The use of self-tracking technology for health
Kooiman, Theresia Johanna Maria
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Kooiman, T. J. M. (2018). The use of self-tracking technology for health: Validity, adoption, and effectiveness. Rijksuniversiteit Groningen.
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Chapter 5 |
Do activity monitors increase
physical activity in adults with
overweight or obesity? A
systematic review and
meta-analysis
Herman J. de Vries Thea J.M. Kooiman Miriam W. van Ittersum Marco van Brussel
Martijn de Groot
Abstract
Objective
To systematically assess contemporary knowledge regarding behavioral physical activity interventions including an activity monitor (BPAI+) in adults with overweight or obesity.
Methods
PubMed/MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL and PEDro were searched for eligible full text articles up to July 1st 2015. Studies eligible for inclusion were (randomized) controlled trials describing physical activity outcomes in adults with overweight or obesity. Methodological quality was independently assessed employing the Cochrane Collaboration's tool for risk of bias. PROSPERO registration: CRD42015024086.
Results
Fourteen studies (1157 participants) were included for systematic review and eleven for meta-analysis. A positive trend in BPAI+ effects on several measures of physical activity was ascertained compared to both waitlist or usual care (WL/UC) and behavioral physical activity interventions without an activity monitor (BPAI-). No convincing evidence of BPAI+
effectiveness on weight loss was found compared to BPAI-.
Conclusions
Behavioral physical activity interventions with an activity monitor increase physical activity in adults with overweight or obesity. Also, adding an activity monitor to behavioral physical activity interventions appears to increase the effect on physical activity, although current evidence has not yet provided conclusive evidence for its effectiveness.
Introduction
Worldwide, 1.46 billion adults suffered from overweight and 502 million had obesity in 2008.1 The global rising prevalence of these conditions is expected to further increase both the health and economic burdens in the following decades.2 Overweight and obesity are frequently caused by a chronic imbalance involving dietary and physical activity patterns.3 Behavioral interventions involving alterations in both physical activity and diet can lead to clinically important weight loss (≥5% of baseline weight) in adults with overweight or obesity.4 Physical activity should be facilitated in intervention programs to enhance the likelihood of not only successful weight loss and weight maintenance but also for health benefits regardless of weight loss.5 A recent systematic review concluded that physical activity was included in 88% of studies that achieved clinically important weight loss, whereby behavioral training (such as self-monitoring) was included in 92% of these studies.6
Over the previous decades, there has been increasing interest in the therapeutic application of objective measures of self-monitoring. One of the first objective measuring instruments for physical activity was introduced in 1965 with the release of the Japanese manpo-kei pedometer, meaning “10,000 steps meter”.7 Currently, devices such as tri-axial accelerometers, gyroscopes and global positioning systems are combined to create activity monitors that are more accurate8, 9 and even integrate behavior change techniques (BCTs) such as social support, prompts/cues, rewards and behavioral outcome self-monitoring.10 Pedometer employment increases physical activity in adults with type 2 diabetes, musculoskeletal diseases and several other outpatient populations.11-14 Furthermore, pedometer based walking interventions have assisted in achieving moderate weight loss in adults.11, 13, 15 Although recent meta-analysis regarding the effects of activity monitors indicates positive outcomes on physical activity, HbA1c, systolic blood pressure and body mass index (BMI) in patients with type 2 diabetes,16 no systematic review regarding the effects of activity monitor based interventions on physical activity in adults with overweight or obesity is yet available. Therefore, the aim of the current systematic review was twofold. The first aim was to establish whether receiving a behavioral physical activity intervention with an activity monitor (BPAI+) increases physical activity in adults with overweight or obesity compared to both waitlist and usual care (WL/UC). The rationale was to determine whether offering a BPAI+ has clinical relevance when increasing physical activity is targeted. The second aim is to establish the added value of activity monitoring in existing
interventions on increment of physical activity. Therefore, BPAI+ was compared with behavioral physical activity interventions without an activity monitor (BPAI-). Additionally, the BPAI+ effect on body weight compared to BPAI- will be examined.
5
Abstract
Objective
To systematically assess contemporary knowledge regarding behavioral physical activity interventions including an activity monitor (BPAI+) in adults with overweight or obesity.
Methods
PubMed/MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL and PEDro were searched for eligible full text articles up to July 1st 2015. Studies eligible for inclusion were (randomized) controlled trials describing physical activity outcomes in adults with overweight or obesity. Methodological quality was independently assessed employing the Cochrane Collaboration's tool for risk of bias. PROSPERO registration: CRD42015024086.
Results
Fourteen studies (1157 participants) were included for systematic review and eleven for meta-analysis. A positive trend in BPAI+ effects on several measures of physical activity was ascertained compared to both waitlist or usual care (WL/UC) and behavioral physical activity interventions without an activity monitor (BPAI-). No convincing evidence of BPAI+
effectiveness on weight loss was found compared to BPAI-.
Conclusions
Behavioral physical activity interventions with an activity monitor increase physical activity in adults with overweight or obesity. Also, adding an activity monitor to behavioral physical activity interventions appears to increase the effect on physical activity, although current evidence has not yet provided conclusive evidence for its effectiveness.
Introduction
Worldwide, 1.46 billion adults suffered from overweight and 502 million had obesity in 2008.1 The global rising prevalence of these conditions is expected to further increase both the health and economic burdens in the following decades.2 Overweight and obesity are frequently caused by a chronic imbalance involving dietary and physical activity patterns.3 Behavioral interventions involving alterations in both physical activity and diet can lead to clinically important weight loss (≥5% of baseline weight) in adults with overweight or obesity.4 Physical activity should be facilitated in intervention programs to enhance the likelihood of not only successful weight loss and weight maintenance but also for health benefits regardless of weight loss.5 A recent systematic review concluded that physical activity was included in 88% of studies that achieved clinically important weight loss, whereby behavioral training (such as self-monitoring) was included in 92% of these studies.6
Over the previous decades, there has been increasing interest in the therapeutic application of objective measures of self-monitoring. One of the first objective measuring instruments for physical activity was introduced in 1965 with the release of the Japanese manpo-kei pedometer, meaning “10,000 steps meter”.7 Currently, devices such as tri-axial accelerometers, gyroscopes and global positioning systems are combined to create activity monitors that are more accurate8, 9 and even integrate behavior change techniques (BCTs) such as social support, prompts/cues, rewards and behavioral outcome self-monitoring.10 Pedometer employment increases physical activity in adults with type 2 diabetes, musculoskeletal diseases and several other outpatient populations.11-14 Furthermore, pedometer based walking interventions have assisted in achieving moderate weight loss in adults.11, 13, 15 Although recent meta-analysis regarding the effects of activity monitors indicates positive outcomes on physical activity, HbA1c, systolic blood pressure and body mass index (BMI) in patients with type 2 diabetes,16 no systematic review regarding the effects of activity monitor based interventions on physical activity in adults with overweight or obesity is yet available. Therefore, the aim of the current systematic review was twofold. The first aim was to establish whether receiving a behavioral physical activity intervention with an activity monitor (BPAI+) increases physical activity in adults with overweight or obesity compared to both waitlist and usual care (WL/UC). The rationale was to determine whether offering a BPAI+ has clinical relevance when increasing physical activity is targeted. The second aim is to establish the added value of activity monitoring in existing
interventions on increment of physical activity. Therefore, BPAI+ was compared with behavioral physical activity interventions without an activity monitor (BPAI-). Additionally, the BPAI+ effect on body weight compared to BPAI- will be examined.
