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1.  A Community-wide Media Campaign to Promote Walking in a Missouri Town 
Preventing Chronic Disease  2005;2(4):A04.
Engaging in moderate physical activity for 30 minutes five or more times per week substantially reduces the risk of coronary heart disease, stroke, colon cancer, diabetes, high blood pressure, and obesity, and walking is an easy and accessible way to achieve this goal. A theory-based mass media campaign promoted walking and local community-sponsored wellness initiatives through four types of media (billboard, newspaper, radio, and poster advertisements) in St Joseph, Mo, over 5 months during the summer of 2003.
The Walk Missouri campaign was conducted in four phases: 1) formative research, 2) program design and pretesting, 3) implementation, and 4) impact assessment. Using a postcampaign-only, cross-sectional design, a telephone survey (N = 297) was conducted in St Joseph to assess campaign impact. Study outcomes were pro-walking beliefs and behaviors.
One in three survey respondents reported seeing or hearing campaign messages on one or more types of media. Reported exposure to the campaign was significantly associated with two of four pro-walking belief scales (social and pleasure benefits) and with one of three community-sponsored activities (participation in a community-sponsored walk) controlling for demographic, health status, and environmental factors. Exposure was also significantly associated with one of three general walking behaviors (number of days per week walking) when controlling for age and health status but not when beliefs were introduced into the model, consistent with an a priori theoretical mechanism: the mediating effect of pro-walking beliefs on the exposure–walking association.
These results suggest that a media campaign can enhance the success of community-based efforts to promote pro-walking beliefs and behaviors.
PMCID: PMC1432093  PMID: 16164808
2.  High Point Walking for Health: Creating Built and Social Environments That Support Walking in a Public Housing Community 
American journal of public health  2009;99(Suppl 3):S593-S599.
We implemented and evaluated multiple interventions to increase walking activity at a multicultural public housing site.
A community-based participatory research partnership and community action teams assessed assets and barriers related to walking and developed multiple interventions to promote walking activity. Interventions included sponsoring walking groups, improving walking routes, providing information about walking options, and advocating for pedestrian safety. A pre–post study design was used to assess the changes in walking activity.
Self-reported walking activity increased among walking group participants from 65 to 108 minutes per day (P=.001). The proportion that reported being at least moderately active for at least 150 minutes per week increased from 62% to 81% (P=.018).
A multicomponent intervention developed through participatory research methods that emphasized walking groups and included additional strategies to change the built and social environments increased walking activity at a public housing site in Seattle.
PMCID: PMC2774172  PMID: 19890163
3.  Exercise on prescription for women aged 40-74 recruited through primary care: two year randomised controlled trial 
Objective To assess the effectiveness of a primary care based programme of exercise on prescription among relatively inactive women over a two year period.
Design Randomised controlled trial.
Setting 17 primary care practices in Wellington, New Zealand
Participants 1089 women aged 40-74 not undertaking 30 minutes of moderate intensity physical activity on at least five days of the week
Intervention Brief physical activity intervention led by nurse with six month follow-up visit and monthly telephone support over nine months.
Main outcome measure Physical activity assessed at baseline and 12 and 24 months. Secondary outcomes were quality of life (SF-36), weight, waist circumference, blood pressure, concentrations of fasting serum lipids, glycated haemoglobin (HbA1c), glucose, insulin, and physical fitness.
Results Mean age was 58.9 (SD 7) years. Trial retention rates were 93% and 89% at 12 and 24 months, respectively. At baseline, 10% of intervention participants and 11% of control participants were achieving 150 minutes of at least moderate intensity physical activity a week. At 12 months rates increased to 43% and 30% and at 24 months to 39.3% and 32.8% (P<0.001), respectively. SF-36 physical functioning (P=0.03) and mental health (P<0.05) scores improved more in intervention compared with control participants, but role physical scores were significantly lower (P<0.01). There were no significant differences in clinical outcomes. More falls (P<0.001) and injuries (P=0.03) were recorded in the intervention group.
Conclusions This programme of exercise on prescription increased physical activity and quality of life over two years, although falls and injuries also increased. This finding supports the use of exercise on prescription programmes as part of population strategies to reduce physical inactivity.
Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ANZCTRN012605000490673.
PMCID: PMC2769033  PMID: 19074218
4.  Sisters in Motion: A Randomized Controlled Trial of a Faith-Based Physical Activity Intervention 
To evaluate a faith-based intervention (“Sisters in Motion”) intended to increase walking among older, sedentary African American women.
RCT, using within-church randomization.
Three Los Angeles churches.
Sixty-two African American women >60 years who reported being active <30 minutes 3×/week and walked <35,000 steps/week as measured by a baseline pedometer reading.
Intervention participants received a multi-component curriculum including Scripture readings, prayer, goal-setting, a community resource guide, and walking competitions. Both intervention and control participants participated in physical activity sessions.
The primary outcome was change in weekly steps walked as measured by pedometer. Secondary outcomes included change in systolic blood pressure (SBP). Outcomes were assessed at baseline and 6 months post intervention.
