| Sign In to gain access to subscriptions and/or personal tools. |
Impact of Using a Pedometer on Time Spent Walking in Older Adults With Type 2 DiabetesFrom Diabetes Australia-Victoria, Melbourne, Australia (Ms Engel), and the School of Psychological Science, La Trobe University, Victoria, Australia (Dr Lindner). Correspondence to Lisa Engel, 54 Fernhill Road, Sandringham, Victoria, Australia, 3191 (lisaengel{at}netspace.net.au).
Purpose The purpose of this study was to investigate the impact of using a pedometer on time spent walking, in sedentary and overweight adults with type 2 diabetes participating in a coaching intervention. It was hypothesized that participants using a pedometer would spend more time walking than would nonpedometer participants. Method A sample of 57 men and women with a mean age of 62 years participated in a randomized controlled trial in a community setting. Participants were allocated to either a pedometer and coaching (intervention) group or a coaching-only (control) group. Coaching for both groups involved education, goal setting, and supportive/motivational strategies to increase time spent walking. The duration of the study was 6 months, with blood pressure, glycosylated hemoglobin, anthropometric, and fitness measurements assessed at baseline and at 3-month intervals. Results A repeated-measures analysis of variance indicated that the coaching-only group spent significantly more time walking than did the pedometer group. However, when an analysis of covariance with all the other variables as covariates was performed, group membership had no influence on time spent walking. Significant reductions in waist circumference and weight were achieved for both groups from baseline to 6 months. Cardiovascular fitness also increased significantly for both groups. Conclusion The study demonstrated that previously sedentary older adults with type 2 diabetes, supported with a coaching intervention, were able to achieve the physical activity targets known to be beneficial to health. However, using a pedometer added no further benefit. Further research on the impact of specific coaching strategies in diabetes management is warranted.
Currently, there is a ground swell of support emerging for the use of pedometers as a motivation and feedback tool. However, support for this role for pedometers appears unfounded given that most of the research on pedometers has focused on their use as a measurement device for assessing physical activity and not as a motivational tool.1,2 Nonetheless, despite the lack of consistent evidence for using pedometers as a means to improve sustained physical activity participation, their inclusion in physical activity interventions has become much more common. Two ambitious projects currently implementing health promotion strategies to increase the physical activity participation of their respective populations are the "10,000 Steps Rockhampton" (Rockhampton is a regional city in Queensland, Australia)3 and "Canada on the Move."4 Both projects are using pedometers as a novel way to encourage people to walk more, with the organizers of Canada on the Move distributing more than 800000 pedometers to Canadians in a breakfast cereal in December 2003.4 To date, it is too early to assess whether these interventions have made a difference in exercise participation in population-based studies. It could also be difficult to isolate and measure the specific effects of pedometers on physical activity outcomes. Currently, only limited research is available on the impact of pedometers on motivation to exercise. One study, examining the potential for 92 sedentary women to increase their steps per day while using a pedometer, found that participants were generally able to increase their step counts. However, in the absence of a control group who did not use a pedometer, it was not possible to assess the impact of the device or whether the process of goal setting was primarily responsible for the increased physical activity.5 In contrast, other research has contradicted these findings. In a 6-week study using a crossover design, 2 groups of 26 adults alternated between receiving feedback from pedometers for 3 weeks of exercise compared to no feedback. There was no overall increase in time spent walking, and using a pedometer did not influence the participants to walk more.6 In the literature related to diabetes management, 2 studies used pedometers as a measure of physical activity in participants with type 2 diabetes.7,8 While Yamanouchi et al7 demonstrated the benefits of exercise, the authors did not comment on any effects of wearing a pedometer. Tudor-Locke et al8 reported that participants found the pedometer to be a novel means of receiving feedback on their physical activity participation. Furthermore, the researchers found that participants sustained their walking over a 2-month follow-up period, during which they did not receive any contact from the researchers. However, the small sample size (n = 9) and the absence of a control group who were not using a pedometer limited the generalizability of these findings. Because of the immediate feedback pedometers provide to the wearer, their potential positive impact on exercise participation has received theoretical support.2 However, further research needs to be conducted to establish whether their widespread use in physical activity interventions is warranted.
