps per day, 40 min per day more walking, and reductions of approximately 1 kg in bodyweight. Effects for other physiological (blood pressure, cholesterol, and glycosylated haemoglobin) and psychosocial (quality of life and pain) outcomes were typically small and often non-significant. Activity trackers appear to be effective at increasing physical activity in a variety of age groups and clinical and non-clinical populations. The benefit is clinically important and is sustained over time. Based on the studies evaluated, there is sufficient evidence to recommend the use of activity trackers.

Can Digital Health Solutions Fill in the Gap for Effective Guideline Implementation in Cardiovascular Disease Prevention: Hope or Hype?

PURPOSE OF REVIEW

To evaluate the use of digital health solutions in improving the implementation of cardiovascular disease (CVD) prevention guidelines and review current evidence supporting it.

RECENT FINDINGS

Healthy diet guideline recommendations can be improved by text-messaging programs and apps for reinforcing healthy food intake and reducing unhealthy nutrients purchase and consumption. Wearable activity trackers are also effective in increasing physical activity levels. Text-messaging programs for smoking cessation have demonstrated benefits in increasing quitting rates; however, evidence on smartphone apps for smoking cessation is still lacking. Smartphone apps have the potential to improve medication adherence; however, better quality evidence is needed. Digital pills are another promising digital solution to improve medication adherence. The use of digital health solutions in CVD prevention is an evolving field and, to date, there is an increasing body of evidence that supports that such technologies are effective in improving CVD prevention guideline implementation.

Breast Cancer Physical Activity Mobile Intervention: Early Findings From a User Experience and Acceptability Mixed Methods Study

BACKGROUND

Physical activity (PA) is the most well-established lifestyle factor associated with breast cancer (BC) survival. Even women with advanced BC may benefit from moderate PA. However, most BC symptoms and treatment side effects are barriers to PA. Mobile health coaching systems can implement functionalities and features based on behavioral change theories to promote healthier behaviors. However, to increase its acceptability among women with BC, it is essential that these digital persuasive systems are designed considering their contextual characteristics, needs, and preferences.

OBJECTIVE

This study aimed to examine the potential acceptability and feasibility of a mobile-based intervention to promote PA in patients with BC; assess usability and other aspects of the user experience; and identify key considerations and aspects for future improvements, which may help increase and sustain acceptability and engagement.

METHODS

A mixed methods case series evaluation of usability and acceptability was conducted in this study. The study comprised 3 sessions: initial, home, and final sessions. Two standardized scales were used: the Satisfaction with Life Scale and the International Physical Activity Questionnaire-Short Form. Participants were asked to use the app at home for approximately 2 weeks. App use and PA data were collected from the app and stored on a secure server during this period. In the final session, the participants filled in 2 app evaluation scales and took part in a short individual interview. They also completed the System Usability Scale and the user version of the Mobile App Rating Scale. Participants were provided with a waist pocket, wired in-ear headphones, and a smartphone. They also received printed instructions. A content analysis of the qualitative data collected in the interviews was conducted iteratively, ensuring that no critical information was overlooked.

RESULTS

The International Physical Activity Questionnaire-Short Form found that all participants (n=4) were moderately active; however, half of them did not reach the recommended levels in the guidelines. System Usability Scale scores were all >70 out of 100 (72.5, 77.5, 95, and 80), whereas the overall user version of the Mobile App Rating Scale scores were 4, 4.3, 4.4, and 3.6 out of 5. The app was perceived to be nice, user-friendly, straightforward, and easy to understand. Recognition of achievements, the possibility of checking activity history, and the rescheduling option were positively highlighted. Technical difficulties with system data collection, particularly with the miscount of steps, could make users feel frustrated. The participants suggested improvements and indicated that the app has the potential to work well for survivors of BC.

CONCLUSIONS

Early results presented in this study point to the potential of this tool concept to provide a friendly and satisfying coaching experience to users, which may help improve PA adherence in survivors of BC.

Evaluation of a Population-Wide Mobile Health Physical Activity Program in 696 907 Adults in Singapore

Background

Evidence of scaled‐up physical activity interventions is scarce. This study evaluates the uptake, engagement, and effectiveness of one such intervention program.

Methods and Results

The program was open to individuals aged ≥17 years in Singapore. The main intervention components comprised device‐based daily physical activity recording paired with step count goals and financial rewards. According to the different reward opportunities, we divided the evaluation period (August 2017 to June 2018) into the baseline monitoring phase, the main challenge phase, and the maintenance phase. Uptake was assessed by the number of individuals registered, and engagement by the step recording duration after registration. The effectiveness was defined as changes in mean daily step count from baseline to the main challenge phase and the maintenance phase. A total of 696 907 participants registered, including more Singapore citizens (versus noncitizens), women, and younger (aged 17–39 years) individuals. The evaluation of engagement and effectiveness included 421 388 (60.5%) participants who provided plausible characteristic information and step count data. The median duration of engagement was 74 (IQR, 14–149) days. Compared with the baseline of 7509 (SD, 3467) steps, mean daily step count increased by 1579 (95% CI, 1564–1594) steps during the main challenge phase and 934 (95% CI, 916–952) steps during the maintenance phase. Greater engagement and activity increase were found in participants who are citizens, women, aged ≥40 years, non‐obese, and using separate wearables (versus smartphones).