Eighty-five percent of participants attended at least 6 of 8 sessions. Intervention participants averaged 12,727 steps per week at baseline, compared to 13,089 steps among controls. Mean baseline SBP was 156 mmHg for intervention participants and 147 mmHg among controls (p=0.10). At 6 months, intervention participants had increased their weekly steps by 9,883 on average, compared to an increase of 2,426 for controls (p=0.016); SBP decreased on average by 12.5 mmHg among intervention participants and only 1.5 mmHg among controls (p=0.007).
The Sisters in Motion intervention led to an increase in walking and a decrease in SBP at 6 months. This is the first RCT of a faith-based physical activity program to increase physical activity among older African American women, and represents an attractive approach to stimulate lifestyle change within this population.
PMCID: PMC2953732  PMID: 20929464
Physical Activity; African Americans; Randomized Controlled Trial
5.  Development of an ecologically valid approach to assess moderate physical activity using accelerometry in community dwelling women of color: A cross-sectional study 
Women of color report the lowest levels of physical activity and highest rates of overweight and obesity in the US. The purpose of this study was to develop an individualized, ecologically valid, field based method to assess physical activity over seven days for community dwelling women of color using accelerometers.
Accelerometer-measured physical activity, Borg perceived exertion, demographics, blood pressure, heart rate, and anthropometric measures were collected from African American and Hispanic or Latina women (N = 209). A threshold for increased physical activity was determined for each participant by calculating the average count per minute (plus one standard deviation) for each participant collected during a self-selected pace that corresponded to a 'recreational' walk about their neighborhood. The threshold was then used to calculate the amount of time spent doing increased intensity physical activity during a typical week.
Women were middle-aged and obese (M BMI = 34.3 ± 9.3). The average individual activity counts per day ranged from 482-1368 in African American women and 470-1302 in Hispanic or Latina women. On average, African American women spent significantly more time doing what was labeled 'increased' physical activity than Hispanic and Latino women. However neither group approached recommended physical activity levels, as African American women, averaged 1.73% and Hispanic and Latino women averaged 0.83% of their day engaged in increased physical activity (p < 0.05).
This study presents a simple field-based method for developing accelerometer thresholds that identify personalized thresholds of moderate intensity physical activity that can be used by in community-based settings. Findings highlight a need for physical activity programs whose starting points are based upon the individual's typical baseline physical activity level, which is likely to be well below the minimum recommended published guidelines.
PMCID: PMC3072301  PMID: 21439052
6.  Analysis of Individual Social-ecological Mediators and Moderators and Their Ability to Explain Effect of a Randomized Neighborhood Walking Intervention 
Using data from the SHAPE trial, a randomized 6-month neighborhood-based intervention designed to increase walking activity among older adults, this study identified and analyzed social-ecological factors mediating and moderating changes in walking activity.
Three potential mediators (social cohesion, walking efficacy, and perception of neighborhood problems) and minutes of brisk walking were assessed at baseline, 3-months, and 6-months. One moderator, neighborhood walkability, was assessed using an administrative GIS database. The mediating effect of change in process variables on change in brisk walking was tested using a product-of-coefficients test, and we evaluated the moderating effect of neighborhood walkability on change in brisk walking by testing the significance of the interaction between walkability and intervention status.
Only one of the hypothesized mediators, walking efficacy, explained the intervention effect (product of the coefficients (95% CI) = 8.72 (2.53, 15.56). Contrary to hypotheses, perceived neighborhood problems appeared to suppress the intervention effects (product of the coefficients (95% CI = -2.48, -5.6, -0.22). Neighborhood walkability did not moderate the intervention effect.
Walking efficacy may be an important mediator of lay-lead walking interventions for sedentary older adults. Social-ecologic theory-based analyses can support clinical interventions to elucidate the mediators and moderators responsible for producing intervention effects.
PMCID: PMC2728705  PMID: 19643024
7.  The effect of two different health messages on physical activity levels and health in sedentary overweight, middle-aged women 
BMC Public Health  2011;11:204.
Most public health guidelines recommend that adults need to participate in 30 minutes of moderate intensity physical activity on most days of the week to maintain good health. Achieving the recommended 30 minutes of exercise a day can be difficult in middle aged, overweight women. This 12 week study evaluated whether a 10,000 steps per day message was more effective than a 30 minutes a day message in increasing physical activity in low active, overweight women.
Thirty participants were randomized into 2 groups: Group 1 was asked to undertake 30 minutes of walking/day, whereas Group 2 was asked to accumulate 10,000 steps/day using their pedometers.
Results showed that there were no changes in anthropometric and blood pressure measures between or within groups. However, the 10,000 step and the 30 minutes groups' daily average number of steps/day were significantly higher than baseline at week 6 (p = 0.038 and p = 0.039 respectively) and at week 12 (p = 0.028 and p = 0.038 respectively). At week 12, the 10,000 steps group were taking an average of 4616 steps per day more (43% increase) than at baseline and the 30 minutes group were taking an average of 2761 steps per day more (35% increase) than at baseline. There was a significant difference in the number of steps with the 10,000 steps group versus 30 minutes group at 12 weeks (p = 0.045).
This study found that low active, overweight women undertook significantly more physical activity when they had a daily 10,000 step goal using a pedometer, than when they were asked to achieve 30 minutes of walking/day. Therefore we suggest that a public health recommendation of "10,000 steps/day", rather than the "30 min/day" could be applied to promote increased physical activity in sedentary middle aged women.
