Interventions Using Wearable Physical Activity Trackers Among Adults With Cardiometabolic Conditions: A Systematic Review and Meta-analysis | Cardiology | JAMA Network Open | JAMA Network
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Figure 1.  Flow Diagram of Screening Stages
Flow Diagram of Screening Stages

RCT indicates randomized clinical trial.

aNo unpublished studies were found.

Figure 2.  Subgroup Meta-analysis of Delivery and Consultation Type by Intervention
Subgroup Meta-analysis of Delivery and Consultation Type by Intervention

Markers indicate standardized mean differences (SMDs), with the size of the markers reflecting weights; horizontal lines indicate 95% CIs; and diamonds indicate pooled means, with the points of the diamonds indicating 95% CIs of the pooled means. The vertical dashed line indicates the point at which there was no difference between intervention and usual care (null effect).

Table 1.  Participant Characteristics From Eligible Studies
Participant Characteristics From Eligible Studies
Table 2.  Meta-analysis of the Association of Accelerometer, Fitness Tracker, and Pedometer Interventions With Physical Activity Levels
Meta-analysis of the Association of Accelerometer, Fitness Tracker, and Pedometer Interventions With Physical Activity Levels
Table 3.  Univariable and Multivariable Metaregressions for PA Tracker Use
Univariable and Multivariable Metaregressions for PA Tracker Use
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    Original Investigation
    Nutrition, Obesity, and Exercise
    July 20, 2021

    Interventions Using Wearable Physical Activity Trackers Among Adults With Cardiometabolic Conditions: A Systematic Review and Meta-analysis

    Author Affiliations
    • 1National Institute for Health Research, School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
    • 2Department of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton, Brighton, United Kingdom
    JAMA Netw Open. 2021;4(7):e2116382. doi:10.1001/jamanetworkopen.2021.16382
    Key Points

    Question  Are interventions using wearable physical activity (PA) trackers, including accelerometers, fitness trackers, and/or pedometers, associated with improved PA levels among people with cardiometabolic conditions?

    Findings  In this systematic review and meta-analysis of 38 randomized clinical trials with 4203 participants, interventions with wearable PA trackers were associated with significantly increased PA levels during approximately 15-weeks follow-up; interventions (particularly pedometers) with additional components, such as consultations with health care professionals, were associated with increased PA levels.

    Meaning  The findings suggest that use of wearable PA trackers (especially pedometers) is associated with increased PA levels among people with cardiometabolic conditions when combined with additional intervention components, such as face-to-face consultations, but these PA level improvements may remain below the targets set by clinical recommendations.

    Abstract

    Importance  Wearable physical activity (PA) trackers, such as accelerometers, fitness trackers, and pedometers, are accessible technologies that may encourage increased PA levels in line with current recommendations. However, whether their use is associated with improvements in PA levels in participants who experience 1 or more cardiometabolic conditions, such as diabetes, prediabetes, obesity, and cardiovascular disease, is unknown.

    Objective  To assess the association of interventions using wearable PA trackers (accelerometers, fitness trackers, and pedometers) with PA levels and other health outcomes in adults with cardiometabolic conditions.

    Data Sources  For this systematic review and meta-analysis, searches of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PsycINFO were performed from January 1, 2000, until December 31, 2020, with no language restriction. A combination of Medical Subject Heading terms and text words of diabetes, obesity, cardiovascular disease, pedometers, accelerometers, and Fitbits were used.

    Study Selection  Randomized clinical trials or cluster randomized clinical trials that evaluated the use of wearable PA trackers, such as pedometers, accelerometers, or fitness trackers, were included. Trials were excluded if they assessed the trackers only as measuring tools of PA before and after another intervention, they required participants to be hospitalized, assessors were not blinded to the trackers, or they used a tracker to measure the effect of a pharmacological treatment on PA among individuals.

    Data Extraction and Synthesis  The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. A random-effects model was used for the meta-analysis.

    Main Outcomes and Measures  The primary outcome was mean difference in PA levels. When the scale was different across studies, standardized mean differences were calculated. Heterogeneity was quantified using the I2 statistic and explored using mixed-effects metaregression.