Conclusions

Mobile health physical activity interventions can successfully reach a large population and be effective in increasing physical activity, despite declining program engagement over time.

A Clinician's Guide to Smartwatch "Interrogation"

Purpose of Review

Wearable technology is rapidly evolving and the data that it can provide regarding an individual’s health is becoming increasingly important for clinicians to consider. The purpose of this review is to help inform health care providers of the benefits of smartwatch interrogation, with a focus on reviewing the various parameters and how to apply the data in a meaningful way.

Recent Findings

This review details interpretation of various parameters found commonly in newer smartwatches such as heart rate, step count, ECG, heart rate recovery (HRR), and heart rate variability (HRV), while also discussing potential pitfalls that a clinician should be aware of.

Summary

Smartwatch interrogation is becoming increasingly relevant as the continuous data it provides helps health care providers make more informed decisions regarding diagnosis and treatment. For this reason, we recommend health care providers familiarize themselves with the technology and integrate it into clinical practice.

Associations of steps per day and step intensity with the risk of diabetes: the Hispanic Community Health Study / Study of Latinos (HCHS/SOL)

BACKGROUND

Higher levels of moderate-to-vigorous physical activity have been associated with a lower risk of diabetes, but less is known about how daily step counts (steps/day) are associated with diabetes risk. Therefore, we examined the association of steps/day and step intensity with incident diabetes.

METHODS

We included 6634 adults from the population-based prospective cohort Hispanic Community Health Study/Study of Latinos (HCHS/SOL) (2008-2017). Cox proportional hazard models that accounted for complex survey design and sampling weights were used to estimate the association of baseline accelerometer-assessed steps/day and step intensity with 6-year risk of incident diabetes as hazard ratios (HR) and 95% confidence intervals (CI). We further examined whether the percent of intense steps at a given accumulation of steps/day was associated with diabetes risk, and if associations were modified by specific cohort characteristics.

RESULTS

The average age of cohort members was 39 years and 52% were female. Adults had an average of 8164 steps/day and spent 12 min/day in brisk ambulation (> 100 steps/min). Over 6 years of follow-up, there were 1115 cases of diabetes. There was a suggestive lower risk of diabetes with more steps/day- adults had a 2% lower risk per 1000 steps/day (HR = 0.98 (95% CI 0.95, 1.00)). Inverse associations between average steps/day and diabetes incidence were observed across many cohort characteristics, but most importantly among adults at high risk for diabetes - those who were older, or had obesity or prediabetes. Adults who accumulated 17 min/day in brisk ambulation compared to < 2 min/day had a 31% lower risk of diabetes (HR = 0.69 (95% CI 0.53, 0.89)). A greater percent of intense steps for a given accumulation of steps/day was associated with further risk reduction.

CONCLUSION

Adults who accumulate more daily steps may have a lower risk of diabetes. Accumulating more steps/day and greater step intensity appear to be important targets for preventing diabetes.

mHealth interventions targeting movement behaviors in Asia: A scoping review

mHealth interventions can promote healthy movement behaviors (physical activity, sedentary behavior, and sleep). However, recent reviews include few studies from Asia, despite it being home to over 60% of the world population. The aim is to map the current evidence for mHealth interventions targeting movement behaviors in Asia. Six databases were searched up until August 2021. Included studies described an mHealth intervention targeting one or more movement behaviors, delivered in a country/territory in Asia, to a general population. A total of 3986 unique records were screened for eligibility in duplicate. Eighty studies with 1,413,652 participants were included. Most were randomized (38.8%) or quasi-experimental (27.5%) trials. Studies were from 17 countries/territories (out of 55); majority were high- (65.0%) or upper middle-income (28.7%). Physical activity was targeted most often (93.8%), few targeted sedentary behavior (7.5%), or sleep (8.8%). Most targeted one movement behavior (90.0%), and none targeted all three together. Interventions typically incorporated a single mHealth component (70.0%; app, pedometer, text messages, wearable) and were delivered remotely (66.3%). The average intervention length was 121.8 (SD 127.6) days. mHealth interventions in Asia have primarily targeted physical activity in high- and upper middle-income countries. There are few interventions targeting sedentary behavior or sleep, and no interventions in low-income countries.

