Benefit and risks of PA and current PA guidelines
Why is physical activity (PA) important for adults and older adults? PA leads to reduced mortality, a reduced risk of over 20 diseases and conditions, and improved function, quality of life and emotional well-being[
1]. Physical inactivity is the fourth leading risk factor for global mortality[
2] and a major cost burden on health services[
1].
What are the PA guidelines? Adults and older adults are advised to be active daily and, in order to obtain health benefits, should achieve at least 150 minutes (2 ½ hours) per week of at least moderate intensity activity in bouts of 10 minutes or more. One effective way to do this is by 30 minutes of moderate intensity activity on at least 5 days weekly[
1,
3,
4]. Regular walking is the most common PA of adults and older adults, walking at a moderate pace (3 mph /5 km/h) qualifies as moderate intensity PA[
5]. Time spent being sedentary for extended periods should also be minimised, as this is an independent disease risk factor[
1] and increases steeply from the age of 45[
6]. Whilst amongst adults in England aged 16 and over, 39% of men and 29% of women were judged to meet the recommended PA levels, based on their self-reported data, only 20% and 17% of men and women aged 60–74 met recommended levels[
6], despite most of these inactive older people being capable of walking[
7]
. Lower socioeconomic groups[
6] and Indian, Pakistani, Bangladeshi and Chinese ethnic groups are significantly less likely to report activity levels that meet the recommended levels, whilst the activity levels of other ethnic groups (Black Caribbean, Black African and Irish) are similar to that of the general population[
8]. Surveys of adults in Europe and the USA also confirm that over 50% do not achieve public health PA recommendations[
9,
10]. Since PA, including walking, is unreliably recalled, surveys may overestimate PA levels[
11]. Objective accelerometer measurement found that only 5% of men and 4% of women aged 35–64 years and 5% men and 0% of women aged 65 or more achieved the recommended PA levels, only a fraction of those self-reporting achieving these levels[
6].
What are the risks from increasing PA? Risks from a sedentary lifestyle far exceed the risks from regular PA[
3,
12,
13]. Moderate intensity PA carries a low injury risk[
14], mainly musculoskeletal injury or falls[
15]. Walking is very low risk, “a near perfect exercise”[
5]. Screening participants for contraindications before participating in light to moderate intensity PA programmes is no longer advocated[
3,
16]. An important safety feature of our study is that individualised goals can be set from the participant’s own baseline, in line with advice that older adults in particular should start with low intensity PA and increase intensity gradually, the “start-low-and-go-slow” approach[
12,
13].
Strategies for increasing PA
How can adults and older adults increase their PA levels? A systematic review of PA interventions reported moderate positive short-term effects, but findings were limited by mainly unreliable self-report measures in motivated volunteers[
17]. Effective interventions explored factors associated with behavioural change, including beliefs about costs and benefits of PA[
18]. Exercise programs in diverse populations can promote short- to medium-term increases in PA when interventions are based on health behaviour theoretical constructs, individually tailored with personalised activity goals and use behavioural strategies[
3,
19]. A critical review and a best practices statement on older peoples’ PA interventions advised home rather than gym-based programmes and behavioural strategies (e.g., goal-setting, self-monitoring, self-efficacy, support, relapse prevention training) rather than health education alone[
13,
20]. National Institute for Health and Clinical Excellence (NICE) guidance concluded that no particular behaviour change model was superior and that training should focus on generic competencies and skills rather than specific models[
21]. Starting low, but gradually increasing to moderate intensity is promoted as best practice, with advice to incorporate interventions into the daily routine (e.g., walking)[
13]. A recent systematic review concluded that walking interventions tailored to people’s needs, targeted at the most sedentary and delivered at the individual or household level, can be effective, although evidence directly comparing interventions targeted at individuals, couples or households is lacking[
22].
Are pedometers helpful? Pedometers are small, inexpensive devices, worn at the hip, that provide direct step-count feedback. A systematic review of 26 studies found pedometer users increased steps/day by 2,491 (1,098–3,885) and PA levels by 27%, with significant reductions in body mass index (BMI) and blood pressure[
23]. A second review (32 studies) found an average increase of 2,000 steps/day for pedometer users[
24]. Step-goals and diaries were key motivational factors[
23,
24]. Several limitations were recognised. Study sizes were relatively small and long-term effects undetermined; many included several components (e.g., pedometer and support) so independent effects were difficult to establish and the inclusion of older people and men was very limited[
23,
24]. Recent studies have addressed some of these limitations. A trial of 210 older women found that a pedometer plus behaviour change intervention increased PA at 3 months but not at 6 months[
25]. Two trials in high risk groups (cardiac disease and impaired glucose tolerance) showed sustained increases in step-count at 12 months[
26,
27]. NICE recently updated its advice from only advising pedometers as part of research[
28] to now advising their use as part of packages including support to set realistic goals, monitoring and feedback[
29].