    Results  A total of 38 randomized clinical trials with 4203 participants were eligible in the systematic review; 29 trials evaluated pedometers, and 9 evaluated accelerometers or fitness trackers. Four studies did not provide amenable outcome data, leaving 34 trials (3793 participants) for the meta-analysis. Intervention vs comparator analysis showed a significant association of wearable tracker use with increased PA levels overall (standardized mean difference, 0.72; 95% CI, 0.46-0.97; I2 = 88%; 95% CI, 84.3%-90.8%; P < .001) in studies with short to medium follow-up for median of 15 (range, 12-52) weeks. Multivariable metaregression showed an association between increased PA levels and interventions that involved face-to-face consultations with facilitators (23 studies; β = −0.04; 95% CI, −0.11 to −0.01), included men (23 studies; β = 0.48; 95% CI, 0.01-0.96), and assessed pedometer-based interventions (26 studies; β = 0.20; 95% CI, 0.02-0.32).

    Conclusions and Relevance  In this systematic review and meta-analysis, interventions that combined wearable activity trackers with health professional consultations were associated with significant improvements in PA levels among people with cardiometabolic conditions.

    Introduction

    A large proportion of the population experiences cardiometabolic conditions, such as type 2 diabetes, prediabetes states (eg, obesity), and cardiovascular disease.1,2 In the UK, 3.3 million people have been diagnosed with type 2 diabetes, and most of them experience additional cardiometabolic conditions or risks, including obesity, increased blood pressure, disturbed blood lipid levels, and a tendency to develop thrombosis and cardiovascular disease.3 The increasing prevalence of cardiometabolic conditions combined with demographic changes mean that the overall cardiometabolic costs will account for more than 20% of the entire National Health Service budget in the next 20 years, with most of these costs being avoidable.4

    Despite the health and economic consequences of cardiometabolic conditions, they are mainly lifestyle related and can be improved by targeting unhealthy lifestyle behaviors. Particularly, a low physical activity (PA) level is a fundamental modifiable risk behavior for people with cardiometabolic conditions and is a major opportunity for intervention.5 Premature deaths could potentially be prevented by addressing low levels of PA more so than any other risk factor,6 such as smoking, alcohol consumption, or stress-related illnesses. Recognizing the importance of PA, several public health guidelines recommend reaching and maintaining health-enhancing levels of PA7 and promote PA interventions in the community and the workplace.8-10 However, promoting PA for people with cardiometabolic conditions remains a challenge.11

    Wearable activity trackers may empower people with cardiometabolic conditions to improve their PA levels and health behaviors. These devices include simple activity trackers, such as pedometers (a portable electrical or electromechanical tracker that counts each step a person takes by detecting the motion of the person along the body’s long axis)12 and accelerometers or fitness trackers (electromechanical trackers used to measure acceleration forces by the use of algorithms to accurately detect periods of wear and nonwear time).13 These wearable activity trackers have recently become popular for motivating people to be more active and monitoring that activity among people with a range of chronic conditions, including cardiometabolic conditions.14 The devices are simple, relatively affordable, user-friendly, and potentially motivational.15

    A number of previous systematic reviews16-19 suggest that these wearable trackers may be associated with increased PA levels among people with chronic conditions, including cardiometabolic conditions. However, there is limited evidence on whether interventions that involve wearable activity trackers are associated with improved PA levels among people with cardiometabolic conditions in the short and long terms. Moreover, to our knowledge, factors that may moderate the effectiveness of these interventions (eg, intervention or patient factors) have not been examined using robust methods, such as metaregression. These knowledge gaps are major barriers for the wider use of these monitoring devices in the care of people with cardiometabolic conditions.