Variability in Physical Inactivity Responses of University Students during COVID-19 Pandemic: A Monitoring of Daily Step Counts Using a Smartphone Application

This study investigated the changes in physical inactivity of university students during the COVID-19 pandemic, with reference to their academic calendar. We used the daily step counts recorded by a smartphone application (iPhone Health App) from April 2020 to January 2021 (287 days) for 603 participants. The data for 287 days were divided into five periods based on their academic calendar. The median value of daily step counts across each period was calculated. A k-means clustering analysis was performed to classify the 603 participants into subgroups to demonstrate the variability in the physical inactivity responses. The median daily step counts, with a 7-day moving average, dramatically decreased from 5000 to 2000 steps/day in early April. It remained at a lower level (less than 2000 steps/day) during the first semester, then increased to more than 5000 steps/day at the start of summer vacation. The clustering analysis demonstrated the variability in physical inactivity responses. The inactive students did not recover daily step counts throughout the year. Consequently, promoting physical activity is recommended for inactive university students over the course of the whole semester.

Effectiveness of physical activity monitors in adults: systematic review and meta-analysis

OBJECTIVE

To estimate the effectiveness of physical activity monitor (PAM) based interventions among adults and explore reasons for the heterogeneity.

DESIGN

Systematic review and meta-analysis.

STUDY SELECTION

The electronic databases MEDLINE, Embase, SPORTDiscus, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched on 4 June 2021. Eligible randomised controlled trials compared interventions in which adults received feedback from PAMs with control interventions in which no feedback was provided. No restrictions on type of outcome measurement, publication date, or language were applied.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were used to synthesise the results. The certainty of evidence was rated by the Grading of Recommendations Assessment and Evaluation (GRADE) approach.

MAIN OUTCOME MEASURES

The three primary outcomes of interest were physical activity, moderate to vigorous physical activity, and sedentary time.

RESULTS

121 randomised controlled trials with 141 study comparisons, including 16 743 participants, were included. The PAM based interventions showed a moderate effect (standardised mean difference 0.42, 95% confidence interval 0.28 to 0.55) on physical activity, equivalent to 1235 daily steps; a small effect (0.23, 0.16 to 0.30) on moderate to vigorous physical activity, equivalent to 48.5 weekly minutes; and a small insignificant effect (-0.12, -0.25 to 0.01) on sedentary time, equal to 9.9 daily minutes. All outcomes favoured the PAM interventions.

CONCLUSIONS

The certainty of evidence was low for the effect of PAM based interventions on physical activity and moderate for moderate to vigorous physical activity and sedentary time. PAM based interventions are safe and effectively increase physical activity and moderate to vigorous physical activity. The effect on physical activity and moderate to vigorous physical activity is well established but might be overestimated owing to publication bias.

STUDY REGISTRATION

PROSPERO CRD42018102719.

Change in Objectively Measured Activity Levels Resulting from the EMPOWER Study Lifestyle Intervention

Purpose

To examine changes in physical activity (PA) during a behavioral weight-loss intervention and determine baseline factors associated with PA goal achievement.

Methods

Overweight/obese community-dwelling adults with valid PA accelerometer data (N=116; mean age 51.7 years; 89% female; 83% non-Hispanic White) were recruited into a single-arm prospective cohort study examining the effects of a 12-month intervention that included 24 in-person group sessions, weight-loss, calorie, fat gram, and PA goals, self-monitoring, and feedback. Minutes of moderate-to-vigorous (MV) PA and steps were measured using a waist-worn accelerometer (ActiGraph GT3x) at baseline, 6 months, and 12 months. Achievement of the 150 minute/week MVPA goal was examined using total minutes and bout minutes (i.e., counting only PA occurring in bouts ≥10 minutes in length). Change in PA was analyzed using non-parametric tests for multiple comparisons. Associations of factors with meeting the PA goal were modeled using binary logistic regression.

Results

At 6 months, there were increases from baseline in MVPA (median [p25, p75]: 5.3 [-0.9, 17.6] minutes/day) and steps (863 [-145, 2790] steps/day), both p<0.001. At 12 months, improvements were attenuated (MVPA: 2.4 [-2.0, 11.4] minutes/day, p=0.047; steps: 374[-570, 1804] p=0.14). At 6 months, 33.6% of individuals met the PA goal (using total or bout minutes). At 12 months, the percent meeting the goal using total MVPA [31%] differed from bout MVPA [22.4%]. Male gender (OR=4.14, p=0.027) and an autumn program start (versus winter; OR=3.39, p=0.011) were associated with greater odds of goal achievement at 6 months.

Conclusions

The intervention increased PA goal achievement at 6 and 12 months with many making clinically meaningful improvements. Our results suggest female participants may require extra support toward improving PA levels.

Resident physicians physical activity during on-call shifts: smartphone-based assessment

BACKGROUND

Physical activity of resident physicians (RPs) during on-call shifts is difficult to objectively evaluate. The integration of smartphones in our daily routines may allow quantitative assessment, employing pedometric assessment.

