It is widely known that physical activity provides strong physical, psychological and cognitive health benefits, with over 20 different conditions showing prevention and treatment effects,1 including mortality reductions comparable with drug treatments in heart failure and stroke.2 Economic effects are important, with physical inactivity responsible for approximately 13.4 million disability-adjusted life-years worldwide, over $100 billion in healthcare expenditure in the US,3 and £0.9 billion in the UK,1 annually. Yet, despite this, around 40% of UK adults report being insufficiently active for health, worse with increasing age and socio-economic deprivation.1 Objectively measured findings are much worse, only 5% achieve guidelines by accelerometry, compared to 50% by self-report.4
Currently, UK, US and World Health Organization (WHO) aerobic guidelines all advocate at least 150 minutes weekly of moderate-to-vigorous physical activity (MVPA) in at least 10-minute bouts for adults and older adults,1,5,6 though the bout requirement is currently under debate,6 and even small amounts of physical activity provide protective health benefits. Walking is by far the most common physical activity, a brisk pace (approximately 3 mph, 5 km/hr) counts as MVPA, and walking is considered a ‘near-perfect’ exercise, with ability to gradually increase frequency and intensity with low risk of harm, while encouraging environmental sustainability.7 Many people count steps and, despite inter-individual variability, a cadence of ≥100 steps/minute (3,000 steps in 30 minutes) is a consistent heuristic (evidence-based, rounded) associated with MVPA,8 and useful for patient advice in answer to the question “how much, how fast?”
The new WHO Global Action Plan on Physical Activity seeks to reduce physical inactivity by 15% by 2030, by creating active societies, environments, people and systems, with universally applicable policies.5 While such population approaches are vitally important, healthcare professionals also have a valuable role in getting their patients more active, with initiatives such as ‘Exercise is Medicine’ in the US to ‘prescribe’ regular physical activity,9 and drives to promote physical activity in UK primary care.10 A recent review made the case more broadly that ‘Movement is Medicine’ and that measurement of physical activity status and cardiorespiratory fitness should be vital signs that all healthcare professionals incorporate into their consultations.11 The rest of this editorial focuses on how we can best get adults and older adults to do more physical activity, utilising effective behaviour change techniques (BCTs) and new technologies. Learning resources for healthcare professionals such as Moving Medicine (https://movingmedicine.ac.uk) and Motivate2Move (https://gpcpd.walesdeanery.org/index.php/welcome-to-motivate-2-move) also provide useful tools. Additionally, excellent guidance for patients with specific long-term conditions including ischaemic heart disease, heart failure, stroke, hypertension, etc. are provided at: http://www.benefitfromactivity.org.uk
What role do BCTs play in effective physical activity interventions?
Some of the biggest reductions in future health problems can be seen when moving people from inactive to moderately active lifestyles, but physical activity needs to be maintained to achieve sustained health benefits.1 How do we first get people more active and then get them to stay active?
Self-efficacy (a person’s belief in their ability to succeed) is a key health psychology construct and a strong predictor of both adoption and maintenance of physical activity in adults. Many interventions have, therefore, focused on increasing self-efficacy.12 Physical activity interventions typically contain multiple BCTs: while many are effective in increasing physical activity levels, e.g. social support, goal setting and self-monitoring;13 ‘graded tasks’ and ‘behaviour practice/rehearsal’ are effective in both increasing and maintaining physical activity levels.14 Qualitative studies also provide valuable insights into important barriers and facilitators to physical activity adoption15 and maintenance16 for adults and older adults.
Another promising approach utilises technology to enhance BCTs, specifically step-counting devices, which encourage self-monitoring. Pedometer-based studies have shown positive physical activity effects at 12 months,17 however, until recently, long-term effectiveness data were lacking. The PACE-UP (Pedometer And Consultation Evaluation – UP) and PACE-Lift (Pedometer Accelerometer Consultation Evaluation – Lift) primary care trials are novel in demonstrating long-term physical activity effects three to four years after a 12-week pedometer-based walking intervention (incorporating the 3,000-in-30 message), provided either by post, or as part of practice nurse physical activity consultations.18 Recent findings confirm that the long-term increases in physical activity achieved sustained health benefits.19 As technology advances it is becoming easier to integrate different step-monitoring devices into physical activity interventions.