PMCID: PMC3078883  PMID: 21453540
8.  Interventions to Increase Walking Behavior 
Medicine and science in sports and exercise  2008;40(7 Suppl):S567-S573.
Walking is the most prevalent and preferred method of physical activity for both work and leisure purposes, thus making it a prime target for physical activity promotion interventions. We identified 14 randomized controlled trials, which tested interventions specifically targeting and assessing walking behavior. Results show that among self-selected samples intensive interventions can increase walking behavior relative to controls. Brief telephone prompts appear to be as effective as more substantial telephone counseling. Although more research is needed, individual studies support prescriptions to walk 5–7 d/wk versus 3–5 d/wk and at a moderate (versus vigorous) intensity pace, with no differences in total walking minutes when single or multiple daily walking bouts are prescribed. Mediated interventions delivering physical activity promotion materials through non-face-to-face channels may be ideal for delivering walking promotion interventions and have shown efficacy in promoting overall physical activity, especially when theory-based and individually tailored. Mass media campaigns targeting broader audiences, including those who may not intend to increase their physical activity, have been successful at increasing knowledge and awareness about physical activity, but are often too diffuse to successfully impact individual behavior change. Incorporating individually tailored programs into broader mass media campaigns may be an important next step, and the Internet could be a useful vehicle.
PMCID: PMC2694671  PMID: 18562974
Walking; Physical Activity; Exercise; Mediated Interventions; Behavior Change
9.  Distance Walked and Run as Improved Metrics over Time-Based Energy Estimation in Epidemiological Studies and Prevention; Evidence from Medication Use 
PLoS ONE  2012;7(8):e41906.
The guideline physical activity levels are prescribed in terms of time, frequency, and intensity (e.g., 30 minutes brisk walking, five days a week or its energy equivalence) and assume that different activities may be combined to meet targeted goals (exchangeability premise). Habitual runners and walkers may quantify exercise in terms of distance (km/day), and for them, the relationship between activity dose and health benefits may be better assessed in terms of distance rather than time. Analyses were therefore performed to test: 1) whether time-based or distance-based estimates of energy expenditure provide the best metric for relating running and walking to hypertensive, high cholesterol, and diabetes medication use (conditions known to be diminished by exercise), and 2) the exchangeability premise.
Logistic regression analyses of medication use (dependent variable) vs. metabolic equivalent hours per day (METhr/d) of running, walking and other exercise (independent variables) using cross-sectional data from the National Runners' (17,201 male, 16,173 female) and Walkers' Health Studies (3,434 male, 12,384 female).
Estimated METhr/d of running and walking activity were 38% and 31% greater, respectively, when calculated from self-reported time than distance in men, and 43% and 37% greater in women, respectively. Percent reductions in the odds for hypertension and high cholesterol medication use per METhr/d run or per METhr/d walked were ≥2-fold greater when estimated from reported distance (km/wk) than from time (hr/wk). The per METhr/d odds reduction was significantly greater for the distance- than the time-based estimate for hypertension (runners: P<10−5 for males and P = 0.003 for females; walkers: P = 0.03 for males and P<10−4 for females), high cholesterol medication use in runners (P<10−4 for males and P = 0.02 for females) and male walkers (P = 0.01 for males and P = 0.08 for females) and for diabetes medication use in male runners (P<10−3).
Although causality between greater exercise and lower prevalence of hypertension, high cholesterol and diabetes cannot be inferred from these cross-sectional data, the results do suggest that distance-based estimates of METhr/d run or walked provide superior metrics for epidemiological analyses to their traditional time-based estimates.
PMCID: PMC3423408  PMID: 22916114
10.  Community-based Randomized Controlled Trial of Non-pharmacological Interventions in Prevention and Control of Hypertension among Young Adults 
Hypertension is a major chronic lifestyle disease. Several non-pharmacological interventions are effective in bringing down the blood pressure (BP). This study focuses on the effectiveness of such interventions among young adults.
To measure the efficacy of physical exercise, reduction in salt intake, and yoga, in lowering BP among young (20-25) pre-hypertensives and hypertensives, and to compare their relative efficacies.
Settings and Design:
The study was done in the urban service area of JIPMER. Pre-hypertensives and hypertensives, identified from previous studies, constituted the universe. The participants were randomized into one control and three interventional groups.
Materials and Methods:
A total of 113 subjects: 30, 28, 28 and 27 in four groups respectively participated for eight weeks: control (I), physical exercise (II) - brisk walking for 50-60 minutes, four days/week, salt intake reduction (III) - to at least half of their previous intake, and practice of yoga (IV) - for 30-45 minutes/day on at least five days/week.
Statistical Analysis Used:
Efficacy was assessed using paired t test and ANOVA with Games Howell post hoc test. An intention to treat analysis was also performed.
A total of 102 participants (29, 27, 25 and 21 in groups I, II, III and IV) completed the study. All three intervention groups showed a significant reduction in BP (SBP/DBP: 5.3/6.0 in group II, 2.6/3.7 in III, and 2.0/2.6 mm Hg in IV respectively). There was no significant change (SBP/DBP: 0.2/0.5 mmHg) of BP in control group (I). Physical exercise was most effective (considered individually); salt intake reduction and yoga were also effective.