AIMS

To evaluate the number of steps that RPs walk during on-call shifts as a marker of physical activity by using smartphone-based pedometers.

METHODS

Step counts were collected from 100 RPs' smartphones who volunteered to participate in the study between January 2018 and May 2019. The conversion rate was 1400 steps = 1 km (application's default). A shift was defined as regular morning work followed by an in-house on-call stay, totalling 26 hours. Statistical analyses included univariate and multivariate linear mixed models, and Fisher exact test. A P-value < 0.05 was considered statistically significant.

RESULTS

The average walking distance was 12 118 steps (8.6 km/RP/shift). Paediatric intensive care unit and neurosurgery residents recorded the longest walking distances 16 347 and 15 630 steps (11.67 and 11.16 km/shift), respectively. Radiology residents walked the shortest distances 4718 steps (3.37 km/shift). Physically active RPs walked significantly longer distances during their shifts than non-physically active RPs: 12 527 steps versus 11 384 steps (8.95 versus 8.13 km/shift, P < 0.05), respectively. Distances covered during weekday shifts were longer than weekend shifts: 12 092 steps versus 11 570 steps (8.63 versus 8.26 km/shift, P < 0.05), respectively.

CONCLUSIONS

Smartphone-based pedometers can aid in analysing physical activity and workload during on-call shifts; such information can be valuable for human resource department, occupational health authorities and medical students with impaired physical mobility when choosing a speciality.

Feasibility, Usability, and Effectiveness of a Machine Learning-Based Physical Activity Chatbot: Quasi-Experimental Study

BACKGROUND

Behavioral eHealth and mobile health interventions have been moderately successful in increasing physical activity, although opportunities for further improvement remain to be discussed. Chatbots equipped with natural language processing can interact and engage with users and help continuously monitor physical activity by using data from wearable sensors and smartphones. However, a limited number of studies have evaluated the effectiveness of chatbot interventions on physical activity.

OBJECTIVE

This study aims to investigate the feasibility, usability, and effectiveness of a machine learning-based physical activity chatbot.

METHODS

A quasi-experimental design without a control group was conducted with outcomes evaluated at baseline and 6 weeks. Participants wore a Fitbit Flex 1 (Fitbit LLC) and connected to the chatbot via the Messenger app. The chatbot provided daily updates on the physical activity level for self-monitoring, sent out daily motivational messages in relation to goal achievement, and automatically adjusted the daily goals based on physical activity levels in the last 7 days. When requested by the participants, the chatbot also provided sources of information on the benefits of physical activity, sent general motivational messages, and checked participants' activity history (ie, the step counts/min that were achieved on any day). Information about usability and acceptability was self-reported. The main outcomes were daily step counts recorded by the Fitbit and self-reported physical activity.

RESULTS

Among 116 participants, 95 (81.9%) were female, 85 (73.3%) were in a relationship, 101 (87.1%) were White, and 82 (70.7%) were full-time workers. Their average age was 49.1 (SD 9.3) years with an average BMI of 32.5 (SD 8.0) kg/m2. Most experienced technical issues were due to an unexpected change in Facebook policy (93/113, 82.3%). Most of the participants scored the usability of the chatbot (101/113, 89.4%) and the Fitbit (99/113, 87.6%) as at least "OK." About one-third (40/113, 35.4%) would continue to use the chatbot in the future, and 53.1% (60/113) agreed that the chatbot helped them become more active. On average, 6.7 (SD 7.0) messages/week were sent to the chatbot and 5.1 (SD 7.4) min/day were spent using the chatbot. At follow-up, participants recorded more steps (increase of 627, 95% CI 219-1035 steps/day) and total physical activity (increase of 154.2 min/week; 3.58 times higher at follow-up; 95% CI 2.28-5.63). Participants were also more likely to meet the physical activity guidelines (odds ratio 6.37, 95% CI 3.31-12.27) at follow-up.

CONCLUSIONS

The machine learning-based physical activity chatbot was able to significantly increase participants' physical activity and was moderately accepted by the participants. However, the Facebook policy change undermined the chatbot functionality and indicated the need to use independent platforms for chatbot deployment to ensure successful delivery of this type of intervention.

Digital Interventions on Healthy Lifestyle Management: Systematic Review

BACKGROUND

Digital interventions have tremendous potential to improve well-being and health care conveyance by improving adequacy, proficiency, availability, and personalization. They have gained acknowledgment in interventions for the management of a healthy lifestyle. Therefore, we are reviewing existing conceptual frameworks, digital intervention approaches, and associated methods to identify the impact of digital intervention on adopting a healthier lifestyle.

OBJECTIVE

This study aims to evaluate the impact of digital interventions on weight management in maintaining a healthy lifestyle (eg, regular physical activity, healthy habits, and proper dietary patterns).