Methods
The protocol for this systematic review and meta-analysis was based on the PRISMA-P
statement17 and registered at PROSPERO (CRD42015024086).18 The review was executed
according to the Cochrane Handbook for Systematic Reviews of Interventions19 following the
PRISMA statement.20
Search strategy
Electronic databases were searched using the sensitivity-maximizing version of the Cochrane Search Strategy to filter for Randomized Controlled Trials (RCT’s) and Controlled Clinical
Trials (CCT’s).19 MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL and PEDro were searched
for eligible articles published prior to July 1st 2015. The employed MeSH terms and keywords included overweight, obesity, accelerometry, actigraphy, physical activity, exercise and energy expenditure. Furthermore, a reference tracking strategy was performed by searching the reference lists and citations of included articles in Web of Science and Scopus. The complete search strategy can be found in the protocol.18
Study selection
Articles were eligible for inclusion if (a) they had a RCT or CCT design; (b) the majority of the
participants were human adults with overweight or obesity (mean baseline BMI ≥27.0 kg/m2
for Caucasians or ≥25.0 kg/m2 for Asians); (c) the intervention included the application of activity monitors; (d) the control group was on a waitlist, received usual care or were provided with a similar physical activity intervention as that of the intervention group but without activity monitor feedback; (e) physical activity changes for both intervention- and control group were described; and (f) the article was full-text available in English. Articles were excluded if (g) the document was a conference abstract, research letter, editorial note or commentary; (h) the intervention included non-spontaneous physical activity or a workplace environment modification; (i) participants were primarily older adults (mean age ≥60 years) or pregnant women; (j) participants were possibly limited in the ability to modify physical activity due to serious comorbidity caused by a chronic disease or it’s treatment; or (k) the intervention period was <2 weeks.
Two independent content area experts [authors HJdV and TJMK] screened potentially eligible articles for inclusion based on titles and abstract. Full-text articles were subsequently screened for final inclusion. Differences in appraisal were resolved by reaching consensus. The strength of inter-rater agreement was measured by Cohen’s coefficient.19
Methodological quality (risk of bias)
The risk of bias was scored by two independent reviewers [HJdV and TJMK] using the Cochrane Collaboration’s tool.19 This tool reviews the random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome
assessment, incomplete outcome data, selective reporting and other biases. Since the blinding of participants is practically infeasible in a self-monitoring intervention, this was not assessed and blinding of personnel was scored separately. Discrepancies between the raters were resolved in a consensus meeting. The strength of inter-rater agreement was measured by Cohen’s Coefficient.19
Synthesis of results
Data extraction was performed by the reviewers utilizing a standard extraction form. Extracted data from the articles included: (a) first author, publication year, and study location, (b) participants age and BMI; (c) intervention characteristics; (d) outcome
measures; and (e) study results. When multiple (≥2) studies compared analogous groups and reported the same outcome measures, results were pooled in RevMan 5.3 software for random-effects meta-analysis using the Inverse Variance method. For statistical pooling, extracted data from Intention To Treat (ITT) analyses was preferred over completer analyses and data measured by an objective instrument was favored over data from subjective instruments.
5
Methods
The protocol for this systematic review and meta-analysis was based on the PRISMA-P
statement17 and registered at PROSPERO (CRD42015024086).18 The review was executed
according to the Cochrane Handbook for Systematic Reviews of Interventions19 following the
PRISMA statement.20
Search strategy
Electronic databases were searched using the sensitivity-maximizing version of the Cochrane Search Strategy to filter for Randomized Controlled Trials (RCT’s) and Controlled Clinical
Trials (CCT’s).19 MEDLINE, Embase, CINAHL, PsycINFO, CENTRAL and PEDro were searched
for eligible articles published prior to July 1st 2015. The employed MeSH terms and keywords included overweight, obesity, accelerometry, actigraphy, physical activity, exercise and energy expenditure. Furthermore, a reference tracking strategy was performed by searching the reference lists and citations of included articles in Web of Science and Scopus. The complete search strategy can be found in the protocol.18
Study selection
Articles were eligible for inclusion if (a) they had a RCT or CCT design; (b) the majority of the
participants were human adults with overweight or obesity (mean baseline BMI ≥27.0 kg/m2
for Caucasians or ≥25.0 kg/m2 for Asians); (c) the intervention included the application of activity monitors; (d) the control group was on a waitlist, received usual care or were provided with a similar physical activity intervention as that of the intervention group but without activity monitor feedback; (e) physical activity changes for both intervention- and control group were described; and (f) the article was full-text available in English. Articles were excluded if (g) the document was a conference abstract, research letter, editorial note or commentary; (h) the intervention included non-spontaneous physical activity or a workplace environment modification; (i) participants were primarily older adults (mean age ≥60 years) or pregnant women; (j) participants were possibly limited in the ability to modify physical activity due to serious comorbidity caused by a chronic disease or it’s treatment; or (k) the intervention period was <2 weeks.