    Our earlier systematic review20 was retracted based on a complex issue that involved the intervention definition, which affected the inclusion criteria for 9 of the 36 studies included in the original systematic review. Thus, in this updated systematic review and meta-analysis, we examined whether interventions that use activity trackers (pedometers, accelerometers, or fitness trackers) as part of the program design were associated with short-term and long-term improvements in PA levels and health outcomes, including blood glucose levels, blood pressure, cholesterol levels, body weight, and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), among people with cardiometabolic conditions compared with usual care. Metaregression was also used to examine whether an association with increased PA levels in the intervention group vs comparator group was moderated by the characteristics of the interventions (type of wearable tracker, setting daily goals, use of consultations with facilitators, evaluation length, use of a theoretical framework, and uptake rate) and patients (age, sex, and index condition).

    Methods

    This systematic review and meta-analysis (CRD42018104448) was conducted and reported in accordance with the Cochrane Handbook21 and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.22 Searches were performed in the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, MEDLINE and PsycINFO from January 1, 2000, until December 31, 2020, with no language restriction. January 2000 was used because an earlier review16 reported that no studies were found before this date. A combination of Medical Subject Heading terms and text words of diabetes, obesity, cardiovascular disease, pedometers, accelerometers, and Fitbits were used. The full search strategy in MEDLINE is available in eTable 1 in the Supplement. Additional studies were obtained from screening the reference lists of included trials and previous systematic reviews. Experts were contacted in the field to inquire about unpublished studies. Trial registers (ClinicalTrials.gov, ISCTRN, the World Health Organization International Clinical Trials Registry Platform, and OpenTrials.net) were also searched to identify any unpublished or ongoing trials.

    Eligibility Criteria
    Population

    Adults 18 years or older with a diagnosis of type 2 diabetes (or at risk for type 2 diabetes), obesity or overweight, and cardiovascular disease were eligible for inclusion. For obesity classification, the World Health Organization definition was used to standardize across studies.23 Studies of people diagnosed with stroke or who had undergone surgery were excluded.

    Intervention

    Randomized clinical trials (RCTs) or cluster RCTs that evaluated the use of wearable activity trackers, such as pedometers, accelerometers, or fitness trackers, were part of the intervention program. Excluded trials were those that used the wearable trackers only as measuring tools of PA before and after another intervention (and thus were not part of the interventional program design), those that required participants to be hospitalized, those in which assessors were not blinded to the wearable trackers, and those that used a wearable tracker to measure the effect of a pharmacologic treatment on an individual’s ability to be physically active.

    Comparator and Outcome

    Participants using wearable activity trackers were compared with a group receiving usual care. The primary outcome was the association of the use of an activity tracker with PA levels. Secondary outcomes were body weight or BMI, blood glucose level, blood pressure, and cholesterol levels.

    Data Collection and Extraction

    Titles and abstracts were assessed by 3 reviewers (A.H., M.P., and C.A.). Data extraction was conducted by 1 reviewer (A.H.) and checked by a second (C.A.) for consistency. A modified version of the Cochrane Public Health Group’s data extraction template24 was used after pilot testing on 5 studies to ensure reliability. The Oxford Implementation Index was used to assess implementation of the intervention and contextual factors.25 This index was adapted for the purposes of this review.

    Assessment of Risk of Bias

    Risk of bias for each study was assessed by 2 reviewers (A.H., C.A.) using the original version of the Cochrane Risk of Bias tool.26 The blinding of participants and personnel was not included in the risk of bias assessment because many studies did not report this domain since it was impossible to blind participants while they were using the technology device. If further information was required on any aspect of study design or outcome, related publications and trial protocols were sought and authors were contacted. Adjustment for cluster RCTs was performed in accordance with the Cochrane Handbook (§23.1.4).21

    Missing Data

    Study authors were contacted by email where there were missing or unclear data (for instance relating to the primary outcome). Studies for which insufficient primary data were available (eg, missing data cannot be obtained) were excluded from the meta-analysis but not from the review.