METHODS

We conducted a systematic literature review to search the scientific databases (Nature, SpringerLink, Elsevier, IEEE Xplore, and PubMed) that included digital interventions on healthy lifestyle, focusing on preventing obesity and being overweight as a prime objective. Peer-reviewed articles published between 2015 and 2020 were included. We used the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and a framework for an evidence-based systematic review. Furthermore, we improved the review process by adopting the Rayyan tool and the Scale for the Assessment of Narrative Review Articles.

RESULTS

Our initial searches identified 780 potential studies through electronic and manual searches; however, 107 articles in the final stage were cited following the specified inclusion and exclusion criteria. The identified methods for a successful digital intervention to promote a healthy lifestyle are self-monitoring, self-motivation, goal setting, personalized feedback, participant engagement, psychological empowerment, persuasion, digital literacy, efficacy, and credibility. In this study, we identified existing conceptual frameworks for digital interventions, different approaches to provide digital interventions, associated methods, and execution challenges and their impact on the promotion of healthy lifestyle management.

CONCLUSIONS

This systematic literature review selected intervention principles (rules), theories, design features, ways to determine efficient interventions, and weaknesses in healthy lifestyle management from established digital intervention approaches. The results help us understand how digital interventions influence lifestyle management and overcome the existing shortcomings. It serves as a basis for further research with a focus on designing, developing, testing, and evaluating the generation of personalized lifestyle recommendations as a part of digital health interventions.

Experiences of Wearable Technology by Persons with Knee Osteoarthritis Participating in a Physical Activity Counseling Intervention: Qualitative Study Using a Relational Ethics Lens

Background

Current evidence indicates physical activity wearables could support persons with knee osteoarthritis (OA) to be more physically active. However, recent evidence also identifies some persons with arthritis experience guilt or worry while using a wearable if they are not as active as they feel they should be. Questions remain around how persons with knee OA experience benefits or downsides using a wearable in their everyday lives. Better understanding is needed if wearables are to be incorporated in arthritis self-management in ethically aware ways.

Objective

Using an ethics lens, we aimed to describe a range of experiences from persons with knee OA who used a wearable during a physical activity counseling intervention study.

Methods

This is a secondary analysis of qualitative interviews nested within a randomized controlled trial. Guided by phenomenography, we explored the experiences of persons with knee OA following participation in a physical activity counseling intervention that involved using a Fitbit Flex and biweekly phone calls with a study physiotherapist (PT) in an 8-week period. Benefits or downsides experienced in participants’ relationships with themselves or the study PT when using the wearable were identified using a relational ethics lens.

Results

Interviews with 21 participants (12 females and 9 males) aged 40 to 82 years were analyzed. Education levels ranged from high school graduates (4/21, 19%) to bachelor’s degrees or above (11/21, 52%). We identified 3 categories of description: (1) participants experienced their wearable as a motivating or nagging influence to be more active, depending on how freely they were able to make autonomous choices about physical activity in their everyday lives; (2) some participants felt a sense of accomplishment from seeing progress in their wearable data, which fueled their motivation; (3) for some participants, sharing wearable data helped to build mutual trust in their relationship with the study PT. However, they also expressed there was potential for sharing wearable data to undermine this trust, particularly if this data was inaccurate.

Conclusions

Findings provide an early glimpse into positive and negative emotional impacts of using a wearable that can be experienced by participants with knee OA when participating in a randomized controlled trial to support physical activity. To our knowledge, this is the first qualitative study that uses a relational ethics lens to explore how persons with arthritis experienced changes in their relationship with a health professional when using a wearable during research participation.

Gait Analysis Using Accelerometry Data from a Single Smartphone: Agreement and Consistency between a Smartphone Application and Gold-Standard Gait Analysis System

Spatio-temporal parameters of human gait, currently measured using different methods, provide valuable information on health. Inertial Measurement Units (IMUs) are one such method of gait analysis, with smartphone IMUs serving as a good substitute for current gold-standard techniques. Here we investigate the concurrent validity of a smartphone placed in a front-facing pocket to perform gait analysis. Sixty community-dwelling healthy adults equipped with a smartphone and an application for gait analysis completed a 2-min walk on a marked path. Concurrent validity was assessed against an APDM mobility lab (APDM Inc.; Portland, OR, USA). Bland–Altman plots and intraclass correlation coefficients (agreement and consistency) for gait speed, cadence, and step length indicate good to excellent agreement (ICC_2,1 > 0.8). For right leg stance and swing % of gait cycle and double support % of gait cycle, results were moderate (0.52 < ICC_2,1 < 0.62). For left leg stance and swing % of gait cycle left results show poor agreement (ICC_2,1 < 0.5). Consistency of results was good to excellent for all tested parameters (ICC_3,1 > 0.8). Thus we have a valid and reliable instrument for measuring healthy adults’ spatio-temporal gait parameters in a controlled walking environment.