Health-Related Coaching Support for incorporating coaching into clinical practice has been provided in a multicenter study involving cardiac patients.12 Results from this study demonstrated that patients randomized to a coaching group achieved significantly greater change in their total cholesterol compared to the usual-care group.12
Hypothesis
The study was approved by the Melbourne Health and La Trobe University ethics committees, and written consent was obtained from all participants.
Design and Setting The duration of the study was 6 months, with repeated measurements performed at 3-month intervals. The setting for the study was either the National Ageing Research Institute, located in the metropolitan area, or the participants' own homes (depending on the participants' preferred option).
Participants Seven participants withdrew from the study prior to its completion, 3 participants withdrew after the first assessment (n = 54), and a further 4 withdrew prior to the 6-month assessment (n = 50). This comprised a 12% dropout rate. Reasons for withdrawal included health problems (unrelated to increased walking) and work commitments.
Testing Procedures Resting arterial blood pressure was measured twice (at least 5 minutes apart) using a mercury sphygmomanometer, with participants at rest and having been sitting down for 5 minutes or more.15 As weight loss has been linked to improved diabetes control,16 body height and weight were measured. Participants were weighed wearing light clothing and without shoes. Weight was measured by SECA electronic scales to the nearest 0.1 kg. Height was measured using a Holtain stadiometer.17 Body mass index was calculated as weight (in kilograms) divided by height (in meters) squared. The waist was taken as the narrowest circumference between the lower costal margin and the iliac crest and calculated to the nearest centimeter using a nonelastic measuring tape.18 Glycosylated hemoglobin (HbA1c) measured by the DCA 2000, was used to ascertain diabetes control. The HbA1c test is regularly used in clinical practice because it gives clinicians an objective measurement of glucose contol over the predeeding 2 to 3 months.19 The test is an important outcome measure in diabetes research.20
Pedometers
Exercise Log
Procedure
Visit 1: Baseline Assessment After the first visit, participants were randomized to either the pedometer (intervention) or coaching-only (control) group using random number tables. Randomization was performed by a research assistant at the National Ageing Research Institute who was not involved in the study. However, once randomization was completed, the principal investigator was aware to which treatment groups participants had been allocated.
Visit 2 Strategies to increase self-efficacy related to walking were also implemented. These strategies included the development of an action plan that detailed the participants' self-selected walking goals. The pedometer and coaching-only groups differed in the nature of the walking goals. The participants in the pedometer group chose steps per day goals. Starting points for steps per day goals were considered based on recommended starting points of Tudor-Locke and Myers.13 Based on their assessment of the literature, values of between 6000 and 8500 steps per day for healthy older adults and between 3500 and 5500 steps per day for older adults with disabilities and chronic illnesses were considered.13 The participants in the coaching-only group set goals based on time spent walking per day. Expected outcomes were also recorded on the action plan, and participants were encouraged to rate these outcomes in terms of their importance. Barriers and concerns were explored, and participants were asked to nominate friends or family members who could be relied on to provide social support. Participants also nominated the delivery of their follow-up visits, either by face-to-face or via the telephone.
Visits/Contacts 3 and 4
Visits 5 and 6: 3-Month and 6-Month Assessments
Statistical Analysis Categorical variables for the pedometer and coachingonly groups were compared using the  2 test of independence while independent
t tests were used to compare all other variables at baseline. Time,
group, and interaction effects were analyzed using analysis of variance
(ANOVA) and analysis of covariance (ANCOVA) with repeated measures for 1
factor time. Pairwise comparisons were analyzed, that is, scores at 3 months
minus baseline (T2 – T1), scores at 6 months minus baseline (T3 –
T1), and scores at 6 months minus scores at 3 months (T3 – T2), to
detect at which time point significant changes occurred. A critical level of
 = .05 was used to investigate all analyses.