    Statistical Analysis

    The statistical analysis proceeded in 2 stages. First, Hartung-Knapp-Sidik-Jonkman random-effects meta-analyses27 were conducted to assess the association of the interventions with the primary and secondary outcomes compared with controls. The Hartung-Knapp-Sidik-Jonkman method was used instead of the DerSimonian-Laird random-effects method because it is globally thought to be a more robust method of choice when study sizes are small and considerable heterogeneity is present. Because all outcomes were continuous, standardized mean differences (SMDs) were calculated using Hedges g.28 Standardized mean differences were interpreted according to the Cohen rule of interpretation in accordance with the Cochrane guidelines (ie, small effect, 0.2; moderate effect, 0.5; and large effect, 0.8).29,30 When required, data were transformed to SMDs using Comprehensive Meta-analysis software.31 Physical activity outcomes were objectively classified by intervention measure (ie, daily step count or moderate to vigorous physical activity [MVPA]). Pooled associations with 95% CIs are presented, and forest plots with I2 and the test-based 95% CIs32 are used to show statistical heterogeneity among studies. When a study contributed more than 1 intervention arm to the analysis, the arms were combined to avoid double counting of the control group. When data were judged to be insufficient to include in meta-analyses, the results were synthesized narratively.

    Second, mixed-effects univariable and multivariable (multilevel) metaregression analyses examined the association of several study-level covariates with the primary outcome (PA levels). The multilevel aspect of the regression model allowed for potential clustering by including random effects for tracker type and study. Ten covariates were selected based on importance and consultation among the authors. Then the categories for the covariates were coded using consensus procedures and as informed by the Oxford Implementation Index25: (1) sex classified by dominance in each study (ie, mostly male or female), (2) age (<50 vs ≥50 years), (3) index condition (ie, type 2 diabetes, overweight or obesity, or cardiovascular disease), (4) type of tracker, (5) outcome measure used to assess PA (steps per day or MVPA), (6) consultations with facilitators, (7) intervention length (≤4 vs >4 months), (8) goal set for physical activity, (9) theory-based intervention, and (10) intervention uptake. Low risk of bias based on all 5 domains that were judged to be low risk was assessed against the high-risk studies with at least 1 high-risk domain in a sensitivity analysis. Covariates that met our significance criterion (2-sided P < .15) were entered into a multivariable metaregression model. The P < .15 threshold was conservative to avoid prematurely discounting potentially important explanatory variables, and adjusted tests were used for controlling type I error.33 All analyses were performed using the meta and metafor packages in R, version 4.0.3 (R Foundation for Statistical Computing). For each meta-analysis with 10 studies or more, funnel plots, the Begg test, and the Egger test were used to examine publication bias. The trim-and-fill method was used as a sensitivity analysis to observe possible small study publication bias.

    Results

    After duplicates were removed, the search retrieved 5670 references. After abstract and title screening of 2754 references and full-text screening of 147 studies, 38 studies34-82 met our inclusion criteria (Figure 1). All eligible studies are listed in eTable 2 in the Supplement. No unpublished studies were identified.

    Characteristics of Included Studies
    Location, Setting, and Participant Characteristics

    Most studies34-39,41-43,45,76,82 were conducted in the US (n = 12) or UK (n = 6). The settings of the studies varied and included hospitals, primary care practices, medical and community centers, and universities. The 38 studies34-82 involved 4203 participants (Table 1). All the studies included adults with a mean age between 35 and 67 years; 16 studies38,42,43,50,51,53,54,65-67,69,71,72,75,78,79 focused on older adults with a mean age older than 60 years. Two studies34,35 included women only, and the remainder36-82 involved mixed-sex populations. The target population recruited in the studies was predominantly those diagnosed with type 2 diabetes (n = 23), but other diagnoses included cardiovascular diseases (n = 8) and obesity or mixed obesity and overweight (n = 7).