Two independent content area experts [authors HJdV and TJMK] screened potentially eligible articles for inclusion based on titles and abstract. Full-text articles were subsequently screened for final inclusion. Differences in appraisal were resolved by reaching consensus. The strength of inter-rater agreement was measured by Cohen’s coefficient.19
Methodological quality (risk of bias)
The risk of bias was scored by two independent reviewers [HJdV and TJMK] using the Cochrane Collaboration’s tool.19 This tool reviews the random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome
assessment, incomplete outcome data, selective reporting and other biases. Since the blinding of participants is practically infeasible in a self-monitoring intervention, this was not assessed and blinding of personnel was scored separately. Discrepancies between the raters were resolved in a consensus meeting. The strength of inter-rater agreement was measured by Cohen’s Coefficient.19
Synthesis of results
Data extraction was performed by the reviewers utilizing a standard extraction form. Extracted data from the articles included: (a) first author, publication year, and study location, (b) participants age and BMI; (c) intervention characteristics; (d) outcome
measures; and (e) study results. When multiple (≥2) studies compared analogous groups and reported the same outcome measures, results were pooled in RevMan 5.3 software for random-effects meta-analysis using the Inverse Variance method. For statistical pooling, extracted data from Intention To Treat (ITT) analyses was preferred over completer analyses and data measured by an objective instrument was favored over data from subjective instruments.
Figure 1.
Flowchart of selected studies.
Results
Study selection
The search strategy identified 1,645 articles, of which 14 full-text articles (including 1,157 participants) that satisfied the inclusion criteria were identified and reviewed.21-34 Selection
agreement between the reviewers was excellent (κ=0.75).19 A flowchart of the study
selection process is depicted in Figure 1. Seven studies compared patients receiving BPAI+ to WL/UC21-24, 28, 31, 33 and seven different studies compared patients receiving BPAI+ to patients
receiving BPAI-.25-27, 29, 30, 32, 34 Five studies comparing patients receiving BPAI+ to WL/UC
used an objective measure to determine physical activity outcomes21-23, 31, 33 and two used a
self-administered questionnaire24, 28. Additionally, four studies comparing patients receiving
BPAI+ to BPAI- used an objective physical activity measure25-27, 34 while three employed a
questionnaire.29, 30, 32 Data from eleven studies21-26, 28-30, 33, 34 were pooled for meta-analysis
including: steps per day, total moderate to vigorous physical activity (MVPA) minutes per time unit, walking MET·minutes/week, physical activity kilocalories per week, weight change in kilograms, relative weight change and BMI change outcomes. No major adverse events related to the interventions were reported. Four studies executed a gender-specific intervention.23-26 All of the individual study characteristics can be found in Table 1.
Methodological quality (risk of bias)
The agreement between the reviewers in the risk of bias assessment was fair (κ=0.52),19
however, consensus was reached. Among the 14 included studies, several increased risks of bias were assessed. One study24 used a non-random component in the sequence generation
process by randomizing work crews instead of individual participants (cluster randomized trial). It is unclear in seven studies25, 26, 29, 30, 32-34 if random sequence generation was used
and in ten studies22, 24-30, 33, 34 whether allocation concealment was applied. Blinding of
intervention personnel was absent in seven studies21, 22, 24, 27, 30, 31, 33 and unclear in three
studies.29, 32, 34 Blinding of outcome assessment was absent in one study26 and unclear in
seven studies.22, 24, 25, 29, 30, 32, 34 Three studies had a high risk of attrition bias due to
incomplete outcome data22, 29, 32 while the risk of attrition bias was unclear in two studies.30, 34 Two studies had a high risk of reporting bias due to selective reporting.31, 34 Another high
risk of bias was introduced by two studies which allowed control group participants to register their own weekly step totals.25, 26 Lastly, an unclear risk of bias may have been
introduced by a study that removed outliers without being able to verify if the data was erroneous31 and a study with a significant between-group age differences at baseline.34 The
5
Figure 1.
Flowchart of selected studies.
Results
Study selection
The search strategy identified 1,645 articles, of which 14 full-text articles (including 1,157 participants) that satisfied the inclusion criteria were identified and reviewed.21-34 Selection agreement between the reviewers was excellent (κ=0.75).19 A flowchart of the study selection process is depicted in Figure 1. Seven studies compared patients receiving BPAI+ to WL/UC21-24, 28, 31, 33 and seven different studies compared patients receiving BPAI+ to patients receiving BPAI-.25-27, 29, 30, 32, 34 Five studies comparing patients receiving BPAI+ to WL/UC used an objective measure to determine physical activity outcomes21-23, 31, 33 and two used a self-administered questionnaire24, 28. Additionally, four studies comparing patients receiving BPAI+ to BPAI- used an objective physical activity measure25-27, 34 while three employed a questionnaire.29, 30, 32 Data from eleven studies21-26, 28-30, 33, 34 were pooled for meta-analysis including: steps per day, total moderate to vigorous physical activity (MVPA) minutes per time unit, walking MET·minutes/week, physical activity kilocalories per week, weight change in kilograms, relative weight change and BMI change outcomes. No major adverse events related to the interventions were reported. Four studies executed a gender-specific intervention.23-26 All of the individual study characteristics can be found in Table 1. Methodological quality (risk of bias)
The agreement between the reviewers in the risk of bias assessment was fair (κ=0.52),19 however, consensus was reached. Among the 14 included studies, several increased risks of bias were assessed. One study24 used a non-random component in the sequence generation process by randomizing work crews instead of individual participants (cluster randomized trial). It is unclear in seven studies25, 26, 29, 30, 32-34 if random sequence generation was used and in ten studies22, 24-30, 33, 34 whether allocation concealment was applied. Blinding of intervention personnel was absent in seven studies21, 22, 24, 27, 30, 31, 33 and unclear in three studies.29, 32, 34 Blinding of outcome assessment was absent in one study26 and unclear in seven studies.22, 24, 25, 29, 30, 32, 34 Three studies had a high risk of attrition bias due to
incomplete outcome data22, 29, 32 while the risk of attrition bias was unclear in two studies.30, 34 Two studies had a high risk of reporting bias due to selective reporting.31, 34 Another high risk of bias was introduced by two studies which allowed control group participants to register their own weekly step totals.25, 26 Lastly, an unclear risk of bias may have been introduced by a study that removed outliers without being able to verify if the data was erroneous31 and a study with a significant between-group age differences at baseline.34 The distribution of the risks of bias is graphically depicted in Figure 2.
