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Practice changer

Advise your patients to use a pedometer, set a step goal, and keep a step diary. This simple intervention takes only a few moments and is effective in increasing patients’ physical activity and decreasing both body-mass index (BMI) and systolic blood pressure.1

Strength of recommendation

A: Based on a meta-analysis of randomized controlled trials (RCTs) and observational studies

Bravata DM, Smith-Spangler C, Sundaram V et al. Using pedometers to increase physical activity and improve health: a systematic review. JAMA 2007; 298:2296–2304.

Illustrative case

Your first 4 patients this morning were a 50-year-old woman with metabolic syndrome, a 62-year-old obese man with high blood pressure, a 44-year-old woman with depression, and a 75-year-old man with a recent admission for myocardial infarction. In addition to managing their medications and reviewing lab results, you have already spent a lot of time discussing the benefits of exercise with each of these patients.

As you prepare to talk with your next patient—a 28-year-old woman with a BMI of 29 whose chief complaint is “wants to lose weight”—you wonder if there are any simple, brief, effective interventions to help your patients increase their physical activity.

BACKGROUND: A long way to go

Although there is no evidence that simply advising patients to walk has any effect, primary care physicians frequently recommend walking as a form of exercise—it is free, requires no special equipment, and is readily accessible to most motivated patients.

The Centers for Disease Control and Prevention recommends that adults engage in moderate physical activity for at least 30 minutes a day, at least 5 days per week.2 Yet 40% of adults do not engage in any leisure-time physical activity. This percentage is higher in women (43%), African-Americans (52%), and Hispanics (54%).3

The health benefits of exercise are clear. Regular physical activity has been shown to decrease overweight and obesity.4 It has also been shown to improve control of type 2 diabetes5 and hypertension.6 Frequent exercise is associated with a decreased mortality rate.7 Walking has been shown to decrease the risk of cardiovascular events in women, regardless of BMI.8

Walking has similarly been shown to decrease overall mortality among men.9 Cardiovascular fitness has also been shown to decrease mortality in adults over 60, even in the absence of weight loss.10

CLINICAL CONTEXT: USPSTF: Advice alone won’t kick-start exercise

We realize, of course, that most of our adult patients could benefit from regular exercise. Exercise is included in the treatment guidelines for overweight/obesity, hypertension, type 2 diabetes, metabolic syndrome, cardiovascular disease, chronic pain, peripheral vascular disease, and depression.11

Eureka! a simple, practical intervention

PURLs EDITOR
Bernard Ewigman. MD, MSPH

Department of Family Medicine
The University of Chicago
be.editor@gmail.com

At last, the humble pedometer gives us a brief intervention for physical exercise that works. yes, we need more research for lots of reasons (always), but this Purl gives us a practical tool that can be recommended in a few minutes, consistent with the realities of daily practice.

The outcomes from this intervention are not dramatic. No lives were saved, no catastrophic diseases averted. yet regular exercise is so fundamentally important to just feeling good and having energy for daily life, not to mention lowering blood pressure and weight.

My guess is that this could become a handy recommendation used daily in family medicine and other primary care practices.

I am interested to know whether you already recommend pedometers to your patients. If not, does this seem like a worthwhile change in your practice?

On a personal note, I made a New year’s resolution to increase my physical activity. as soon as I finish this commentary, I am ordering a pedometer.

However, few office-based interventions have been shown to lead to increased physical activity. Patients sometimes resist making lifestyle changes, and providers are uncertain how to effectively promote physical activity. Furthermore, counseling patients to exercise without a specific intervention has not been shown to lead to long-term increases in physical activity. The US Preventive Services Task Force (USPSTF) finds there is insufficient evidence to recommend behavioral counseling alone for exercise, citing the lack of evidence for long-term efficacy.12,13

STUDY SUMMARY: Pedometer users walked 2491 additional steps

This meta-analysis included 26 RCTs and observational studies of pedometer use in adult outpatients that reported a change in the number of steps walked per day. The 2767 participants in these studies were 85% women, with a mean age of 49. In the 7 studies that reported race, 93% of patients were white. At baseline, most participants were overweight, with normal blood pressure (mean 129/79 mm Hg) and relatively well-controlled lipid levels (mean total cholesterol 198 mg/dL, HDL 52 mg/dL, LDL 113 mg/dL). The mean baseline activity level was 7473 steps per day (range 2140–12,371). Duration of interventions ranged from 3 to 104 weeks, with a mean of 18 weeks. Sixteen of the studies used the Yamax pedometer, which has been validated for accuracy and reliability.

Participants in the RCTs who used pedometers increased their physical activity by 2491 steps per day more than controls. After excluding 1 study with a much higher increase in physical activity than the others, the increase was 2004 steps per day (95% confidence interval [CI], 878–3129; P<.001). In the observational studies, participants walked 2183 steps per day more than they had at baseline (95% CI, 1571–2796; P<.001). Overall, pedometer users increased their number of steps by 27% over baseline.

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