    Intervention and Outcome Characteristics

    Twenty-nine studies34-39,41,46,48-51,53,55,57,65-78 involved pedometers as part of the intervention program to encourage PA, whereas 9 studies42,43,45,54,56,79-82 used accelerometers or fitness trackers as part of the intervention program to encourage PA. In terms of content, interventions focused mainly on the association with PA levels, prevention of disease, and weight management (eTable 3 in the Supplement). Seventeen studies36,38-41,48-51,55,64,65,71,74,76-78,82 (42%) used a theoretical framework that consisted of social cognitive approaches (eg, health belief model, theory of planned behavior, or transtheoretical model); however, behavior change outcomes were not reported in the results of 11 studies.36,38,41,46,48,49,51,54,71,72,76,77 Twelve studies34,36,37,39,42,50,51,54,56,70,73,82 tested simple pedometer, accelerometer, or fitness tracker interventions. This finding meant, for instance, that after an initial consultation session, patients were provided with the accelerometer, fitness tracker, or pedometer and a log book to self-monitor their outcomes using written instructions, but no additional support was provided by facilitators or health care professionals. A total of 26 studies35,38,41,43,45,46,48,49,53,55,57,64-69,71,72,74-81 (61%) tested interventions that also involved consultation sessions (ie, patients were supported by facilitators who were mainly health care professionals via face-to-face consultations and/or regular telecommunications during the intervention). The median duration for receiving the intervention was 17 weeks, but this varied considerably across studies (range, 1 week to 18 months). Physical activity was measured using steps per day in 25 studies34,37,41-43,48,50,51,55,65-78,81,82 (66%) and MVPA in 9 studies36,38,39,45,46,49,54,56,80 (24%).

    Risk of Bias

    The quality of the studies was variable (eTable 4 in the Supplement). A total of 22 studies37,39,42,45,46,49-51,54-56,66,68-74,76,78,79,82 (58%) had a low risk of bias for the random sequence generation, and 20 studies37,41-43,46,49-51,54,60,64,65,68,69,71,72,75,76,78 (53%) had low risk for allocation concealment. Only 1 study36 was deemed high risk for this criterion. Similarly, blinding of outcome assessment was moderately reported, with 16 studies49,51,53,55,57,66,68-72,74,78,79,81,82 (42%) reporting low risk; however, 12 studies34,35,38,41-43,45,46,48,54,73,76 (32%) reported high risk for this domain. Criteria for incomplete outcome data were mostly satisfied across studies, displaying low risk in 27 studies34,37,38,42,43,46,48-51,53-56,66,69-72,74-80,82 (70%); however, 8 studies35,36,41,57,65,69,73,77 (21%) reported high risk. For selective reporting, only 3 studies37-39 (8%) exhibited high risk of bias.

    Synthesis of Results

    Thirty-four of the 38 studies34,36-52,54-56,58-78,80-82 (89%) were included in the meta-analysis, involving 3793 participants. The exclusion of 4 studies35,53,57,79 was because the studies were not amenable for inclusion. The results of those studies are reported narratively in the Narrative Synthesis subsection of the Results section.

    PA Levels

    Summary estimates from the meta-analyses are presented in Table 2. Across all studies34,36-52,54-56,58-78,80-82 that involved interventions with wearable activity trackers vs comparators, there was a significant association between wearable tracker use and increased PA during an approximately 15-week period (SMD, 0.72; 95% CI, 0.46-0.97; prediction interval, −0.72 to 2.16; I2 = 88%; 95% CI, 84.3%-90.8%; P < .001) (eFigure 1 in the Supplement). Pedometer-based interventions were significantly associated with increased PA compared with comparators (SMD, 0.68; 95% CI, 0.44-0.93). Accelerometer- and fitness tracker–based interventions were not associated with increased PA compared with comparators (SMD, 0.92; 95% CI, −0.10 to 1.94). For pedometer-based interventions, the PA measure translated to 1877.30 steps per day (95% CI, 1139.70-2614.90 steps per day) in the intervention group compared with the usual care group (eFigure 2 in the Supplement). This value is generally lower than recommendations of governments and agencies globally,61 with a mean of 3000 steps being achieved daily (National Obesity Forum UK: 3000-6000 steps per day as sedentary; America on the Move: an additional 2000 steps each day to stop weight gain). Heterogeneity was high for both interventions encompassing pedometer use (I2 = 89%; 95% CI, 85%-92%) and accelerometer or fitness tracker use (I2 = 86%; 95% CI, 74%-92%).