Comparison at Baseline Between Groups
Changes in Time Spent Walking
A repeated-measures ANOVA was used to test the hypothesis that the intervention group who used a pedometer would spend significantly more time walking than the coaching-only group during the 6-month period. As mentioned above, both groups increased their time spent walking significantly, F(1, 46) = 107.56, P = .000. In contrast to what was initially predicted, the control group walked significantly more than the intervention group did at both the 3- and 6-month assessments, F(1, 46) = 5.47, P = .02, with a significant interaction effect observed, F(1, 46) = 4.08, P = .05. However, using ANCOVA and statistically controlling for age, duration of diabetes, blood pressure, BMI, weight, waist circumference, shuttle test performance, and HbA1c, group membership had no influence on time spent walking, F(1, 25) = 1.68, P = .207. During the study, monthly support was provided to participants by telephone or face-to-face contact. A 1-way ANOVA was used to test the impact of the different methods of support delivery on time spent walking. The results indicated no difference in time spent walking for participants receiving either delivery, F(1, 48) = 1.901, P = .174. Neither age, gender, or socioeconomic status was associated with time spent walking. The mean number of steps per day taken by the pedometer group was 7296 (SD = 2066), with a range of 4840 to 11270 steps.
Changes in Anthropometric, Cardiovascular, and Blood Glucose Variables
There were no significant changes detected in blood pressure and HbA1c at either the 3-month or 6-month periods for the whole sample. However, significant reductions were detected in waist circumference and weight at both 3 and 6 months. Changes in BMI also reached significance, but not until the 6-month assessment. Cardiovascular fitness also significantly increased from baseline to 3 months in both groups. The increase in fitness was then sustained for a further 3 months (see Figure 2).
Adverse Events During the 6-month period of the study, no major injuries were reported from either group other than transient shin soreness.
Findings of the present study did not support the proposition that older adults with type 2 diabetes receiving personalized coaching and using a pedometer would spend more time walking than would older adults not using a pedometer. The results indicated that both groups in the study met or exceeded the national physical activity guidelines of 150 minutes or more of physical activity each week. But although some individuals in the present study reported that they found a pedometer helpful, the data revealed that when used in conjunction with coaching strategies, pedometers did not contribute an additional benefit related to time spent walking. A plausible explanation for the surprising results could relate to the difference in behavior between the 2 groups. The pedometer group set goals based on the number of steps per day, while the coaching-only group set goals based on a certain amount of time spent walking each day. Anecdotal evidence suggested that on days when their incidental activity was high, the pedometer group did not necessarily include a purposeful walk because the participants had already achieved their target step count for that day. In contrast, the walking goals for the coaching-only group were related to time spent walking in addition to any incidental activity. While the study does not provide any statistical evidence to support the argument, it is possible that the coaching-only group was more likely to establish a consistent pattern of walking and a regular routine, independent of prompts such as a pedometer.
Some support for this assumption was evident at the 6-month follow-up. At this assessment, time spent walking for the pedometer group had lagged further behind the coaching-only group, reinforcing a trend identified at the 3-month assessment. More important, while the mean time spent walking for the pedometer group had remained at the recommended guidelines, only 38% of this group was walking 150 minutes or more, compared to the coaching-only group, in which 88% of participants were achieving the guidelines. It should be noted that no significant differences between the 2 groups were detected on any of the anthropometric, cardiovascular fitness, or glycosylated hemoglobin variables at 6 months. So while a greater proportion of the coaching-only group achieved the recommended physical activity guidelines compared to the pedometer group, no extra benefits for this group were detected during the study period. Perhaps a greater time period is required before the difference in time spent walking between the 2 groups would be reflected in differences in outcomes.
Coaching Intervention The study also validates the use of telephone contact to provide ongoing support as comparisons between the 2 modes of support showed that there was no difference in time spent walking for participants who received face-to-face or telephone contact.