Ta ble 1 . Cha ra ct er ist ics o f i nc lude d s tu di es , di vi de d by c om pa ris on ( BP AI + ve rs us W L/ UC a nd v er sus B PA I-) . St ud y Pa rt ici pa nt s ( M ± S D) Co nt ro l g ro up In te rv en tio n g ro up BP AI Us e o f t he A ct iv ity M on ito r Comp ar ison: B PA I+ v er sus W L/ UC Ba ke r, G . 2008 Sco tla nd 21 Nu mb er ( ra nd omi ze d) : 8 0 (c : 40, i: 39) % ma le (ra nd omi ze d) : 20. 3 (c: 20. 0% , i : 20. 5% ) Ag e ( ra nd omi ze d) : 49. 2 ± 8. 8 (c: 51. 2 ± 7. 9, i: 47 .3 ± 9. 3) BM I ( ra nd omi ze d) : 29. 0 ± 5. 6* (c : 29. 4 ± 6. 3, i: 28. 5 ± 4. 8) Ta rg et g ro up : C om m uni ty sa m pl e. W ait -li st co nt ro l gro up Ba se d o n: T ran st he or et ical M od el . Co nt ac t: 1 indi vi dua l s es sio n a t ba se line (3 0 m in) . Be ha vi ora l c omp on en ts : D isc us sion of m ot iv at ion an d ba rr ie rs to w ar ds P A, in di vi du al go al -s et tin g, p la n m ak in g. Ad di tio na l f ee db ac k: - Res ou rc es : -Di et ar y a dv ice : N on e Du ra tio n: 1 2 we ek s AM : Om ro n H J-10 9E St ep -O -M et er . In st ru ct io n A M : P ar tic ip an ts wer e sh own ho w to us e t he A M to m oni to r da ily s te p co unt . PA go al : I ncr ea se st ep s/ d b y 3, 000 o n 5 d/ w . T hi s g oa l w as re ac he d w ith s ub g oa ls unt il w ee k 7 a nd t he n m ai nt ai ne d unt il we ek 1 2. AM feed ba ck : Da ily st ep s + P A d ia ry Da ta re ca ll f ro m A M : 7 da ys Bo nd , D . S. 2014 USA 22 Nu mb er ( ra nd omi ze d) : 8 0 (c : 38, i: 42) % ma le (ra nd omi ze d) : 13. 5 (c: 11. 4, i: 15. 0) Ag e ( ra nd omi ze d) : 46. 0 ± 8. 9 (c: 48. 1 ± 8. 1, i: 44 .2 ± 9. 2) BM I ( ra nd omi ze d) : 45. 0 ± 6. 5 (c: 44. 4 ± 5. 8, i: 45 .6 ± 7. 0) Ta rg et g ro up : P ati en ts aw ai tin g b ar ia tr ic s ur ge ry . Us ual car e: St anda rd pr e-su rgi ca l ca re ; ad vi ce to ad op t act iv e l ife st yl e and e ng ag e i n w al ki ng an d sim ila r a ct ivi tie s bu t n o f or m al pr es cr ipt io n o r str ate gi es to ch an ge P A be hav ior . Ba se d o n: T ra ns the or et ica l M ode l, T he or y o f P la nne d Be ha vi or , So cia l C ogn iti ve a nd Se lf-De te rm in at io n The or y. Co nt ac t: 6 indi vi dua l s es sio ns (3 0-45 m in ) Be ha vi ora l c omp on en ts : I nc re as e kn ow le dg e, g oal -se tt in g, a ct io n p la nn in g, P A c ues , r ev ie w o f p ro gr es s, pr obl em -so lvi ng . Ad di tio na l f ee db ac k: - Res ou rc es : S es sio n ha ndo ut s Di et ar y A dv ice: N on e Du ra tio n: 6 we ek s AM : P edo m et er (unk no w n m ode l) In st ru ct io n A M : R ec or d da ily st eps a nd bo ut -re la te d w al ki ng m in ut es in a m on itor in g lo g. PA go al :1 ) mo der at e i nt en sit y wa lk in g i n bo ut s ≥ 10 m in fo r 30 m in /d a nd 2) in cr ea se st ep s/d b y 5, 000/ d. T hi s go al w as rea ch ed in sma ller su b g oa ls p er we ek . AM feed ba ck : da ily s te ps + m oni to ring lo g Da ta re ca ll f ro m A M : U nkn ow n M org an , P.J . Nu m be r ( ra nd omi ze d) : 110 (c: 45, i: 6 5) W ait -li st co nt ro l gro up Ba se d o n: S oc ia l C ogn iti ve T he or y. Co nt ac t:1 i nd iv id ua l s es sio n ( 75 m in ). AM : P ed om et er (Y ama x SW -2 00) . In st ru ct io n A M : U nkn ow n 2011 Aust ra lia 24 % ma le (ra nd omi ze d) : 100 Ag e ( ra nd omi ze d) : 44. 4 ± 8. 6 (c: 43. 7 ± 9. 1, i: 44 .8 ± 8. 3) BM I ( ra nd omi ze d) : 30. 5 ± 3. 6 (c: 30. 2 ± 3. 5, i: 30 .7 ± 3. 6) Ta rg et g ro up : M al e s hi ft wo rk er s. Be ha vi ora l c omp on en ts : E du cat ion , g oal -s et tin g, u se o f a cr ed ib le so ur ce , s m al l f in an cia l i nce nt iv es . Ad di tio na l f ee db ac k: ≤ 7 i nd iv id ual ize d e -m ai ls as res po ns e o n wei gh t, ea tin g a nd ex er cis e d ia rie s. Res ou rc es : C al or yK in g web sit e, web sit e us er g ui de , w ei gh t l os s b ook. Di et ar y a dv ice: E duc at io n a bo ut di et a nd w ei ght lo ss . Du ra tio n: 1 4 we ek s PA go al : I ndi vi dua lly di sc us se d dur ing fi rs t se ss io n, unk no w n w he the r t he g oa l w as sp ec ifi ca lly fo r s tep s. AM feed ba ck : D ai ly st ep s. Da ta re ca ll f ro m A M : 1 da y. M org an , P.J . 2013 Aust ra lia 23 Nu mb er ( ra nd omi ze d) : 159 (c: 52, i1: 54, i2: 53 ) % ma le (ra nd omi ze d) : 100 Ag e ( ra nd omi ze d) : 47. 5 ± 11. 0 ( c: 4 8. 0 ± 1. 2, i1: 48. 0 ± 10. 8, i2: 46. 5 ± 11. 1) BM I ( ra nd omi ze d) : 32. 7 ± 3. 5 (33. 1 ± 3. 9, i1: 32. 4 ± 3. 3, i2 : 32. 8 ± 3. 