    The cumulative plot (eFigure 3 in the Supplement) of PA performance based on total session time engagement provided no evidence that studies with longer periods of engagement in PA performed better in general. However, 9 studies38,43,44,48,50,69,70,76,81 did not report the length of the sessions and therefore could not be included.

    Moderators of Associations

    The results of the univariable and multivariable analyses are given in Table 3. Interventions using consultations with a health care professional (β = 0.45; 95% CI, 0.001-0.93; P = .04), pedometer-based interventions (β = 0.29; 95% CI, 0.02-0.38; P = .03), steps per day used as outcome measurement (β = 0.48; 95% CI, 0.04-0.76; P = .04), and the inclusion of predominately male participants in studies (β = 0.19; 95% CI, 0.03-0.29; P = .02) were associated with improved PA levels in the univariable regression analyses. The remaining factors, including index diagnosis of participants, age of participants, length of the intervention, goal setting, underpinning the intervention with a theoretical framework, intervention uptake, and risk of bias scores, were not associated with PA level and were not eligible for inclusion in the multivariable regression analysis. The overall multivariable model was statistically significant (χ23 = 24.18; P = .03), and the I2 statistic decreased from 68% to 39%. Consultations with a health care professional (b = −0.04; 95% CI, −0.11 to −0.01; P = .01), pedometer use (b = 0.20; 95% CI, 0.02-0.32; P = .004), and male sex (b = 0.48; 95% CI, 0.01-0.96, P = .046) remained significantly associated with increased PA in the multivariable model. Thus, interventions that involved regular consultations with health care professionals (compared with self-monitoring only), male sex, and pedometer-based interventions (compared with accelerometers and fitness trackers) were the 3 main factors associated with improved PA levels.

    A post hoc subgroup analysis was conducted using the enhanced consultation and monitoring device variables whereby studies were divided into 4 groups to best visualize the results of the metaregression analyses (Figure 2). Pedometer interventions that incorporated consultations with health care professionals were associated with increased PA (SMD, 0.83; 95% CI, 0.53-1.14) as were unsupervised pedometer interventions (SMD, 0.28; 95% CI, 0.02-0.53). Accelerometer and/or fitness tracker interventions with consultations and without consultations were not associated with increased PA.

    Secondary Outcomes

    Interventions with wearable activity trackers were associated with statistically significant reductions in blood glucose levels compared with comparators (mean difference, −0.14%; 95% CI, −0.27% to −0.01%) (Table 2). Pedometer-based interventions had the strongest association with improved blood glucose level (mean difference, −0.19; 95% CI, −0.35 to −0.03); however, accelerometer performance was not associated with improved blood glucose level in 5 studies.39-43 There were no associations of wearable activity tracker interventions with systolic blood pressure, diastolic blood pressure, total cholesterol level, high-density lipoprotein cholesterol level, low-density lipoprotein cholesterol level, BMI, and weight.

    Publication Bias

    Publication bias was not obvious for any intervention by visual inspection of the funnel plots (eFigure 4 in the Supplement) and as indicated by the Egger statistic (test for funnel plot asymmetry: pedometers: z = 0.97, P = .33; accelerometers: z = 0.49, P = .62). The trim-and-fill method also confirmed no evidence of publication bias. All forest plots are provided in eFigure 5 in the Supplement.

    Narrative Synthesis

    Three pedometer studies37,44,45 and 1 accelerometer study36 reported nonamenable data for meta-analysis. Two of these studies36,44 reported an association with a greater number of steps, and the other 2 studies37,45 reported no association with a greater number of steps between intervention and comparator group.

    Discussion

    This systematic review and meta-analysis found that interventions using wearable activity trackers were associated with significant improvements in PA among people with cardiometabolic conditions compared with individuals who received usual care. Interventions that combined the use of activity trackers with additional components, such as regular consultation sessions with a health care professional (face to face or remotely), had the strongest associations with PA improvement. The PA improvements were more pronounced among male participants.