A systematic review of interventions to promote physical activity in six Gulf countries

Physical activity (PA) levels are low in Gulf Cooperation Council countries (GCC; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, United Arab Emirates). We carried out a systematic review (PROSPERO registration number 131817) to assess the effect of interventions to increase PA levels in this region. We also assessed their effects on anthropometry and cardiovascular risk. A systematic search of six databases (Medline, EMBASE, SPORTDiscus, CINAHL, Cochrane, Web of Science) was performed to identify randomized and non-randomized intervention studies performed in adults and children published between January 1985 and November 2020. We included studies published in English or Arabic, and included PA interventions regardless of setting, delivery, and duration. The primary outcomes were changes in PA duration and intensity. Secondary outcomes included anthropometric measures (e.g., weight, body mass index) and cardiovascular risk profiles (e.g., lipid measures, blood glucose). Two independent reviewers screened studies in accordance with pre-determined criteria, extracted data, assessed risk of bias (Cochrane Risk of Bias 2 and Newcastle Ottawa Scale) and undertook a narrative synthesis. From 13,026 records identified, 14 studies were included. Nine studies focussed exclusively on changing PA behaviour, resulting in statistically significant increases in step count ranging from an additional 757 steps/day (95% confidence interval [CI] 0-1,513) to 3,853 steps/day (95% CI 3,703-4,002). Five identified studies were multi-component lifestyle interventions, targeting people at higher risk (due to obesity or type 2 diabetes). Evidence for increases in PA from multi-component studies was limited, although improvements were seen in outcomes e.g. body weight and blood lipid levels. In conclusion, relatively few studies have focussed on changing PA behaviour, despite the urgent need in the GCC. Limited evidence suggested that pedometer-based programmes encouraging step counting and walking were effective in promoting PA, at least in the short term. Policies to roll out such interventions should be implemented and evaluated.

Is it worth it? Cost-effectiveness analysis of a commercial physical activity app

BACKGROUND

Government interest in investing in commercial physical activity apps has increased with little evidence of their cost-effectiveness. This is the first study to our knowledge to examine the cost-effectiveness of a commercial physical activity app (Carrot Rewards) despite there being over 100,000 in the major app stores.

METHODS

A cost-effectiveness analysis was performed to calculate the incremental cost-effectiveness ratio (ICER) of the app compared to a no-intervention reference scenario using a five-year time horizon. Primary data was collected between 2016 and 2017. Data synthesis, model creation, and statistical analyses were conducted between 2019 and 2020. An age-, sex-, and geography-dependent Markov model was developed assuming a public healthcare payer perspective. A closed cohort (n = 38,452) representing the population reached by Carrot Rewards in two Canadian provinces (British Columbia, Newfoundland & Labrador) at the time of a 12-month prospective study was used. Costs and effects were both discounted at 1.5% and expressed in 2015 Canadian dollars. Subgroup analyses were conducted to compare ICERs between provinces, sexes, age groups, and engagement levels.

RESULTS

Carrot Rewards had an ICER of $11,113 CAD per quality adjusted life year (QALY), well below a $50,000 CAD per QALY willingness-to-pay (WTP) threshold. Subgroup analyses revealed that the app had lower ICERs for British Columbians, females, highly engaged users, and adults aged 35-64 yrs., and was dominant for older adults (65 + yrs). Deterministic sensitivity analyses revealed that the ICER was most influenced by the relative risk of diabetes. Probabilistic sensitivity analyses revealed varying parameter estimates predominantly resulted in ICERs below the WTP threshold.

CONCLUSIONS

The Carrot Rewards app was cost-effective, and dominant for older adults. These results provide, for the first time, rigorous health economic evidence for a commercial physical activity app as part of public health programming.

Smart technology vs. face-to-face physical activity interventions in older adults: a systematic review protocol

OBJECTIVE

The objective of this review is to determine the effect of physical activity interventions delivered via smart technology compared with face-to-face interventions for improving physical activity and physical function in older adults.

INTRODUCTION

Physical activity is a modifiable risk factor for multiple noncommunicable diseases and reduces the risk of premature mortality. Despite this, one in four adults does not meet recommended levels of physical activity. This pattern of inactivity increases with age. Smart technology, such as wearables, tablets, or laptops, is one solution for improving physical activity. Research has shown that different smart technology solutions can increase physical activity in older adults. While individual studies support smart technology to increase physical activity, there are no systematic reviews comparing the effects of smart technology with traditional face-to-face physical activity interventions.

INCLUSION CRITERIA

We will include randomized controlled trials of physical activity interventions delivered via smart technology (eg, wearables, tablets, computers) compared with face-to-face (ie, in person) interventions for community-dwelling older adults aged 60 years or older.