4) Ta rg et g ro up : M en . W ait -li st co nt ro l gro up Res our ces gr oup ( i1 ): Ba se d on : So cia l C ogn iti ve T he or y. Co nt ac t: N on e Be ha vi ora l c omp on en ts : T ai lo rin g fo r men , s el f-s el ec ted goal -s et tin g, ad vi ce for soc ial su pp or t s tr at eg ie s. Ad di tio na l f ee db ac k: - Res ou rc es : W ei gh t-l os s D VD , w ei ght lo ss ha ndbo ok a nd su pp or t b ook, t ap e m eas ur e, ki loj ou le cou nt er b ook. Di et ar y a dv ice: A ch ie ve a n eg at iv e en er gy b al an ce o f 2000 k J p er d ay . 7 d ie t r el at ed w ei gh t l os s m es sa ge s. Du ra tio n: 3 m ont hs Onl ine gr oup ( i2 ): Res ou rc es : S am e as re sou rc es g rou p, w ith ad di tion al web sit e u se ( Ca lo ry Ki ng web sit e) a nd w ebs ite us er g ui de . Onl ine m oni to ring ins te ad o f pa pe r-b as ed log book. Feed ba ck : 7 indi vi dua liz ed f ee dba ck e -m ai ls a bo ut th ei r fo od a nd e xe rc ise di ar y e nt rie s. AM : P ed om et er (mo del u nk no wn ). In st ru ct io n A M : R ec or d p ed omet er -ba se d st ep s fo r fo ur d ay s ea ch w eek in th e su pp or t b ooks an d to t ick of f a c he ckb ox wh en g oa ls a re a ch ie ved . PA go al : 1 sel f-d et er mi ned S M AR T g oa l per mo nt h. 2 P A r el at ed w ei gh t l os s m es sa ge s; i nc re as e da ily s te ps a nd r educ e sit tin g t im e. AM feed ba ck : D ai ly s te ps + i1 : pa pe r lo gb oo k, i2: o nl in e d ia ry e nt rie s. Da ta re ca ll f ro m A M : U nkn ow n Pa tr ick , K . 2011 USA 28 Nu mb er ( ra nd omi ze d) : 441 (c: 217, i: 224) % ma le (ra nd omi ze d) : 100 Ag e ( ra nd omi ze d) : 43. 9 ± 8. 0 (c: 42. 8 ± 8. 0, i: 44 .9 ± 7. 8) BM I ( ra nd omi ze d) : 34. 3 ± 4. 1* (c : 34. 3 ± 4. 0, i: 34. 2 ± 4. 2) W ait -li st co nt ro l gro up , wi th ac ce ss to an al ter na te web sit e co nt ai ni ng gen er al h ea lth in for m at ion of in ter es t t o m en but no t l ik el y t o le ad to c han ge s Ba se d o n: So cia l C ogn iti ve T he or y, B DM . Co nt ac t: O rie nt at io n c onv er sa tio n w ith i ns tr uc tio n o f t he web sit e, e -m ai l or te le ph on e con tac t t o f ac ili tat e int er ac tio n w ith w eb sit e a nd t ro ubl es ho ot ing , di sc us sio n of go al s w ith h ea lth car e p rov id er , op tion al e -ma il con tac t f or h eal th -re la te d que st io ns . Be ha vi ora l c omp on en ts : S el f-s el ec ted g oa l-s etti ng , ta ilo rin g o f web sit e c on ten t ( in fo rmed b y a ss es sed h ea lth be hav ior s) , u se of b eh av ior al ski lls . Ad di tio na l f ee db ac k: W ee kl y gr ap hi ca l feed ba ck o f o th er AM : P ed om et er (Y ama x Di gi w al ke r). In st ru ct io n A M : M oni to r da ily st eps a nd rec or d t he da ta o n t he w ebs ite to a ss ist w ith go al se tt in g. PA go al : 1) ≥ 10, 00 0 st ep s/ d on ≥ 5 d/ w an d 2 ) s tr en gt h t rai ni ng ≥ 2 d /w tar ge tin g ≥2 b od y ar eas . AM feed ba ck : D ai ly st ep s, on lin e l og book, we ek ly g ra ph ica l feed ba ck o f P A be ha vi or s.
5
Ta ble 1 . Cha ra ct er ist ics o f i nc lude d s tu di es , di vi de d by c om pa ris on ( BP AI + ve rs us W L/ UC a nd v er sus B PA I-) . St ud y Pa rt ici pa nt s ( M ± S D) Co nt ro l g ro up In te rv en tio n g ro up BP AI Us e o f t he A ct iv ity M on ito r Comp ar ison: B PA I+ v er sus W L/ UC Ba ke r, G . 2008 Sco tla nd 21 Nu mb er ( ra nd omi ze d) : 8 0 (c : 40, i: 39) % ma le (ra nd omi ze d) : 20. 3 (c: 20. 0% , i : 20. 5% ) Ag e ( ra nd omi ze d) : 49. 2 ± 8. 8 (c: 51. 2 ± 7. 9, i: 47 .3 ± 9. 3) BM I ( ra nd omi ze d) : 29. 0 ± 5. 6* (c : 29. 4 ± 6. 3, i: 28. 5 ± 4. 8) Ta rg et g ro up : C om m uni ty sa m pl e. W ait -li st co nt ro l gro up Ba se d o n: T ran st he or et ical M od el . Co nt ac t: 1 indi vi dua l s es sio n a t ba se line (3 0 m in) . Be ha vi ora l c omp on en ts : D isc us sion of m ot iv at ion an d ba rr ie rs to w ar ds P A, in di vi du al go al -s et tin g, p la n m ak in g. Ad di tio na l f ee db ac k: - Res ou rc es : -Di et ar y a dv ice : N on e Du ra tio n: 1 2 we ek s AM : Om ro n H J-10 9E St ep -O -M et er . In st ru ct io n A M : P ar tic ip an ts wer e sh own ho w to us e t he A M to m oni to r da ily s te p co unt . PA go al : I ncr ea se st ep s/ d b y 3, 000 o n 5 d/ w . T hi s g oa l w as re ac he d w ith s ub g oa ls unt il w ee k 7 a nd t he n m ai nt ai ne d unt il we ek 1 2. AM feed ba ck : Da ily st ep s + P A d ia ry Da ta re ca ll f ro m A M : 7 da ys Bo nd , D . S. 2014 USA 22 Nu mb er ( ra nd omi ze d) : 8 0 (c : 38, i: 42) % ma le (ra nd omi ze d) : 13. 