    Pedometer use had a significant association with improved PA when used in the context of interventions that involved regular consultations with a health care professional compared with self-monitoring interventions without consultations. Accelerometer and fitness tracker interventions were not associated with PA levels compared with comparators when simple self-monitoring or regular consultation-based interventions were used. However, the current comparison involved only 8 studies35,36,41,57,65,69,73,77 compared with 26 pedometer studies35,38,41,43,45,46,48,49,53,55,57,64-69,71,72,74-81 and few patients, and although the effect size was larger for accelerometer and fitness tracker interventions (0.92 vs 0.68 for the pedometer), the 95% CI was wider than that for pedometers. All these factors should be considered when interpreting the efficacy of the interventions. Pedometers are often criticized because they do not measure daily steps precisely enough but may be more suited in the short term for patients with high-risk conditions with an objective of reaching a certain number of steps per day. Moreover, interventions using pedometers typically measured PA using steps per day, whereas interventions using accelerometer or fitness trackers measured PA using MVPA. Thus, the choice of PA measurement (steps per day vs MVPA) might account for the differential performance of these interventions.

    Some findings showed that interventions were associated with improved PA levels when they included consultations and longer periods of PA engagement (ie, longer and more regular sessions). However, 9 studies38,43,44,48,50,69,70,76,81 did not report the total PA engagement time per session. Interventions were also associated with reduced blood glucose levels. Although the change was statistically significant compared with the usual care group, the clinical relevance of the magnitude of change was small. Other secondary health outcomes, such as blood pressure, cholesterol levels, weight, and BMI, were not associated with the intervention.

    The findings of this review are consistent with the results of earlier systematic reviews17,48 involving populations at high risk that suggested improvements in PA levels at short-term follow-up assessments when using wearable trackers. One review48 reported an association of a wearable tracker intervention with increased PA level (SMD, 0.57; 95% CI, 0.24-0.91) but was based solely on people with type 2 diabetes. Furthermore, a recent systematic review and meta-analysis by Brickwood et al23 of consumer-based wearable activity trackers in general populations indicated an association with improved PA levels, but availability of long-term follow-up data was limited. Although that study was similar to the present study with regard to the focus on electronic devices for monitoring PA, the population does not overlap with that in the present study; the study by Brickwood et al23 focused on studies conducted among healthy general populations and not among those at risk for chronic conditions. Another study18 of wearable devices, mostly including fitness trackers, found that these devices were associated with improved physical health in clinical populations with cardiometabolic diseases. None of the aforementioned reviews used metaregressions to robustly examine factors associated with the effectiveness of these interventions. Findings from the current analysis support the use of interventions that contain consultation sessions with health professionals for boosting the PA benefits for people with cardiometabolic conditions.

    In this study, interventions of the use of wearable activity trackers and in particular pedometers were associated with greater PA levels per day among people with cardiometabolic conditions. Nevertheless, the improvements were generally lower than those recommended in the 2018 Physical Activity Guidelines Advisory Committee Scientific Report by the US Department of Health and Human Services50 and in other recommendations from global governments and agencies.51 For instance, the National Obesity Forum UK classified 3000 to 6000 steps per day as sedentary, the Northern Irelands Public Health Agency promoted an additional 3000 steps, and the America on the Move program suggested an additional 2000 steps each day to stop weight gain.77 For accelerometers and fitness trackers, public health guidelines have endorsed 30 minutes (up to 60 minutes) per day (or 150-210 minutes per week) in MVPA, typically in minimal 10-minute bouts.52,53 However, MVPA time engagement could not be assessed because the total session times were reported inconsistently or sometimes not at all reported in studies.

    The findings of the present study suggest that interventions that combine the use of monitoring devices (particularly pedometers) with regular consultations with health care professionals predominantly among male participants are associated with the greatest PA improvements and that these interventions may help reach the recommendations of governments and agencies for people with cardiometabolic conditions. Giving feedback and lifestyle advice to patients regularly may support the effectiveness of these interventions. A previous study54 suggested positive associations of multimodal pedometer interventions with PA levels in a variety of populations, including those with type 2 diabetes and cardiac conditions, but to our knowledge, this was the first study to assess the association of face-to-face consultations and measurement with PA levels in people with cardiometabolic conditions. These findings warrant consideration in future trials and further investigation using more robust methods, such as meta-analyses of individual participant data. The choice of measurement outcome (steps or MVPA) and their performance differences also need to be better understood in these patient populations.

