Main results
confusion
SECONDARY, CARDIOVASCULAR DISEASE
During the twelve-month study period, the written personalised prescription combined with a pedometer did not significantly modify total weekly energy expenditure. However, there was a sustained increase in weekly step count and weekly moderate-intensity activity duration in the PPIL group compared with the verbal advice group. The prescription appeared most effective in sedentary patients. Quality of life (SF-36), blood pressure, weight, and waist circumference were not substantially modified by either strategy. The DPAQ questionnaire revealed that participants perceived few barriers to physical activity. Participants adhered well to the intervention with around 80% of PPIL participants regularly using their pedometers and logbooks.The reason that the effectiveness of the PPIL strategy was not clearly demonstrated in terms of weekly energy expenditure compared with the control could be due to the chosen accelerometer. This is because the cut-off ranges were developed for active people and not specifically for the primary care setting (Freedson adult cut-points for activity intensity and Swartz MET rate conversion for energy expenditure). It is therefore difficult to interpret the accelerometer report in our insufficiently active population at risk of cardiovascular disease. It is possible that improvements in activity could have been undetected, as accelerometer counts might not have reached the cut-off to be classified in the higher category. This is supported by a 40% higher averaged self-estimated moderate-intensity activity duration than that measured by the accelerometer, and self-reports of vigorous activity that was not detected on the accelerometer. Further research is required to calibrate accelerometer cut-off ranges specifically adapted for activity levels and energy expenditure in physically inactive older adults.Furthermore, it is possible that any improvements in activity were “diluted” in the 24-h energy expenditure results because including all activities, even 1-MET activities, may have caused classification and/or confusion bias.Overall, baseline activity levels were higher than expected in these insufficiently active participants. Although it is possible that wearing the accelerometer may have been a novelty for the participants and created a Hawthorne effect, which leads people to being more active when participating in research compared with daily life [Furthermore, baseline activity levels were heterogeneous which could have influenced obtained results, making them more dispersed and less accurate. Baseline measurements revealed that some participants needed to improve their activity more than others, who were much more active. This meant the groups were not perfectly equilibrated in terms of activity, explaining why the ratio of “initially inactive” participants appeared larger in the PPIL group. It may be that definitive inclusion based on initial assessment results would obtain a more homogeneous population; however, the GPs did not have the baseline estimation results at this time. GPs also did not have the estimation results at randomisation so discrepancies in initial activity were not considered.We obtained only modest improvements for some, but not all the study outcomes. These efficacy data are consistent with the results from a recent Cochrane meta-analysis of 14 interventional studies including 4762 participants comparing the use of a pedometer with verbal advice on physical activity. Despite the heterogenous study quality in terms of control groups and strong attrition bias, no long-term change in participant physical activity levels or significant change in blood pressure was observed. However, as with our study, sedentary patients had a greater increase in physical activity, which was associated with improved quality of life (SF-36 mental component) [The fact that our results reveal modest improvements could still prove beneficial as evidenced in a 2019 meta-analysis which revealed that any physical activity, regardless of intensity, and less time being sedentary reduce mortality with a non-linear dose–response. In this study, the participants were divided into quartiles according to their physical activity level at inclusion and assessed using an accelerometer. After a median of 5.8 years follow-up, the hazard ratios for mortality were 1 for the reference group (sedentary), 0.48 (95% CI [0.43–0.54]) for the second quartile (lightly active), 0.34 (95% CI [0.26–0.45]) for the third quartile (moderately active) and 0.27 (95% CI [0.23–0.32]) for the fourth quartile (very active) [In the present study, the written, personalised physical activity prescription was employed as a practical prevention tool for use in general practice to reduce cardiovascular risk. However, it is difficult to say whether prescribing physical activity is a primary or secondary prevention tool or whether it is both [Participants and their GPs generally appeared motivated to participate in this study. Those enrolled in the verbal advice group were as motivated to participate in the study as those in the PPIL group. They undoubtedly appreciated that their GP recruited them in a study aiming to improve their quality of life and reduce their cardiovascular risk factors. This may explain why there was little difference between the groups, along with the possibility that the regular follow-ups made the control group perform better. Furthermore, participants adhered well to wearing the pedometer and completing the logbook, demonstrating this type of intervention is feasible in primary care. As an alternative to the pedometer, a smartphone app or connected watch could be used to self-track activity [Within a multidimensional treatment approach to reduce cardiovascular risk factors, the patient’s lifestyle is more than behaviours involving eating, physical activity, and substance use [