What about the role of new fitness technologies?
New fitness technologies, which include tracking devices and smartphone applications to motivate users, provide objective physical activity measures, including but not restricted to step-counts. Recent studies investigating a wide range of tracking devices and smartphone applications revealed moderate-to-strong validity,20,21 though accuracy can be reduced with different body placement of tracking devices and smartphones, and slower walking speeds in older adults and those with chronic diseases.21 The adoption of such technologies is based on age, socioeconomic factors, such as being in employment, psychological factors, including level of motivation, and availability of time.21 They have also not highlighted advantages over more standard behavioural interventions for weight loss,22 and this may in part be explained by the importance of incorporating appropriate BCTs within them. This is particularly important for sedentary adults, where barriers to physical activity need to be identified to then promote individualised daily action plans.21 Other areas of motivation may lie within healthcare, whereby activity-monitor-based counselling was shown to be effective in improving health outcomes in those with chronic illnesses, including chronic heart failure.23 However, only a very small amount of applications include the recommended guidance of 150 minutes weekly, with further difficulties in predicting intensity.24 Therefore, in order to standardise and promote public health initiatives, considerations for those who are most at-risk of physical inactivity need to be addressed.
There have been significant developments in fitness technologies since the advent of pedometers to measure steps as a means of measuring physical activity. Though much of the current evidence on the newer technologies is short term, they have the capability of incorporating longer-lasting effects, particularly using BCTs. The challenge, therefore, lies with the continuous collaboration between application developers, health researchers and behaviour change experts to develop evidence-based technology using a multi-faceted approach to encourage physical activity.21 Nevertheless, these technologies have tremendous potential to impact public health and policies. Also, looking to the future, it would be beneficial to better understand the ‘whiches conundrum’,25 that is determining ‘which BCTs delivered through which technology channels, should be employed for which behaviours and for which populations’. All of which should enable us to achieve the public health imperative of getting more people walking more often.7 And, if you are ever asked “is it worth it?” – remember that walking adds both years to life and life to years.
Conflicts of interest
TH was the Chief Investigator of the PACE-Lift and PACE-UP trials and CW worked on these trials as a research assistant and trainee health psychologist. The authors report no other conflicts of interest.
1. Public Health England. Health matters: getting every adult active every day. London: Department of Health, 2016. Available from: https://www.gov.uk/government/publications/health-matters-getting-every-adult-active-every-day
2. Naci H, Ioannidis JP. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ 2013;347:f5577. https://doi.org/10.1136/bmj.f5577
3. Ding D, Lawson KD, Kolbe-Alexander TL et al. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet 2016;388:1311–24. https://doi.org/10.1016/S0140-6736(16)30383-X
4. Troiano RP, Berrigan D, Dodd KW, Mâsse LC, Tilert T, Mcdowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40:181–8. https://doi.org/10.1249/mss.0b013e31815a51b3
5. World Health Organization. Global action plan on physical activity 2018–2030: more active people for a healthier world. Geneva: WHO, 2018. Available from: https://www.who.int/ncds/prevention/physical-activity/global-action-plan-2018-2030/en/
6. US Department of Health and Human Services. 2018 physical activity guidelines advisory scientific report. Washington, DC: Office of Disease Prevention and Health Promotion, 2018. Available from: https://health.gov/paguidelines/second-edition/report/
7. Stamatakis E, Hamer M, Murphy MH. What Hippocrates called ‘man’s best medicine’: walking is humanity’s path to a better world. Br J Sports Med 2018;52:753–4. https://doi.org/10.1136/bjsports-2018-099371