Physical exercise, salt intake reduction, and yoga are effective non-pharmacological interventions in significantly reducing BP among young hypertensives and pre-hypertensives. These can therefore be positively recommended for hypertensives. There is also a case to deploy these interventions in the general population.
PMCID: PMC2822195  PMID: 20165628
Community-based randomized controlled trial; hypertension; relative efficacies; physical exercise; salt intake reduction; yoga; young adults
11.  Promoting Physical Activity in Patients with Colon Adenomas: A Randomized Pilot Intervention Trial 
PLoS ONE  2012;7(7):e39719.
Physical activity decreases risk of colon polyps and colon cancer and might reduce risk of colon cancer recurrence. Focusing on recent calls for translation of epidemiologic evidence into clinical care, our pilot study delivered an evidence-based physical activity intervention in adults with polyps, who are thus at elevated risk of developing colon cancer. The objective was to evaluate change in physical activity, measured by steps per day and minutes of moderate/vigorous physical activity.
Sixteen adults with adenomas detected and removed at screening colonoscopy were recruited to a 12-week physical activity intervention. Participants were randomized to receive a standard (30 minutes/day) or high (60 minutes/day) walking program. Physical activity was measured via blinded pedometer and accelerometer at baseline and follow-up. Intervention messages focused on self-monitoring using pedometers and overcoming barriers to engaging in physical activity.
Participants in both arms significantly increased objectively measured minutes of moderate/vigorous physical activity over the course of the intervention. Both arms exceeded the intervention goal, but there was not a significant difference between arms at follow-up. Results were similar for pedometer measured physical activity, with a significant overall increase in steps/day from baseline to follow-up, but no between arm difference in change.
Simple interventions of minimal contact time focusing on walking can significantly increase physical activity in individuals at increased risk of developing colon cancer.
Trial Registration NCT01476631
PMCID: PMC3396639  PMID: 22808053
12.  Can lay-led walking programmes increase physical activity in middle aged adults? A randomised controlled trial 
Design: Randomised controlled trial with one year follow up. Physical activity was measured by questionnaire. Other measures included attitudes to exercise, body mass index, cholesterol, aerobic capacity, and blood pressure.
Setting: Primary care and community.
Participants: 260 men and women aged 40–70 years, taking less than 120 minutes of moderate intensity activity per week.
Main results: Seventy three per cent of people completed the trial. Of these, the proportion increasing their activity above 120 minutes of moderate intensity activity per week was 22.6% in the advice only and 35.7% in the health walks group at 12 months (between group difference =13% (95% CI 0.003% to 25.9%) p=0.05). Intention to treat analysis, using the last known value for missing cases, demonstrated smaller differences between the groups (between group difference =6% (95% CI -5% to 16.4%)) with the trend in favour of health walks. There were improvements in the total time spent and number of occasions of moderate intensity activity, and aerobic capacity, but no statistically significant differences between the groups. Other cardiovascular risk factors remained unchanged.
Conclusions: There were no significant between group differences in self reported physical activity at 12 month follow up when the analysis was by intention to treat. In people who completed the trial, health walks was more effective than giving advice only in increasing moderate intensity activity above 120 minutes per week.
PMCID: PMC1732126  PMID: 11896130
13.  Evaluation of a community-based participatory physical activity promotion project: effect on cardiovascular disease risk profiles of school employees 
BMC Public Health  2010;10:313.
The efficacy of physical activity in improving cardiovascular disease (CVD) risk profiles has been well established. However, the effectiveness of health promotion programs implemented at the community level remains controversial. This study evaluated a school-based work-site physical activity program.
Using a community-based participatory research model, a work-site wellness intervention was implemented in a rural public school system in Southwestern Oklahoma. During the 2005-2006 school year, 187 participants (mean age 45 years) completed a pre intervention screening for CVD risk factors followed by a physical activity promotion program. Post intervention screening was conducted after a 6 month period. During both screening sessions, body composition, blood pressure, lipids, glucose and self-reported physical activity levels were assessed. The focus of the intervention was on promoting physical activity. Opportunities for in school physical activity were created by marking hallways, adding a treadmill in each school, and allowing teachers to use planning periods for physical activity.
During the post intervention screening, compared to pre intervention levels, participants had lower total, low, and high density lipoprotein-cholesterol (t = 5.9, p < 0.0001, t = 2.6, p = 0.01, and t = 13.2, p < 0.0001 respectively), lower systolic blood pressure (t = 2.9, p = 0.004), and higher self-reported physical activity levels (Sign t = -1.901, p = 0.06).
A successful participatory program was associated with improvements in several CVD risk factors among school employees. Limitations of this study such as seasonal variation in the outcome variables and lack of a control group limit our ability to draw solid conclusions about the effectiveness of the intervention.
PMCID: PMC2894775  PMID: 20525391
14.  Pilot Study of a Faith-Based Physical Activity Program Among Sedentary Blacks 
Preventing Chronic Disease  2008;5(2):A51.