How do step-count goals relate to PA recommendations? Step-count goals lead to more effective interventions, but no specific approach to goal-setting is favoured[
23]. Goals are based on either a fixed target (e.g., 10,000 steps/day)[
30,
31] or by advising incremental increases on baseline, as a percentage (5% per week[
32], 10% biweekly[
33] or 20% monthly[
25]) or by a fixed number of extra steps. Those advocating a fixed number of extra daily steps have developed step-based guidelines to fit with existing evidence based guidelines with their emphasis on 30 minutes of at least moderate intensity PA on 5 or more days weekly[
34]. Despite individual variation, moderate intensity walking appears approximately equal to at least 100 steps per minute[
34,
35]. Multiplied by 30 minutes this produces a minimum of 3,000 steps per day, to be done over and above habitual activity. Several studies have advocated adding in 3,000 steps/day on most days weekly, either from the beginning[
26] or by increasing incrementally (initially an extra 1,500 steps/day and increasing)[
36,
37] or increasing by 500 steps/day biweekly[
27]. Studies that advised adding 3,000 steps/day to baseline produced significant improvements in step-counts at 3 months and two measured outcomes at 12 months and showed sustained improvements in step-counts[
26,
27], waist circumference[
26] and fasting glucose levels[
27]. Although there is no evidence at present to inform a moderate intensity cadence (steps/minute) in older adults, Tudor-Locke et al. advocate using the adult cadence of 100 steps/minute in older adults (whilst recognising that this may be unobtainable for some individuals) and advise that the 30 minutes can be broken down into bouts of at least 10 minutes[
38]. This model was used in a primary care walking intervention in 41 older people which found significant step-count increases from baseline to week 12, maintained at week 24[
39,
40].
Could accelerometers be useful in a pedometer-based walking intervention? Accelerometers are small activity monitors, worn like pedometers, more expensive, but able to provide a time-stamped record of PA frequency (step-counts) and intensity (activity counts). They require computer analysis and give no immediate feedback, functioning as blinded pedometers in objectively measuring baseline and outcome data, but providing objective data on time spent in different PA intensities, including time spent in at least moderate intensity activity and time spent sedentary, two important public health outcomes. Pedometer studies without accelerometers have relied on self-report measures of these outcomes. Accelerometers are valid and acceptable to adults[
6,
41] and older adults[
6,
42,
43]. Although both instruments measure step-count and are highly correlated[
44,
45], pedometers usually record lower step-counts, particularly at lower walking speeds, and accelerometers cannot reliably be substituted for pedometers at an individual level[
45]. Thus, although we will use the accelerometer to measure outcomes, we will use a blinded pedometer, worn simultaneously at baseline, to set individual step-count targets.
Are pedometers cost-effective? There is limited knowledge on the cost-effectiveness of pedometer-based interventions in the UK. Recent systematic reviews that considered the economic outcomes of pedometer-based interventions found no evidence[
46,
47], partly attributable to insufficient data[
48]. However, a recent study assessed the cost-effectiveness of giving an individualised walking programme and pedometer with or without a consultation compared with usual walking activity alongside a trial of 79 people[
49]. The incremental cost-effectiveness ratios per person achieving an additional 15,000 steps/week were £591 and £92 with and without the consultation. However, no data on quality of life were collected and impacts on long-term outcomes were not estimated.
What is primary care’s role in promoting PA? Primary care centres (general practices) in the UK provide healthcare and health promotion free at the point of access, to a registered list of local patients, using disease registers to provide annual or more frequent review of chronic disorders (for many of which PA will be of benefit), via a multi-disciplinary health care team to provide continuity of care. NICE guidance found that brief interventions in primary care are cost-effective and therefore recommends that all primary care practitioners should take the opportunity, whenever possible, to identify inactive adults and provide advice on increasing PA levels[
28]. New National Health Service health checks include adults up to age 74 and incorporate advice on increasing PA, often by primary care nurses[
50]. Primary care nurses have been shown to be effective at increasing PA, particularly walking, in this age group[
51]. Health professional PA advice in consultations is individually tailored[
52] and has greater impact than other PA advice[
53]. PA promotion by other routes, for older adults in particular, is unlikely to be as effective[
54]]. Exercise prescribing guidance in primary care reinforces the importance of follow-up to chart progress, set goals, solve problems, and identify and use social support[
55]; this will be an important feature of the nurse PA consultations in this trial. Evaluation of the UK Step-O-Meter Programme, delivering pedometers through primary care, showed self-reported PA increases, but advised investigation with a RCT design[
36]. Two small trials have assessed the effectiveness of pedometers plus PA consultations: one showed a significant effect on step-counts at 12 weeks in 79 middle-aged adults[
37]; the other showed a significant effect on step-counts at 12 weeks, maintained at 24 weeks in 41 older primary care patients and called for a further, larger primary care trial[
39,
40].
