NIHR: physical activity can prevent obesity, heart disease and diabetes

People maintain increases in physical activity three years after receiving pedometers

NIHR: physical activity can prevent obesity, heart disease and diabetes

Why was this study needed?

Increasing physical activity can help prevent obesity, some cancers, heart disease and diabetes. However, 2016 Health Survey data for England revealed that only 66 per cent of men and 58 per cent of women aged over 19 meet the NHS-advised target of at least 150 minutes of moderate activity a week.

Walking is a safe and accessible way for people to meet this target. Studies suggest that pedometers can encourage people to increase their steps per day and boost their overall activity. However, long-term changes are needed to have a positive effect on health, and few studies have followed people for long enough to see whether behaviour change is sustained.

A previous NIHR Signal reported the 12-month effects of the PACE-UP trial where people were given pedometers with either postal or nurse support. This study provides continued three-year follow-up of people in both arms of that trial, along with four-year follow-up for a similar trial, PACE-Lift.

What did this study do?

Both randomised controlled trials recruited inactive adults from 10 general practices in England and initially conducted 12-week pedometer interventions with one-year follow-up.

PACE-UP involved 1,023 adults aged 45 to 75 years. Two intervention groups received a pedometer with instructions either by post or nurse consultation. A control group received no intervention but were also sent a pedometer and brief instruction at 12 months. Six hundred and eighty-one people (67 per cent) completed three-year follow-up.

PACE-Lift included 298 adults aged 60 to 74 years who were given a pedometer and accelerometer (which measures the intensity of activity) with nurse support, or no intervention. At 12 months, control participants also received a pedometer. Four-year follow-up was available for 225 (76 per cent).

Participants were aware of group assignment but did not see their final activity measurements.

What did it find?

  • After three years in PACE-UP, both intervention groups were doing more steps than the control group. The pedometer by post group were doing 627 extra steps a day (95 per cent confidence interval [CI] 198 to 1,056), and the nurse support group were doing 670 additional steps a day (95 per cent CI 237 to 1,102).
  • After four years in PACE-Lift, there was an indication that the pedometer group were also doing more steps than controls, but this did not reach statistical significance (407 extra steps a day, 95 percent CI -177 to +992).
  • Intervention groups in both trials were spending more time doing moderate or vigorous physical activity each week in bouts of greater than 10 minutes. For PACE-UP, this amounted to 28 extra minutes (95 per cent CI 7 to 49) for those posted the pedometer and 24 extra minutes (95 per cent CI 3 to 45) for the nurse support group. In PACE-Lift, participants who received the pedometer were doing 32 extra minutes compared to controls (95 per cent CI 5 to 60).
  • There was no difference in sedentary time between groups in either trial.
  • There were also no effects on pain, depression, anxiety or health-related quality of life at three or four years, which was consistent with the 12-month trial.

What does current guidance say on this issue?

The Department of Health recommends that adults perform at least 150 minutes of moderate aerobic activity, such as brisk walking or cycling, each week. Alternatively, they may do 75 minutes of vigorous aerobic activity such as running or a mix of moderate and vigorous aerobic activity. Strengthening exercises are also recommended twice per week.

NICE public guidelines on walking and cycling recommend that one-to-one support is offered at regular intervals to help people develop a long-term walking habit. This could be provided face-to-face, via telephone, print-based materials, email, the internet or text messaging. Support could include individual, targeted information, goal-setting (which may include the use of pedometers), monitoring and feedback.

What are the implications?

This study provides promising evidence that the beneficial effects of pedometers demonstrated in the short-term can be sustained to three or four years.

Pedometers were equally useful when instruction was given via post only or through repeated nurse consultations. However, the availability of in-depth instruction in some format seems key to effects, as the control groups also received pedometers at one year but without on-going support.

The most cost-effective way of providing follow-up and encouraging people to make sustained changes to their activity needs to be explored further. 

Expert view:

Anna Anderson HEE/NIHR clinical doctoral research fellow, University of Leeds

Increasing physical activity is a health behaviour change with wide-ranging undisputed benefits. However, for the benefits to be fully realised, increases in physical activity must be maintained long-term. Maintaining health behaviour changes is often even more challenging than initiating them. Yet, in clinical practice, we typically support our patients to initiate such changes and then expect them to maintain the change independently. 

Physical inactivity is currently a major public health issue in the UK. As physiotherapy staff, we have a key role to play in addressing this. It is therefore important that we optimise our use of interventions which empower people to both initiate and maintain increases in their physical activity levels. Correspondingly, these studies’ findings are highly relevant and encouraging.

Of specific note, the PACE-UP postal intervention resulted in similar long-term increases in physical activity compared to the more intensive nurse support intervention. This highlights the potential difference we could make through using an intervention that is simple and quick to administer. The PACE-UP intervention resources are freely available online. Our challenge is therefore clear – will we use these evidence-based resources to help play our part in tackling the current physical inactivity crisis?

Citation and funding: Harris T, Kerry SM, Limb ES, et al. Physical activity levels in adults and older adults 3-4 years after pedometer-based walking interventions: Long-term follow-up of participants from two randomised controlled trials in UK primary care. PLoS Med. 2018;15(3):e1002526.This project was funded by the National Institute for Health Research. PACE-UP trial and three-year follow-up by Health Technology Assessment (HTA) Programme (project number HTA 10/32/02 ISRCTN42122561). PACE-Lift trial by the Patient Benefit Programme (project number PB-PG-0909-20055). The PACE-UP three-year follow-up was also supported by the Collaboration for Leadership in Applied Health Research and Care (CLAHRC), South London.
Bibliography: Department of Health. UK physical activity guidelines. London: Department of Health; 2015.Harris T, Kerry SM, Victor CR, et al. A primary care nurse-delivered walking Intervention in older adults: PACE (pedometer accelerometer consultation evaluation)-lift. NICE. Physical activity: walking and cycling. PH41. London: National Institute for Health and Care Excellence; 2012.NIHR DC. Patients receiving pedometers by post increased their physical activity for at least 12 months. Southampton: National Institute for Health Research Dissemination Centre; 2017.NHS Digital. Health survey for England, 2016. London: NHS Digital; 2017.

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