8. Tudor-Locke C, Han H, Aguiaret EJ et al. How fast is fast enough? Walking cadence (steps/min) as a practical estimate of intensity in adults: a narrative review. Br J Sports Med 2018;52:776–88. https://doi.org/10.1136/bjsports-2017-097628
9. Cowan RE. Exercise Is Medicine Initiative: physical activity as a vital sign and prescription in adult rehabilitation practice. Arch Phys Med Rehabil 2016;97(9 suppl):S232–S237. https://doi.org/10.1016/j.apmr.2016.01.040
10. Brooks J, Ahmad I, Easton G. Promoting physical activity: the general practice agenda. Br J Gen Pract 2016;66:454–5. https://doi.org/10.3399/bjgp16X686689
11. Fletcher GF, Landolfo C, Niebauer J, Ozemek C, Arena R, Lavie CJ. Promoting physical activity and exercise. J Am Coll Cardiol 2018;72:1622–39. https://doi.org/10.1016/j.jacc.2018.08.2141
12. Williams SL, French DP. What are the most effective intervention techniques for changing physical activity self-efficacy and physical activity behaviour – and are they the same? Health Educ Res 2011;26:308–22. https://doi.org/10.1093/her/cyr005
13. Arnautovska U, O’Callaghan F, Hamilton K. Behaviour change techniques to facilitate physical activity in older adults: what and how. Ageing Soc 2017;38:2590–616. Available at: https://www.cambridge.org/core/journals/ageing-and-society/article/behaviour-change-techniques-to-facilitate-physical-activity-in-older-adults-what-and-how/E15C2DF567E2BF7C1AA912A22D5B5867
14. Howlett N, Trivedi D, Troop NA, Chater AM. Are physical activity interventions for healthy inactive adults effective in promoting behavior change and maintenance, and which behavior change techniques are effective? A systematic review and meta-analysis. Transl Behav Med 2018;online first. https://doi.org/10.1093/tbm/iby010
15. Normansell R, Smith J, Victor C et al. Numbers are not the whole story: a qualitative exploration of barriers and facilitators to increased physical activity in a primary care based walking intervention. BMC Public Health 2014;14:1272. https://doi.org/10.1186/1471-2458-14-1272
16. Wahlich C, Beighton C, Victor C et al. ‘You started something… then I continued by myself’: a qualitative study of physical activity maintenance. Prim Health Care Res Dev 2017;18:574–90. https://doi.org/10.1017/S1463423617000433
17. Hobbs N, Godfrey A, Lara J et al. Are behavioral interventions effective in increasing physical activity at 12 to 36 months in adults aged 55 to 70 years? A systematic review and meta-analysis. BMC Med 2013;11:75. https://doi.org/10.1186/1741-7015-11-75
18. 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:e1002526. https://doi.org/10.1371/journal.pmed.1002526
19. Harris T, Limb E, Hosking F et al. Effect of two pedometer-based walking intervention on long-term health outcomes using routine primary care data. Lancet 2018;online first. https://doi.org/10.1016/S0140-6736(18)32878-2
20. Ferguson T, Rowlands AV, Olds T, Maher C. The validity of consumer-level, activity monitors in healthy adults worn in free-living conditions: a cross-sectional study. Int J Behav Nutr Phys Act 2015;12:42. https://doi.org/10.1186/s12966-015-0201-9
21. Sullivan AN, Lachman ME. Behavior change with fitness technology in sedentary adults: a review of the evidence for increasing physical activity. Front Public Health 2017;4:289. https://doi.org/10.3389/fpubh.2016.00289
22. Jakicic JM, Davis KK, Rogers RJ et al. Effect of wearable technology combined with a lifestyle intervention on long-term weight loss: the IDEA randomized clinical trial. JAMA 2016;316:1161–71. https://doi.org/10.1001/jama.2016.12858
23. Vaes AW, Cheung A, Atakhorrami M, et al. Effect of ‘activity monitor-based’ counseling on physical activity and health-related outcomes in patients with chronic diseases: a systematic review and meta-analysis. Ann Med 2013;45:397–412. https://doi.org/10.3109/07853890.2013.810891
24. McConnell MV, Turakhia MP, Harrington RA, King AC, Ashley EA. Mobile health advances in physical activity, fitness, and atrial fibrillation: moving hearts. J Am Coll Cardiol 2018;71:2691–701. https://doi.org/10.1016/j.jacc.2018.04.030
25. Winter SJ, Sheats JL, King AC. The use of behavior change techniques and theory in technologies for cardiovascular disease prevention and treatment in adults: a comprehensive review. Prog Cardiovasc Dis 2016;58:605–12. https://doi.org/10.1016/j.pcad.2016.02.005