Theory on which the intervention is based and relevant pilot and preparatory work. The pedometer-based intervention is centred on work cited above showing that pedometers can increase step-counts and PA intensity[
23,
24], but extending this to ensure that the study covers older adults, men, has a 12 month follow-up, and is designed to examine pedometer and support components separately. The patient handbook, diary and practice nurse PA consultations will use behaviour change techniques (BCTs) (e.g., goal-setting, self-monitoring, feedback, boosting motivation, encouraging social support, addressing barriers, relapse anticipation etc.). These techniques have been successfully used by non-specialists in primary care after brief training[
56] and are emphasized in the Health Trainer Handbook[
57], based on evidence from a range of psychological methods and intended for National Health Service behaviour change programmes, with local adaptation[
57]. We have adapted the Health Trainer Handbook for use in this trial into PACE-UP nurse and patient handbooks, to focus specifically on PA using pedometers. The BCTs have been classified according to Michie’s refined taxonomy of BCTs for PA interventions[
58] (Tables
1 and
2). Diary recording of pedometer step-counts provides clear material for PA goal setting, self-monitoring and feedback, and should fit well with this approach. Relevant pilot and preparatory work includes observational work using pedometers and accelerometers in primary care[
42] and a trial with older primary care patients developing the PA consultations and pedometer-based walking intervention (PACE-Lift trial ISRCTN42122561)[
59].
Table 1
PACE-UP patient handbook and diary, and behavioural change techniques included
Patient handbook | Health benefits of increasing walking | 1, 2 |
PA guidelines | 4 |
Moderate intensity PA and relating it to number of steps | |
| PACE-UP walking programme and step-count targets | 7,9,16 |
Review participant baseline step-count | 19 |
How to increase PA safely | 21 |
Useful websites | 4 |
How to keep going when PACE-UP programme finishes | 1,2,16,26,29,35 |
Patient diary | How to use pedometer and record steps in diary | 16, 21 |
Frequently asked questions on PACE-UP trial | |
Weekly recording of step-count and walking in diary (weeks 1–12) | 7,9,19,26 |
Achievement of targets (weeks 1–12) | 10,12,13 |
Planning when to walk, where to walk, who to walk with | 20,29 |
Week 2 Tips and motivators: make walking part of your daily routine | 20 |
Week 3 Ttips and motivators: remember personal benefits, what to do if you | 2,20,35 |
are falling behind your targets | |
Week 4 Keep it up: praise and reward yourself, encouraging social support | 12,13,29 |
Week 5 Keep motivated: write down step-counts, ask for support | 12,16,29 |
Week 6 Now we are moving: obstacles and solutions | 8 |
Week 7 How to make these changes permanent – ideas for new walks, making time for walking, what gains have been made so far? | 38,17,11 |
Week 8 Maintain the gain: pacing, tips for safe exercising | 9,21,35 |
Week 9 Be busy being active: keep monitoring with pedometer, places, people and thoughts that motivate you | 16,29,36 |
Week 10 Change does not happen in a straight line! Preparing for setbacks | 8,35 |
Week 11 Make it a healthy habit: building regular exercise habits, creating if-then plans | 1,2,7,23 |
Week 12 I’ve changed: how to keep up your walking programme | 16,20,29 |
Congratulations you have completed the programme | 11,16,17 |
| How to keep going when PACE-UP programme finishes | 1,16,29 |
Table 2
PACE-UP practice nurse physical activity consultations and behaviour change techniques included
1 | Session 1: First steps (30 minutes) Week 1 | Review health status, current activity, health benefits of PA | 1, 2 |
Cost-benefit analysis for increasing PA | 2 |
PA guidelines and how to increase PA safely | 4, 21 |
Moderate intensity PA and relating it to number of steps | |
Review participant baseline step-count | 19, |
Teach use of pedometer and recording walks and steps in diary | 21, 26 |
Ideas for increasing steps | 20 |
Goal-setting – PACE-UP goals or tailored to the individual patient | 7, 9, 16 |
Use of rewards for effort and for achieving goals | 12, 13 |
Summarise and check patient understanding, plan time for next meeting | |
Communication strategies to overcome resistance and promote patient-led change | 37 |
5 | Session 2: Continuing the changes (20 minutes) Week 5 | Review step-count and walking diary | 10, 19 |
Encourage progress in increasing walking and achieving step-count goals | 12, 13 |
Troubleshoot any problems with pedometer or diary | 8 |
Review target and agree goals for next stage | 7, 9, 16 |
Barriers and facilitators to increasing PA, overcoming barriers, encouraging support | 8, 29 |
Pacing and avoiding boom and bust | 9, 35 |
Check confidence levels, build confidence to make change | 18, 29, 36 |
Summarise and check patient understanding, plan time for next meeting | |
Communication strategies to overcome resistance and promote patient-led change | 37 |
9 | Session 3: Building lasting habits (20 minutes) Week 9 | Review step-count and walking diary | 10, 19 |
Review overall progress over the sessions | 11, 17 |
Encourage progress in increasing walking and achieving goals | 12, 13 |
Preparing for setbacks | 35 |
Building habits: discuss methods of maintaining lasting change, including repetition, if-then rules and support | 7, 29, 23, 29, 35 |
Setting goals: maintaining current activity or increasing further? | 7, 9, 16, 26 |
Remind re contact with research assistant in 3–4 weeks | |
| | Communication strategies to overcome resistance and promote patient-led change | 37 |