5 (c: 11. 4, i: 15. 0) Ag e ( ra nd omi ze d) : 46. 0 ± 8. 9 (c: 48. 1 ± 8. 1, i: 44 .2 ± 9. 2) BM I ( ra nd omi ze d) : 45. 0 ± 6. 5 (c: 44. 4 ± 5. 8, i: 45 .6 ± 7. 0) Ta rg et g ro up : P ati en ts aw ai tin g b ar ia tr ic s ur ge ry . Us ual car e: St anda rd pr e-su rgi ca l ca re ; ad vi ce to ad op t act iv e l ife st yl e and e ng ag e i n w al ki ng an d sim ila r a ct ivi tie s bu t n o f or m al pr es cr ipt io n o r str ate gi es to ch an ge P A be hav ior . Ba se d o n: T ra ns the or et ica l M ode l, T he or y o f P la nne d Be ha vi or , So cia l C ogn iti ve a nd Se lf-De te rm in at io n The or y. Co nt ac t: 6 indi vi dua l s es sio ns (3 0-45 m in ) Be ha vi ora l c omp on en ts : I nc re as e kn ow le dg e, g oal -se tt in g, a ct io n p la nn in g, P A c ues , r ev ie w o f p ro gr es s, pr obl em -so lvi ng . Ad di tio na l f ee db ac k: - Res ou rc es : S es sio n ha ndo ut s Di et ar y A dv ice: N on e Du ra tio n: 6 we ek s AM : P edo m et er (unk no w n m ode l) In st ru ct io n A M : R ec or d da ily st eps a nd bo ut -re la te d w al ki ng m in ut es in a m on itor in g lo g. PA go al :1 ) mo der at e i nt en sit y wa lk in g i n bo ut s ≥ 10 m in fo r 30 m in /d a nd 2) in cr ea se st ep s/d b y 5, 000/ d. T hi s go al w as rea ch ed in sma ller su b g oa ls p er we ek . AM feed ba ck : da ily s te ps + m oni to ring lo g Da ta re ca ll f ro m A M : U nkn ow n M org an , P.J . Nu m be r ( ra nd omi ze d) : 110 (c: 45, i: 6 5) W ait -li st co nt ro l gro up Ba se d o n: S oc ia l C ogn iti ve T he or y. Co nt ac t:1 i nd iv id ua l s es sio n ( 75 m in ). AM : P ed om et er (Y ama x SW -2 00) . In st ru ct io n A M : U nkn ow n 2011 Aust ra lia 24 % ma le (ra nd omi ze d) : 100 Ag e ( ra nd omi ze d) : 44. 4 ± 8. 6 (c: 43. 7 ± 9. 1, i: 44 .8 ± 8. 3) BM I ( ra nd omi ze d) : 30. 5 ± 3. 6 (c: 30. 2 ± 3. 5, i: 30 .7 ± 3. 6) Ta rg et g ro up : M al e s hi ft wo rk er s. Be ha vi ora l c omp on en ts : E du cat ion , g oal -s et tin g, u se o f a cr ed ib le so ur ce , s m al l f in an cia l i nce nt iv es . Ad di tio na l f ee db ac k: ≤ 7 i nd iv id ual ize d e -m ai ls as res po ns e o n wei gh t, ea tin g a nd ex er cis e d ia rie s. Res ou rc es : C al or yK in g web sit e, web sit e us er g ui de , w ei gh t l os s b ook. Di et ar y a dv ice: E duc at io n a bo ut di et a nd w ei ght lo ss . Du ra tio n: 1 4 we ek s PA go al : I ndi vi dua lly di sc us se d dur ing fi rs t se ss io n, unk no w n w he the r t he g oa l w as sp ec ifi ca lly fo r s tep s. AM feed ba ck : D ai ly st ep s. Da ta re ca ll f ro m A M : 1 da y. M org an , P.J . 2013 Aust ra lia 23 Nu mb er ( ra nd omi ze d) : 159 (c: 52, i1: 54, i2: 53 ) % ma le (ra nd omi ze d) : 100 Ag e ( ra nd omi ze d) : 47. 5 ± 11. 0 ( c: 4 8. 0 ± 1. 2, i1: 48. 0 ± 10. 8, i2: 46. 5 ± 11. 1) BM I ( ra nd omi ze d) : 32. 7 ± 3. 5 (33. 1 ± 3. 9, i1: 32. 4 ± 3. 3, i2 : 32. 8 ± 3. 4) Ta rg et g ro up : M en . W ait -li st co nt ro l gro up Res our ces gr oup ( i1 ): Ba se d on : So cia l C ogn iti ve T he or y. Co nt ac t: N on e Be ha vi ora l c omp on en ts : T ai lo rin g fo r men , s el f-s el ec ted goal -s et tin g, ad vi ce for soc ial su pp or t s tr at eg ie s. Ad di tio na l f ee db ac k: - Res ou rc es : W ei gh t-l os s D VD , w ei ght lo ss ha ndbo ok a nd su pp or t b ook, t ap e m eas ur e, ki loj ou le cou nt er b ook. Di et ar y a dv ice: A ch ie ve a n eg at iv e en er gy b al an ce o f 2000 k J p er d ay . 7 d ie t r el at ed w ei gh t l os s m es sa ge s. Du ra tio n: 3 m ont hs Onl ine gr oup ( i2 ): Res ou rc es : S am e as re sou rc es g rou p, w ith ad di tion al web sit e u se ( Ca lo ry Ki ng web sit e) a nd w ebs ite us er g ui de . Onl ine m oni to ring ins te ad o f pa pe r-b as ed log book. Feed ba ck : 7 indi vi dua liz ed f ee dba ck e -m ai ls a bo ut th ei r fo od a nd e xe rc ise di ar y e nt rie s. AM : P ed om et er (mo del u nk no wn ). In st ru ct io n A M : R ec or d p ed omet er -ba se d st ep s fo r fo ur d ay s ea ch w eek in th e su pp or t b ooks an d to t ick of f a c he ckb ox wh en g oa ls a re a ch ie ved . PA go al : 1 sel f-d et er mi ned S M AR T g oa l per mo nt h. 2 P A r el at ed w ei gh t l os s m es sa ge s; i nc re as e da ily s te ps a nd r educ e sit tin g t im e. AM feed ba ck : D ai ly s te ps + i1 : pa pe r lo gb oo k, i2: o nl in e d ia ry e nt rie s. Da ta re ca ll f ro m A M : U nkn ow n Pa tr ick , K . 