Physical activity participation is low among blacks, and strategies are needed to successfully create immediate and sustained behavior change related to physical activity. Churches can play an important role in health promotion efforts among blacks because of their central role in spiritual guidance, communication, social support, and networking. This pilot study evaluated the feasibility and acceptability of implementing a physical activity program for sedentary black adults in churches.
We used a preintervention/postintervention single-group design to evaluate the effect of a 3-month faith-based physical activity intervention on daily walking and moderate- and vigorous-intensity physical activity among sedentary blacks. Eighty-seven black adults participated in eight group sessions that included discussion of physical activity-related topics, an instructor-led physical activity session, and weekly incentives to promote physical activity. We used a questionnaire to assess moderate and vigorous physical activity in minutes per week at baseline and after 3 months. Walking was assessed weekly in steps per day by using a pedometer.
Participants (mean age, 52 yrs; mean body mass index, 35 kg/m2) reported 27 ± 54 and 10 ± 25 minutes per week in moderate-intensity and vigorous-intensity physical activity, respectively, and walked 4822 ± 2351 steps per day at baseline. After 12 weeks, moderate- and vigorous-intensity physical activity increased by 67 ± 78 and 44 ± 66 minutes per week, respectively (P ≤ .01), and daily walking increased by 1373 ± 728 steps per day (P < .001).
These data suggest that a faith-based physical activity intervention may be an appropriate strategy for increasing physical activity among sedentary black adults. Future research will determine the impact of this program in a randomized, controlled design.
PMCID: PMC2396995  PMID: 18341786
15.  Relationship Between Physical Functioning and Physical Activity in the Lifestyle Interventions and Independence for Elders Pilot (LIFE-P) 
To determine if participation in usual moderate-intensity or more vigorous physical activity (MVPA) is associated with physical function performance and to identify socio-demographic, psychosocial and disease-related covariates that may also compromise physical function performance.
Cross-sectional analysis of baseline variables of randomized controlled intervention trial.
Four separate academic research centers.
Four hundred twenty-four older adults aged 70–89 years at risk for mobility-disability (scoring <10 on the Short Physical Performance Battery, SPPB) and able to complete the 400 m walk test within 15 minutes.
Minutes of MVPA (dichotomized according to above or below 150 min•wk−1 of MVPA) assessed by the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire, SPPB score, 400 M walk test, gender, body mass index (BMI), depressive symptoms, age and number of medications.
The SPPB summary score was associated with minutes of MVPA (ρ = 0.16, P = 0.001). In multiple regression analyses, age, minutes of MVPA, number of medications and depressive symptoms were associated with performance on the composite SPPB (P < 0.05). There was an association between 400 m walk time and minutes of MVPA (ρ = −0.18; P = 0.0002). In multiple regression analyses, age, gender, minutes of MVPA, BMI and number of medications were associated with performance on the 400 m walk test (P < 0.05).
Minutes of MVPA, gender, BMI, depressive symptoms, age, and number of medications are associated with physical function performance and all should be taken into consideration in the prevention of mobility-disability.
PMCID: PMC2952066  PMID: 20738437
older adults; mobility-disability; physical function performance; older adults; mobility-disability; physical function performance
16.  Effects of Scheduled Exercise on Cancer-Related Fatigue in Women with Early Breast Cancer 
The Scientific World Journal  2014;2014:271828.
While physical activity during cancer treatment is found beneficial for breast cancer patients, evidence indicates ambiguous findings concerning effects of scheduled exercise programs on treatment-related symptoms. This study investigated effects of a scheduled home-based exercise intervention in breast cancer patients during adjuvant chemotherapy, on cancer-related fatigue, physical fitness, and activity level. Sixty-seven women were randomized to an exercise intervention group (n = 33, performed strength training 3x/week and 30 minutes brisk walking/day) and a control group (n = 34, performed their regular physical activity level). Data collection was performed at baseline, at completion of chemotherapy (Post1), and 6-month postchemotherapy (Post2). Exercise levels were slightly higher in the scheduled exercise group than in the control group. In both groups, cancer-related fatigue increased at Post1 but returned to baseline at Post2. Physical fitness and activity levels decreased at Post1 but were significantly improved at Post2. Significant differences between intervention and control groups were not found. The findings suggest that generally recommended physical activity levels are enough to relief cancer-related fatigue and restore physical capacity in breast cancer patients during adjuvant chemotherapy, although one cannot rule out that results reflect diminishing treatment side effects over time.
PMCID: PMC3915861  PMID: 24563628
17.  WalkMore: a randomized controlled trial of pedometer-based interventions differing on intensity messages 
BMC Public Health  2014;14:168.
Pedometer-based programs have elicited increased walking behaviors associated with improvements in blood pressure in sedentary/low active postmenopausal women, a population at increased risk of cardiovascular disease. Such programs typically encourage increasing the volume of physical activity with little regard for its intensity. Recent advances in commercially available pedometer technology now permit tracking of both steps/day and time in moderate (or greater) intensity physical activity on a daily basis. It is not known whether the dual message to increase steps/day while also increasing time spent at higher intensity walking will elicit additional improvements in blood pressure relative to a message to only focus on increasing steps/day. The purpose of this paper is to present the rationale, study design, and protocols employed in WalkMore, a 3-arm 3-month blinded and randomized controlled trial (RCT) designed to compare the effects of two community pedometer-based walking interventions (reflecting these separate and combined messages) relative to a control group on blood pressure in sedentary/low active post-menopausal women, a population at increased risk of cardiovascular disease.