METHODS

We will search four databases (AMED, CINAHL, Embase, MEDLINE) from inception for relevant studies. All abstracts and full texts will be screened independently and in duplicate. Risk of bias, data extraction, and quality assessment will be completed in the same manner. If possible, a meta-analysis will be performed of the primary outcomes of physical activity, physical function, and adherence rate. Subgroup analyses will be conducted by type of physical activity, and type of smart technology, where possible.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020135232.

Approaches to Promote Reduction in Sedentary Behavior in Patients With Minor Ischemic Stroke: A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to determine whether an approach that promotes reduction in sedentary behavior (SB) during hospitalization and after hospital discharge reduces SB in patients with minor ischemic stroke (MIS) compared with an approach that promotes an increase in physical activity levels.

DESIGN

Randomized controlled trial design.

SETTING

During hospitalization and after hospital discharge.

PARTICIPANTS

We randomly assigned patients (N=61) with MIS (average age, 71.3±8.3y; 65.6% men) admitted to an acute hospital to either the intervention group (reduced SB, n=31) or the control group (increased physical activity levels, n=30).

INTERVENTIONS

During hospitalization, the intervention group received education on reducing SB, goal setting for SB after hospital discharge, and self-monitoring of SB and step count. In contrast, the control group received education on increasing physical activity levels and self-monitoring of step count. Patients in both groups wore an accelerometer during hospitalization until 3 months after hospital discharge. The intervention group received self-monitoring of SB and step count, stickers including information about reducing their SB, and phone calls once every 2 weeks for encouragement and feedback. The control group only wore the accelerometer.

MAIN OUTCOME MEASURES

The primary outcome was SB (in percentage) at 3 months after hospital discharge.

RESULTS

There was an interaction between the 2 groups for SB. Compared with the control group, the intervention group showed a significantly reduced SB (intervention group: baseline, 70.5%; 3 months after hospital discharge, 48.6%; control group: baseline, 71.5%; 3 months after hospital discharge, 57.5%; F value=5.981; P=.018).

CONCLUSIONS

The results suggested that an approach that promotes SB reduction during hospitalization and after hospital discharge is effective in reducing SB in patients with MIS 3 months after hospital discharge.

Effects of a three-armed randomised controlled trial using self-monitoring of daily steps with and without counselling in prediabetes and type 2 diabetes-the Sophia Step Study

BACKGROUND

This aimed to evaluate the effects of self-monitoring of daily steps with or without counselling support on HbA1c, other cardiometabolic risk factors and objectively measured physical activity (PA) during a 2-year intervention in a population with prediabetes or type 2 diabetes.

METHODS

The Sophia Step Study was a three-armed parallel randomised controlled trial. Participants with prediabetes or type 2 diabetes were recruited in a primary care setting. Allocation (1:1:1) was made to a multi-component intervention (self-monitoring of steps with counselling support), a single-component intervention (self-monitoring of steps without counselling support) or standard care. Data were collected for primary outcome HbA1c at baseline and month 6, 12, 18 and 24. Physical activity was assessed as an intermediate outcome by accelerometer (ActiGraph GT1M) for 1 week at baseline and the 6-, 12-, 18- and 24-month follow-up visits. The intervention effects were evaluated by a robust linear mixed model.

RESULTS

In total, 188 subjects (64, 59, 65 in each group) were included. The mean (SD) age was 64 (7.7) years, BMI was 30.0 (4.4) kg/m2 and HbA1c was 50 (11) mmol/mol, 21% had prediabetes and 40% were female. The dropout rate was 11% at 24 months. Effect size (CI) for the primary outcome (HbA1c) ranged from -1.3 (-4.8 to 2.2) to 1.1 (-2.4 to 4.6) mmol/mol for the multi-component vs control group and from 0.3 (-3.3 to 3.9) to 3.1 (-0.5 to 6.7) mmol/mol for the single-component vs control group. Effect size (CI) for moderate-to-vigorous physical activity ranged from 8.0 (0.4 to 15.7) to 11.1 (3.3 to 19.0) min/day for the multi-component vs control group and from 7.6 (-0.4 to 15.6) to 9.4 (1.4 to 17.4) min/day for the single-component group vs control group.

CONCLUSION

This 2-year intervention, including self-monitoring of steps with or without counselling, prevented a decrease in PA but did not provide evidence for improved metabolic control and cardiometabolic risk factors in a population with prediabetes or type 2 diabetes.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02374788 . Registered 2 March 2015-Retrospectively registered.

Behavioral Medicine for Sedentary Behavior, Daily Physical Activity, and Exercise to Prevent Cardiovascular Disease: A Review

PURPOSE OF REVIEW

Behavioral medicine is a multidisciplinary field that has a key role in reducing risk factors for cardiovascular disease (CVD). The purpose of this review is to describe the role of behavioral medicine for CVD prevention, using physical activity behaviors (e.g., sedentary behavior, daily physical activity, or exercise) as an exemplar. Application of behavioral medicine to improve dietary behaviors is also briefly discussed.