2011 USA 28 Nu mb er ( ra nd omi ze d) : 441 (c: 217, i: 224) % ma le (ra nd omi ze d) : 100 Ag e ( ra nd omi ze d) : 43. 9 ± 8. 0 (c: 42. 8 ± 8. 0, i: 44 .9 ± 7. 8) BM I ( ra nd omi ze d) : 34. 3 ± 4. 1* (c : 34. 3 ± 4. 0, i: 34. 2 ± 4. 2) W ait -li st co nt ro l gro up , wi th ac ce ss to an al ter na te web sit e co nt ai ni ng gen er al h ea lth in for m at ion of in ter es t t o m en but no t l ik el y t o le ad to c han ge s Ba se d o n: So cia l C ogn iti ve T he or y, B DM . Co nt ac t: O rie nt at io n c onv er sa tio n w ith i ns tr uc tio n o f t he web sit e, e -m ai l or te le ph on e con tac t t o f ac ili tat e int er ac tio n w ith w eb sit e a nd t ro ubl es ho ot ing , di sc us sio n of go al s w ith h ea lth car e p rov id er , op tion al e -ma il con tac t f or h eal th -re la te d que st io ns . Be ha vi ora l c omp on en ts : S el f-s el ec ted g oa l-s etti ng , ta ilo rin g o f web sit e c on ten t ( in fo rmed b y a ss es sed h ea lth be hav ior s) , u se of b eh av ior al ski lls . Ad di tio na l f ee db ac k: W ee kl y gr ap hi ca l feed ba ck o f o th er AM : P ed om et er (Y ama x Di gi w al ke r). In st ru ct io n A M : M oni to r da ily st eps a nd rec or d t he da ta o n t he w ebs ite to a ss ist w ith go al se tt in g. PA go al : 1) ≥ 10, 00 0 st ep s/ d on ≥ 5 d/ w an d 2 ) s tr en gt h t rai ni ng ≥ 2 d /w tar ge tin g ≥2 b od y ar eas . AM feed ba ck : D ai ly st ep s, on lin e l og book, we ek ly g ra ph ica l feed ba ck o f P A be ha vi or s.Ta rg et g ro up : M en . in di et o r phys ica l act iv ity (e .g. , in for m at ion on st re ss , h ai r l os s, w or ks ite inj ur y pr ev ent io n) . he al th be ha vi or s. Res ou rc es : W eb -ba se d l ea rni ng . Di et ar y a dv ice: D ie tar y g oal s an d i nf or m at ion ab ou t a he al thy di et thr oug h t he w ebs ite . Du ra tio n: 12 m on th s Da ta re ca ll f ro m A M : 1 d ay St au dt er , M . 2011 USA 31 Nu mb er ( ra nd omi ze d) : 106 (c : 54, I: 5 2) % m al e ( co m pl et er s) : 20. 2 ( c: 27. 3% , i : 1 3. 3% ) Ag e ( co m pl et er s) : 50. 0 ± 9. 3 (c: 50 ± 8. 4, i: 50 ± 10. 1) BM I ( co mp le te rs ): 32. 5 ± 5. 4 (c: 32. 6 ± 6. 2, i: 32 .3 ± 4. 6, p= .915) Ta rg et g ro up : M ili ta ry ben efi cia rie s. Us ual car e: "Us ua l L ife st yl e", no cha ng e i n ac tiv ity a dv ise d. Dur ing thr ee da ta co lle ct io n se ssi on s, 3 0 mi nu tes wer e spe nt o n nut rit io na l gui da nc e, in or der to mi ni mi se di et ar y bi as es . Ba se d o n: T he or y o f P la nne d B eha vi or . Co nt ac t: O nl in e m es sag e b oar d, t hr ee d at a c ol le ct ion se ssi on s a t b as el ine , m id s tud y a nd po st st udy. Be ha vi ora l c omp on en ts : E nc ou rag em en t, s tr at eg ie s f or im pr ov em ent thr oug h t he o nl ine m es sa ge bo ar d. Ad di tio na l f ee db ac k: P os iti ve o nl in e feed ba ck . Di et ar y a dv ice: N ut rit io na l gu id an ce , s am e a s c. Res ou rc es : N ew L ife st yl es web sit e. Du ra tio n: 1 2 we ek s AM : P ed om et er (Y ama x SW -2 00) In st ru ct io n A M : W ea r t he p ed omet er da ily a nd r ec or d da ily s te ps o n t he web sit e. PA go al : C rea te w eek ly st ep g oa ls, in cr ea sin g b y 500 -1, 00 0 s te ps /w , u nt il re ach in g u lti m at e w al ki ng go al o f 10, 000 st eps /d. AM feed ba ck : D ai ly st ep s, on lin e l og book. The w ebs ite co nv er te d t ra ck ed s te ps int o di st anc e t ra ve le d o n a v irt ua l j our ne y a nd pr ov id ed tar ge ts to i nc re as e m ot iv at ion . Da ta re ca ll f ro m A M : 1 d ay Tu do r-Lo ck e, C . 2004 Can ad a 33 Nu mb er ( ra nd omi ze d) : 6 0 (c : 30, i: 30) % m al e ( co m pl et er s) : 55. 3 ( c: 60. 9% , i : 5 0% ) Ag e ( co m pl et er s) : 52. 7 ± 5. 2 (c: 52. 5 ± 4. 8, i: 52 .8 ± 5. 7) BM I ( co mp le te rs ): 33. 3 ± 5. 6 (c: 32. 5 ± 5. 0, i: 34 .1 ± 6. 1) Ta rg et g ro up : P ati en ts w ith type 2 di abe te s. W ait -li st co nt ro l gro up Ba se d o n: So cia l C ogn iti ve T he or y, T ran st he or et ical M od el . Co nt ac t: 4 g ro up ses sio ns in th e fi rs t fo ur we ek s. Be ha vi ora l c omp on en ts : G oa l s et ting a nd pr obl em -so lvi ng e xe rc ise s. Res ou rc es : F irs t S te p Pr og ra m m an ua l. Ad di tio na l f ee db ac k: - Di et ar y a dv ice: N on e Du ra tio n: 1 6 we ek s AM : P ed om et er (mo del u nk no wn ) In st ru ct io n A M : U se b ot h p ed omet er an d c al en dar for g oal -s et tin g a nd se lf-m on ito rin g. PA go al : U nkn ow n AM feed ba ck : Da ily st ep s a nd P A ca le nd ar . Da ta re ca ll f ro m A M : U nkn ow n Comp ar ison: B PA I+ v er sus B PA I- BP AI - Us e o f t he A ct iv ity M on ito r a dd ed in B PA I+ Pa l, S . 