120 sedentary/low active post-menopausal women (45-74 years of age) will be randomly assigned (computer-generated) to 1 of 3 groups: A) 10,000 steps/day (with no guidance on walking intensity/speed/cadence; BASIC intervention, n = 50); B) 10,000 steps/day and at least 30 minutes in moderate intensity (i.e., a cadence of at least 100 steps/min; ENHANCED intervention, n = 50); or a Control group (n = 20). An important strength of the study is the strict control and quantification of the pedometer-based physical activity interventions. The primary outcome is systolic blood pressure. Secondary outcomes include diastolic blood pressure, anthropometric measurements, fasting blood glucose and insulin, flow mediated dilation, gait speed, and accelerometer-determined physical activity and sedentary behavior.
This study can make important contributions to our understanding of the relative benefits that walking volume and/or intensity may have on blood pressure in a population at risk of cardiovascular disease.
Trial registration Record NCT01519583, January 18, 2012
PMCID: PMC3931482  PMID: 24528783
Walking; Physical activity; Pedometer; Accelerometer; Exercise
18.  Advantage of distance- versus time-based estimates of walking in predicting adiposity 
Physical activity recommendations are defined in terms of time spent being physically active (e.g., 30 minutes brisk walking, five days a week). However, walking volume may be more naturally assessed by distance than time. Analyses were therefore performed to test whether time or distance provide the best metric for relating walking volume to estimated total and regional adiposity.
Linear and logistic regression analyses were used to relate exercise dose to body mass index (BMI), body circumferences, and obesity in a cross-sectional sample of 12,384 female and 3,434 male walkers who reported both usual distance walked and time spent walking per week on survey questionnaires. Metabolic equivalent hours per day (METhr/d, 1 MET=3.5 ml O2•kg−1•min−1) were calculated from the time and pace, or distance and pace, using published compendium values. Results: Average METhr/d walked was 37% greater when calculated from time spent walking vs. usual distance in women, and 31% greater in men. Per METhr/d, declines in BMI and circumferences (slope±SE) were nearly twice as great, or greater, for distance- vs. time-derived estimates for kg/m2 of BMI (females: −0.58±0.03 vs. −0.31±0.02; males: −0.35±0.04 vs. −0.15±0.02), cm of waist circumference (females: −1.42±0.07 vs. −0.72±0.04; males: −0.96±0.10 vs. −0.45±0.07), and reductions in the odds for total obesity (odds ratio, females: 0.72 vs. 0.84; males: 0.84 vs. 0.92), and abdominal obesity (females: 0.74 vs. 0.85; males: 0.79 vs. 0.91, all comparisons significant).
Distance walked may provide a better metric of walking volume for epidemiologic obesity research, and better public health targets for weight control, than walking duration. Additional research is required to determine whether these results, derived in a sample that regularly walks for exercise, apply more generally.
PMCID: PMC3780575  PMID: 22525767
obesity; energy; physical activity; exercise volume; guidelines
19.  A randomised controlled trial of three pragmatic approaches to initiate increased physical activity in sedentary patients with risk factors for cardiovascular disease. 
BACKGROUND: Physical activity is a major modifiable risk factor for cardiovascular disease, but it is unclear what combination of feasible approaches, using existing resources in primary care, work best to initiate increased physical activity. AIM: To assess three approaches to initiate increased physical activity. DESIGN OF STUDY: Randomised controlled (2 X 2 X 2) factorial trial. SETTING: Four general practices. METHOD: One hundred and fifty-one sedentary patients with computer documented risk factors for cardiovascular disease were randomised to eight groups defined by three factors: prescription by general practitioners (GPs) for brisk exercise not requiring a leisure facility (for example, walking) 30 minutes per day, 5 days per week; counselling by practice nurses, based on psychological theory to modify intentions and perceived control of behaviour, and using behavioural implementation techniques (for example, contracting, 'rehearsal'); use of the Health Education Authority booklet 'Getting active, feeling fit'. RESULTS: Single interventions had modest effects. There was a trend from the least intensive interventions (control +/- booklet) to the more intensive interventions (prescription and counselling combined +/- booklet) for both increased physical activity and fitness (test for trend, P = 0.02 and P = 0.05, respectively). Only with the most intense intervention (prescription and counselling combined) were there significant increases in both physical activity and fitness from baseline (Godin score = 14.4, 95% confidence interval [CI] = 7.8 to 21, which was equivalent to three 15-minute sessions of brisk exercise and a 6-minute walking distance = 28.5 m, respectively, 95% CI = 11.1 to 45.8). Counselling only made a difference among those individuals with lower intention at baseline. CONCLUSION: Feasible interventions using available staff, which combine exercise prescription and counselling explicitly based on psychological theory, can probably initiate important increases in physical activity.