RECENT FINDINGS

Behavioral medicine interventions that address physical activity behaviors are associated with improved cardiovascular risk factors. Interventions framed in behavior change theory that integrate behavior change techniques to reduce sedentary behavior and promote daily physical activity and exercise have similarly been applied to improve certain dietary behaviors and show promise for reducing CVD risk factors. Behavioral medicine has an important role in improving various physical activity behaviors for all populations, which is essential for preventing or managing CVD. Further investigation into behavioral medicine interventions that address personal, environmental, and social factors that influence participation in physical activity behaviors, as well as the adoption of a more optimal dietary pattern, is warranted.

Long-term Effectiveness of mHealth Physical Activity Interventions: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Mobile health (mHealth) interventions can increase physical activity (PA); however, their long-term impact is not well understood.

OBJECTIVE

The primary aim of this study is to understand the immediate and long-term effects of mHealth interventions on PA. The secondary aim is to explore potential effect moderators.

METHODS

We performed this study according to the Cochrane and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched PubMed, the Cochrane Library, SCOPUS, and PsycINFO in July 2020. Eligible studies included randomized controlled trials of mHealth interventions targeting PA as a primary outcome in adults. Eligible outcome measures were walking, moderate-to-vigorous physical activity (MVPA), total physical activity (TPA), and energy expenditure. Where reported, we extracted data for 3 time points (ie, end of intervention, follow-up ≤6 months, and follow-up >6 months). To explore effect moderators, we performed subgroup analyses by population, intervention design, and control group type. Results were summarized using random effects meta-analysis. Risk of bias was assessed using the Cochrane Collaboration tool.

RESULTS

Of the 2828 identified studies, 117 were included. These studies reported on 21,118 participants with a mean age of 52.03 (SD 14.14) years, of whom 58.99% (n=12,459) were female. mHealth interventions significantly increased PA across all the 4 outcome measures at the end of intervention (walking standardized mean difference [SMD] 0.46, 95% CI 0.36-0.55; P<.001; MVPA SMD 0.28, 95% CI 0.21-0.35; P<.001; TPA SMD 0.34, 95% CI 0.20-0.47; P<.001; energy expenditure SMD 0.44, 95% CI 0.13-0.75; P=.01). Only 33 studies reported short-term follow-up measurements, and 8 studies reported long-term follow-up measurements in addition to end-of-intervention results. In the short term, effects were sustained for walking (SMD 0.26, 95% CI 0.09-0.42; P=.002), MVPA (SMD 0.20, 95% CI 0.05-0.35; P=.008), and TPA (SMD 0.53, 95% CI 0.13-0.93; P=.009). In the long term, effects were also sustained for walking (SMD 0.25, 95% CI 0.10-0.39; P=.001) and MVPA (SMD 0.19, 95% CI 0.11-0.27; P<.001). We found the study population to be an effect moderator, with higher effect scores in sick and at-risk populations. PA was increased both in scalable and nonscalable mHealth intervention designs and regardless of the control group type. The risk of bias was rated high in 80.3% (94/117) of the studies. Heterogeneity was significant, resulting in low to very low quality of evidence.

CONCLUSIONS

mHealth interventions can foster small to moderate increases in PA. The effects are maintained long term; however, the effect size decreases over time. The results encourage using mHealth interventions in at-risk and sick populations and support the use of scalable mHealth intervention designs to affordably reach large populations. However, given the low evidence quality, further methodologically rigorous studies are warranted to evaluate the long-term effects.

Daily Step Counts from the First Thailand National Steps Challenge in 2020: A Cross-Sectional Study

Thailand’s first national steps challenge has been implemented in 2020 with the goal to raise the level of physical activity nationwide by monitoring achievements through a smartphone application. This study examined the daily step counts of participants in the first national steps challenge. Six data points from 186,653 valid participants were retrieved and analyzed in five periods using Poisson regression. The mean daily steps peaked at 3196 in Period 1, and steadily dropped to 1205 in Period 5. The daily steps per period were analyzed using the participants’ characteristics, such as the type of participant, sex, age, body mass index, and area of residence. The overall mean daily steps of the participants meant physical activity was far below the recommended level and tended to drop in later periods. The general population achieved significantly higher mean daily steps than public health officers or village health volunteers (24.0% by multivariate analysis). Participants who were female, younger (<45 years), obese (body mass index > 30), and living in rural areas had fewer mean daily steps (13.8%, 44.3%, 12.7%, and 14.7% by multivariate analysis, respectively), with statistical significance. In the future, the national steps challenge should be continuously implemented by counting all steps throughout a day, using more strategies to draw attention and raise motivation, advocating for more participants, as well as reporting the whole day step counts instead of distance.