2009 Aust ra lia 25 Nu mb er ( ra nd omi ze d) : 3 0 (c : 15, i: 15) % ma le (ra nd omi ze d) : 0 Ag e ( co m pl et er s) : 43 ± 28. 8* (c: 44 ± 24. 9# , i : 42 ± 3 3. 2# , p= .287) BM I ( co mp le te rs ): 29. 3 ± 2. 6* (c: 28. 6 ± 2. 7# , i : 29. 9 ± 2. 5# , p= .423) Ta rg et g ro up : W omen . Ba se d o n: - Co nt ac t: R ev iew o f P A gu id el in es a t b as el in e. Be ha vi ora l c omp on en ts : -AM : A sea led p ed om et er . C on tr ol p ar tic ip an ts wo re t hi s s ea led ped omet er fo r 1 2 w eek s wi th we ek ly rec or di ng . PA go al : S et sma ll a ch ie va bl e go al s l ik e 1 0 m in w al ks , gr ad ua lly in cr eas e g oal w ee kl y t o ≥ 30 m in /d . N o s te p g oal s w er e se t. Feed ba ck : Re co rd in g o f t ot al w ee kl y s te ps . Res ou rc es : N at io na l Au st ra lia n P hy sica l Act iv ity G ui de lin es . Di et ar y a dv ice: M ai nt ai n di et fo r dur at io n o f t he st udy. Du ra tio n: 1 2 we ek s Ba se d o n: - Co nt ac t/ Be ha vi ora l c omp on en ts : S ame a s c . AM : P ed om et er (Y ama x S W -200) In st ru ct io n A M : M on itor d ai ly st ep s, r ec or d on a cal en dar . PA go al : S et sma ll a ch iev ab le g oa ls, we ek ly in cr ea se t o 1) w al ki ng ≥30 m in /d a nd 2) 1 0, 000 s te ps /d . Feed ba ck : D ai ly s te ps a nd c al enda r. Da ta re ca ll f ro m A M : 1 da y. Res ou rc es /d iet ar y a dv ice/ du ra tio n: sa me a s c . Pa l, S . 2011 Aust ra lia 26 Nu mb er ( ra nd omi ze d) : 3 2 (c : 16, i: 16) % ma le (ra nd omi ze d) : 0 Ag e ( co m pl et er s) : 43. 5 ± 9. 1 (c: 45. 27 ± 8. 4# , i : 41. 4 ± 9. 8# , p> .05) BM I ( co mp le te rs ): 29. 3 ± 4. 1* (c: 29. 7 ± 4. 1# , i : 28. 9 ± 4. 3# , p> .05) Ta rg et g ro up : W omen . Ba se d o n: - Co nt ac t: Di scu ss io n a t b as el in e a bo ut P A gu id el in es . Be ha vi ora l c omp on en ts : AM : A sea led p ed om et er . P ar tic ip an ts rec or de d w ee kl y st eps . PA go al : ≥ 30 m in /d w al ki ng on top of b as el in e ac tiv ity . Feed ba ck : Re co rd in g o f t ot al w ee kl y s te ps . Res ou rc es : Na tio na l A us tr al ia n P hys ica l A ct iv ity G ui de line s. Di et ar y a dv ice: M ai nt ai n n or m al d ie t. Du ra tio n: 1 2 we ek s. Ba se d o n: - Co nt ac t/ Be ha vi ora l c omp on en ts : S ame a s c . AM : P ed om et er (Y ama x SW -2 00) . In st ru ct io n A M : R ec or d s te ps /d o n a ca le nda r. PA go al : ≥ 10, 000 st ep s/ d. Feed ba ck : D ai ly s te ps a nd c al enda r. Da ta re ca ll f ro m A M : 1 da y. Res ou rc es /d iet ar y a dv ice/ du ra tio n: S ame a s c . Pa sc ha li, A. A. 2005 USA 27 Nu mb er ( ra nd omi ze d) : 3 0 (c : 15, i: 15) % ma le (ra nd omi ze d) : 46. 2 (c: 47 % , i : 47 % , p >. 05) Ag e ( ra nd omi ze d) : 48. 1 ± 7. 1 (c: 47. 0 ± 7. 2, i: 48 .8 ± 6. 1, p> .05) BM I: Unk no w n ( inc lus io n: ≥30) Targ et g ro up : C om m uni ty sa m pl e Ba se d o n: So cia l C ogn iti ve T he or y Co nt ac t: M ont hl y c ouns el ing by be ha vi or the ra pi st (1 5 m in) . Be ha vi ora l c omp on en ts : B as ic b eh av io ra l s el f-ma na gem en t pr inc ipl es , di sc us sio n o f g oa ls, pr obl em s e nc ount er ed a nd pr obl em so lv ing . AM : Tr i-A xia l a cc el er om et er (B io tr ai ner ), d isp la y t ur ned o ff. PA go al : B ris k w al ki ng or e xe rc ise o f e qu iv al en t i nt en sit y ≥ 3 time s p w. Feed ba ck : P ape r di ar y w ith di sc us sio n o f s el f-r ep or ted ex er cis e. Res ou rc es : 2 4-pa ge m anua l w ith e xe rc ise in st ruc tio ns a nd s el f-ma na gem en t. Di et ar y a dv ice: N on e. Ba se d o n: S oc ia l C ogn iti ve T he or y. Co nt ac t/ Be ha vi ora l c omp on en ts : S ame a s c . AM : Tr i-a xia l a cc el er omet er (B io Tr ai ner ). In st ru ct io n A M : W ea r t he A M a nd m oni to r da ily s te ps . PA go al : B ris k wa lk in g o r ex er cis e o f eq ui va len t i nt en sit y ≥3 ti m es p w . Feed ba ck : Act iv ity u ni ts a cc umu la ted o n a cc el er omet er , m ont hl y hi st or y di spl aye d g ra phi ca lly o n a co m put er and w as pr int ed, pa pe r di ar y. D isc us sio n o f t he ac ce le rom et er d at a. Da ta re ca ll f ro m A M : 28 d ay s. Res ou rc es /d iet ar y a dv ice/ du ra tio n: S ame a s c .