PMCID: PMC1314829  PMID: 15006124
20.  Non-pharmacological Interventions in Hypertension: A Community-based Cross-over Randomized Controlled Trial 
Hypertension is the most prevalent non-communicable disease causing significant morbidity/mortality through cardiovascular, cerebrovascular, and renal complications.
This community-based study tested the efficacy of non-pharmacological interventions in preventing/controlling hypertension.
Materials and Methods:
This is a cross-over randomized controlled trial (RCT) of the earlier RCT (2007) of non-pharmacological interventions in hypertension, conducted in the urban service area of our Institute. The subjects, prehypertensive and hypertensive young adults (98 subjects: 25, 23, 25, 25 in four groups) were randomly allotted into a group that he/she had not belonged to in the earlier RCT: Control (New Group I), Physical Exercise (NG II)-brisk walking for 50 to 60 minutes, three to four days/week, Salt Intake Reduction (NG III) to at least half of their previous intake, Yoga (NG IV) for 30 to 45 minutes/day, five days/week. Blood pressure was measured before and after eight weeks of intervention. Analysis was by ANOVA with a Games-Howell post hoc test.
Ninety-four participants (25, 23, 21, 25) completed the study. All three intervention groups showed significant reduction in BP (SBP/DBP mmHg: 5.3/6.0 in NG II, 2.5/2.0 in NG III, and 2.3/2.4 in NG IV, respectively), while the Control Group showed no significant difference. Persistence of significant reduction in BP in the three intervention groups after cross-over confirmed the biological plausibility of these non-pharmacological interventions. This study reconfirmed that physical exercise was more effective than Salt Reduction or Yoga. Salt Reduction, and Yoga were equally effective.
Physical exercise, salt intake reduction, and yoga are effective non-pharmacological methods for reducing blood pressure in young pre-hypertensive and hypertensive adults.
PMCID: PMC3214443  PMID: 22090672
Cross-over randomized controlled trial; hypertension; non-pharmacological interventions
21.  The contribution of walking to work to adult physical activity levels: a cross sectional study 
To objectively examine the contribution to adult physical activity levels of walking to work.
Employees (n = 103; 36.3 ± 11.7 years) at 17 workplaces in south-west England, who lived within 2 miles (3.2 km) of their workplace, wore Actigraph accelerometers for seven days during waking hours and carried GPS receivers during the commute to and from work. Physical activity volume (accelerometer counts per minute (cpm)) and intensity (minutes of moderate to vigorous physical activity (MVPA)) were computed overall and during the walk to work.
Total weekday physical activity was 45% higher in participants who walked to work compared to those travelling by car (524.6. ± 170.4 vs 364.6 ± 138.4 cpm) and MVPA almost 60% higher (78.1 ± 24.9 vs 49.8 ± 25.2 minutes per day). No differences were seen in weekend physical activity, and sedentary time did not differ between the groups. Combined accelerometer and GPS data showed that walking to work contributed 47.3% of total weekday MVPA.
Walking to work was associated with overall higher levels of physical activity in young and middle-aged adults. These data provide preliminary evidence to underpin the need for interventions to increase active commuting, specifically walking, in adults.
PMCID: PMC3975276  PMID: 24618001
Physical activity measurement; Accelerometer; Walking; Adult physical activity guidelines
22.  Increasing older adults’ walking through primary care: results of a pilot randomized controlled trial 
Family Practice  2012;29(6):633-642.
Physical activity can positively influence health for older adults. Primary care is a good setting for physical activity promotion.
To assess the feasibility of a pedometer-based walking programme in combination with physical activity consultations.
Design: Two-arm (intervention/control) 12-week randomized controlled trial with a 12-week follow-up for the intervention group. Setting: One general practice in Glasgow, UK. Participants: Participants were aged ≥65 years. The intervention group received two 30-minute physical activity consultations from a trained practice nurse, a pedometer and a walking programme. The control group continued as normal for 12 weeks and then received the intervention. Both groups were followed up at 12 and 24 weeks. Outcome measures: Step counts were measured by sealed pedometers and an activPALTM monitor. Psychosocial variables were assessed and focus groups conducted.
The response rate was 66% (187/284), and 90% of those randomized (37/41) completed the study. Qualitative data suggested that the pedometer and nurse were helpful to the intervention. Step counts (activPAL) showed a significant increase from baseline to week 12 for the intervention group, while the control group showed no change. Between weeks 12 and 24, step counts were maintained in the intervention group, and increased for the control group after receiving the intervention. The intervention was associated with improved quality of life and reduced sedentary time.
It is feasible to recruit and retain older adults from primary care and help them increase walking. A larger trial is necessary to confirm findings and consider cost-effectiveness.
PMCID: PMC3501246  PMID: 22843637
Ageing, patient education, physical activity, prevention, primary care, quality of life
23.  Physical activity as an aid to smoking cessation during pregnancy: Two feasibility studies 
BMC Public Health  2008;8:328.
Pharmacotherapies for smoking cessation have not been adequately tested in pregnancy and women are reluctant to use them. Behavioural support alone has a modest effect on cessation rates; therefore, more effective interventions are needed. Even moderate intensity physical activity (e.g. brisk walk) reduces urges to smoke and there is some evidence it increases cessation rates in non-pregnant smokers. Two pilot studies assessed i) the feasibility of recruiting pregnant women to a trial of physical activity for smoking cessation, ii) adherence to physical activity and iii) womens' perceptions of the intervention.