Relationship to Previous Physical Activity Interventions In individuals with type 2 diabetes, to date, only 3 studies have empirically examined physical activity interventions that aimed to achieve activity targets of 150 minutes or more per week.7,8,18 Physical activity goals were prescribed for participants in 2 of these studies, but no coaching or support counseling was included.7,18 Both studies achieved significant improvements in physical activity participation, but the sustainability of the exercise behavior change could not be estimated because of the lack of long-term follow-up. In contrast, the First Step Program, devised by Tudor-Locke and colleagues, and the present study included intervention components that assisted participants to select their own walking goals and also provided follow-up postintervention.8 This collaborative process also achieved significant results, with participants in the "First Step Program" achieving a mean of 158 minutes walking per week at the follow-up assessment8 and those in the present study achieving a mean of 183 minutes per week. The strategies used in the present study were effective immediately in changing exercise behavior. More important, the long-term follow-up at 6 months further validated the approach, as the exercise-behavior change was sustained for a further 3 months, during which time participants had no contact with the coach. Participants in the present study achieved a modest but significant weight loss. As the present study did not focus on dietary changes to achieve weight loss, it was not expected that participants would achieve substantial weight losses. The fact that a significant, albeit small, weight loss was apparent in a short time frame with only moderate-intensity physical activity and no dietary intervention is noteworthy, as often adults may not fully recognize the positive impact this level of exercise can contribute to weight control. Significant reductions in waist circumference were also reported in the present study, supporting the findings of Tudor-Locke et al.8 Tudor-Locke's First Step Program achieved waist circumference reductions similar to the reductions participants achieved in the present study.8 In addition, the present study showed that moderate walking increased cardiovascular fitness over a 3-month period and that this increase was sustained for a further 3 months. As mentioned earlier, reduced HbA1c levels are an important goal for any diabetes-related interventions.20 Unfortunately, the present study was not able to demonstrate significant reductions in HbA1c levels from baseline to 6 months. These results did not corroborate findings from other studies.18 This discrepancy could be due to the mean baseline HbA1c levels in the present study being lower than the levels of participants in previous studies. Also, while weight loss in the present study was significant, it was modest nonetheless. Previous research has shown that greater weight loss is likely to result in reduced HbA1c.16 The present findings need to be considered in respect to some research limitations. The small sample size of the study could have reduced the power to detect significant differences between groups and limited generalization of the present findings to other populations. Also, assessment of the impact of the coaching intervention on time spent walking remains inconclusive because there was no normal-treatment-only comparison group. Further examination of coaching appears to be warranted. In addition, assessment of which coaching strategy had the most impact on motivation to walk was not possible as numerous strategies were used concurrently with all groups. Also, there were no participants of non-Caucasian ethnicity, and the entry criteria excluded people older than 75 years. Future research could focus on whether the device is useful in younger age groups or in situations in which regular contact with a health professional was not possible. For example, the use of a pedometer may assist people who live in remote areas to stay focused on their walking goals in the absence of regular health professional support. Further research into diabetes and coaching using face-to-face versus telephone contact is also warranted, using larger sample sizes and a range of demographic characteristics. The findings of this study reinforced the benefits associated with moderate-intensity physical activity in previously sedentary adults, but the use of pedometers may not be an influential strategy for reversing inactivity in people with type 2 diabetes.
This research was funded by a grant from the Diabetes Australia Research Trust. The authors of this study appreciate the support of Dr Keith Hill (director of public health) and staff in the Public Health Department at the National Ageing Research Institute. Thanks also to all the participants who volunteered their time and without whom this study would not have been possible.
The Diabetes Educator, Vol. 32, No. 1,
98-107 (2006) This article has been cited by other articles:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
|
 |
Sign In to gain access to subscriptions and/or personal tools.
Top
Abstract
Research Design and Methods
150
minutes of walking per week. Response to the intervention was immediate, with
67% of participants achieving the physical activity recommendations by the end
of the first week. 