    Only 1 study55 reported data on the association of a pedometer-based intervention with PA levels recorded after a 1-year follow-up period. Long-term follow-up assessments are needed to generate evidence regarding the sustainability of the association over time. Providing longer-term assessments of these interventions may have greater potential to impact the clinical outcome performance and might provide more information on the intervention program than current short-term assessments.

    Strengths and Limitations

    This study has strengths. First, 4 major databases were searched for relevant literature. Second, the analysis used well-established statistical methods, including multilevel, multivariable metaregression, to explore the association of certain moderators with the outcome of interest.

    This study also has limitations. Because the included studies did not provide amenable data for scores, correlations, or SD changes before and after the intervention, the effects of changes at baseline could not be considered in the meta-analysis, which could have affected the results. Furthermore, because the PA promotion technique was poorly reported across studies, we were not able to assess this in regression analysis. Metaregressions were performed to explore the heterogeneity observed in the main analyses, but important uncertainties remained regarding risk of bias assessments with many unclear domains, and participant characteristics, such as age and sex, were based only on aggregate data. In addition, it was not possible to assess for commercial bias because few studies declared their commercial interests. Because of the heterogeneous nature of cardiovascular disease index among the 8 trials35,36,41,57,65,69,73,77 and the limited number of trials that focused on participants with overweight or obesity, the trials were combined under the definition of a cardiometabolic condition. Only study populations at risk for a cardiometabolic condition were accepted as part of our inclusion criteria; however, this is a potential limitation because studies that did not explicitly report this may have been missed. In addition, it was not possible to look at behavior change outcomes, such as those reported in line with the theoretical domains framework, because only 1 trial49 mentioned explicitly in their aims that such outcomes would be collected.

    Conclusions

    In this systematic review and meta-analysis of individuals with cardiometabolic conditions, interventions that combined activity trackers (especially pedometers) with complementary intervention components, such as consultations with health care professionals, were significantly associated with increased levels of PA. Understanding how to improve these interventions further for greater PA improvements in the longer term may have implications in the care of people with cardiometabolic conditions.

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    Article Information

    Accepted for Publication: May 6, 2021.

    Published: July 20, 2021. doi:10.1001/jamanetworkopen.2021.16382

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Hodkinson A et al. JAMA Network Open.

    Corresponding Author: Alexander Hodkinson, PhD, National Institute for Health Research, School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, UK (alexander.hodkinson@manchester.ac.uk).

    Author Contributions: Dr Hodkinson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Hodkinson, Kontopantelis, Van Marwijk, Bower, Panagioti.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Hodkinson, Van Marwijk, Panagioti.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Hodkinson, Kontopantelis, Adeniji, Panagioti.

    Obtained funding: Van Marwijk, Bower, Panagioti.

    Administrative, technical, or material support: Hodkinson.

    Supervision: Kontopantelis, Van Marwijk, Bower, Panagioti.

    Conflict of Interest Disclosures: Dr Bower reported receiving grants from the National Institute of Health Research (NIHR) during the conduct of the study. Dr Panagioti reported receiving grants from the NIHR School for Primary Care Research during the conduct of the study. No other disclosures were reported.

    Funding/Support: This study was funded by project 298 from the NIHR School for Primary Care Research. This publication presents independent research funded by project 390 from the NIHR School for Primary Care Research.

    Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

    Disclaimer: The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

    Additional Contributions: We thank several of the authors of the articles included in this study who helped answer questions about their data and who are part of our ongoing individual patient data meta-analysis consortium network.

    Additional Information: For all summary-level data, PDF copies of the studies with highlights of where the outcome data and intervention definitions can be found, statistical code for the meta-analysis, and data transformations have been published on Mendeley and are freely available to download at the following link: https://data.mendeley.com/datasets/pp4vdypj2x/1.

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