Pregnant smokers volunteered for an intervention combining smoking cessation support, physical activity counselling and supervised exercise (e.g. treadmill walking). The first study provided six weekly treatment sessions. The second study provided 15 sessions over eight weeks. Physical activity levels and continuous smoking abstinence (verified by expired carbon monoxide) were monitored up to eight months gestation.
Overall, 11.6% (32/277) of women recorded as smokers at their first antenatal booking visit were recruited. At eight months gestation 25% (8/32) of the women achieved continuous smoking abstinence. Abstinent women attended at least 85% of treatment sessions and 75% (6/8) achieved the target level of 110 minutes/week of physical activity at end-of-treatment. Increased physical activity was maintained at eight months gestation only in the second study. Women reported that the intervention helped weight management, reduced cigarette cravings and increased confidence for quitting.
It is feasible to recruit pregnant smokers to a trial of physical activity for smoking cessation and this is likely to be popular. A large randomised controlled trial is needed to examine the efficacy of this intervention.
PMCID: PMC2559842  PMID: 18811929
24.  The effect of a worksite based walking programme on cardiovascular risk in previously sedentary civil servants [NCT00284479] 
BMC Public Health  2006;6:136.
A significant proportion of Europeans do not meet the recommendations for 30 mins of physical activity 5 times per week. Whether lower frequency, moderate intensity exercise alters cardiovascular disease (CVD) risk has received little attention. This study examined the effects of 45 minutes self-paced walking, 2 d· wk-1 on aerobic fitness, blood pressure (BP), body composition, lipids and C-Reactive Protein (CRP) in previously sedentary civil servants.
37 subjects (24 women) aged 41.5 ± 9.3 years were randomly assigned to either two 45 minute walks per week (walking group) or no training (control group). Aerobic fitness, body composition, blood pressure (BP), CRP and lipoprotein variables were measured at baseline and following 8 weeks. Steps counts were measured at baseline and during weeks 4 and 8 of the intervention.
Compared to the control group, the walking group showed a significant reduction in systolic BP and maintained body fat levels (P < 0.05). There were no changes other risk factors. Subjects took significantly more steps on the days when prescribed walking was performed (9303 ± 2665) compared to rest days (5803 ± 2749; P < 0.001).
These findings suggest that walking twice per week for 45 minutes at ~ 62% HRmax, improves activity levels, reduces systolic BP and prevents an increase in body fat in previously sedentary adults. This walking prescription, however, failed to induce significant improvements in other markers of cardiovascular disease risk following eight weeks of training.
PMCID: PMC1501013  PMID: 16716211
25.  Randomised controlled trial of a complex intervention by primary care nurses to increase walking in patients aged 60–74 years: protocol of the PACE-Lift (Pedometer Accelerometer Consultation Evaluation - Lift) trial 
BMC Public Health  2013;13:5.
Physical activity is essential for older peoples’ physical and mental health and for maintaining independence. Guidelines recommend at least 150 minutes weekly, of at least moderate intensity physical activity, with activity on most days. Older people’s most common physical activity is walking, light intensity if strolling, moderate if brisker. Less than 20% of United Kingdom 65–74 year olds report achieving the guidelines, despite most being able to. Effective behaviour change techniques include strategies such as goal setting, self-monitoring, building self-efficacy and relapse prevention. Primary care physical activity consultations allow individual tailoring of advice. Pedometers measure step-counts and accelerometers measure physical activity intensity. This protocol describes an innovative intervention to increase walking in older people, incorporating pedometer and accelerometer feedback within a primary care nurse physical activity consultation, using behaviour change techniques.
Design: Randomised controlled trial with intervention and control (usual care) arms plus process and qualitative evaluations.
Participants: 300 people aged 60–74 years registered with 3 general practices within Oxfordshire and Berkshire West primary care trusts, able to walk outside and with no restrictions to increasing their physical activity.
Intervention: 3 month pedometer and accelerometer based intervention supported by practice nurse physical activity consultations. Four consultations based on behaviour change techniques, physical activity diary, pedometer average daily steps and accelerometer feedback on physical activity intensity. Individual physical activity plans based on increasing walking and other existing physical activity will be produced.
Outcomes: Change in average daily steps (primary outcome) and average time spent in at least moderate intensity physical activity weekly (secondary outcome) at 3 months and 12 months, assessed by accelerometry. Other outcomes include quality of life, mood, exercise self-efficacy, injuries. Qualitative evaluations will explore reasons for trial non-participation, the intervention’s acceptability to patients and nurses and factors enhancing or acting as barriers for older people in increasing their physical activity levels.
The PACE-Lift trial will determine the feasibility and efficacy of an intervention for increasing physical activity among older primary care patients. Steps taken to minimise bias and the challenges anticipated will be discussed. Word count 341.
Trial registration number
PMCID: PMC3543841  PMID: 23289648
Physical activity; Older people; Pedometers; Accelerometers; Walking intervention; Cognitive behavioural; Primary care; Practice nurse

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