Interventions to promote walking: systematic review
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39198.722720.BE (Published 07 June 2007) Cite this as: BMJ 2007;334:1204
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Trials such as those of Tully and colleagues [1] form part of a body
of evidence concerned with quantifying the health benefits of walking,
some of which has been synthesised in other recent systematic reviews such
as that of Murphy and colleagues [2] and all of which contributes to 'the
epidemiological evidence for the health benefits of moderate intensity
physical activity' we referred to in the discussion section of the full
version of our paper. Evidence of this kind forms part of the
justification for our decision to investigate a related but different
question: how best to promote walking. The focus of our systematic review
was clearly stated in the abstract as being on 'studies of the effects of
any type of intervention on how much people walk'. As Tully and Cupples
point out, their published trial [1] does not address this question. We
did not 'fail' to find a relationship between walking and health outcomes
because we were not primarily seeking to establish such a relationship;
our review was focused on a point further upstream in the putative causal
chain.
We are sorry that Odent had difficulty translating one of our
conclusions into French. Efficacy and effectiveness are standard terms in
medical research. The difference between them has been neatly encapsulated
in English as that between 'Can it work?' and 'Will it work?' [3] and in
French as that between 'résultats dans un contexte expérimental contrôlé
en conditions "idéales", sur un échantillon donné' and 'résultats de
l'application réelle dans la population générale'. [4] As we explained
with illustrations in our discussion section, much of the available
evidence is of the former kind.
We did not argue, as Smith implies, for the 'mass implementation' of
any particular intervention in the NHS in the absence of credible
evidence. We agree that more, and more rigorous, evaluation of
interventions is needed to populate an evidence base sufficient to satisfy
health care commissioners, and also that much of what needs to be done
lies outside the realm of health care; that is why we argued for (and some
of us are applying) more effort to investigate the effects of large scale
community level interventions, including changes to the built environment.
However, accumulating 'good evidence of clinical effectiveness and cost-
effectiveness' in this field is extremely challenging. [5] If Smith agrees
that 'something should be done' in the meantime, it is surely better that
that 'something' should be informed by knowledge of what approaches appear
most likely to be effective -- even if it is simply an opportunistic
encounter in primary care.
[1] Tully M, Cupples M, Chan W, McGlade K, Young I. Brisk walking,
fitness, and cardiovascular risk: a randomized controlled trial in primary
care. Prev Med 2005;41:622-8.
[2] Murphy M, Nevill A, Murtagh E, Holder R. The effect of walking on
fitness, fatness and resting blood pressure: a meta-analysis of
randomised, controlled trials. Prev Med 2007;44:377-385.
[3] http://www.euro.who.int/observatory/Glossary/TopPage?phrase=E
[4] http://www.proz.com/kudoz/1153744
[5] http://guidance.nice.org.uk/page.aspx?o=PhysicalActivityandEnv
Competing interests:
None declared
Competing interests: No competing interests
The paper by Ogilvie et al(1) is a good example of the challenges
faced by Public Health when trying to implement the health improvement
agenda (encouraging the uptake of healthy lifestyles) from within the NHS.
The problems faced by health service commissioners is neatly summarised in
the last sentence of this paper “we still have much to learn about exactly
who will benefit from what type of intervention and by how much”. However,
the authors do not feel this uncertainty should delay implementation of
interventions because it is a major public health problem.
Decisions about health policy are based on a combination of three
factors: evidence, values and resources(2). The weights placed on these
components differ by individual and organisation. In recent years there
has been a cultural shift within the NHS to focus on evidence based
medicine(3); any new intervention or service should have good evidence of
clinical effectiveness and cost-effectiveness before implementation. As a
commissioner of health services it would be very difficult to prioritise
this lifestyle intervention against other medical interventions where
there is extremely good evidence of what one will achieve with scarce
resources.
If the health improvement agenda was located within local
authorities, as suggested recently by Blackman(4), this would not be so
critical. The evidence required and values held by these organisations
when setting priorities are different; the process is also overseen by
democratically elected members who represent the views of their local
populations (i.e. the funders). To affect population health requires a
balanced approach between helping the individual and changing the
environment(5). Local authorities are the organisations with direct
responsibility for the implementation of environmental interventions.
There is also no reason why they can not provide many of the interventions
aimed at individuals as these do not need highly skilled health
professionals to be successful(6).
I do agree that something should be done but mass implementation
because it is a “big problem” is not enough justification when the
evidence is weak. This fallacy was exposed by Normand(7). However, if
schemes are adopted by PCTs (or local authorities) there needs to be
ongoing evaluation to add to the evidence base. As a matter of urgency a
national evaluation programme needs to be developed. A key aim should be
the development of a practical evaluation framework, which can be modified
to fit most health improvement schemes. The programme will ensure
consistency and comparability of results and aid dissemination of
findings. Resources are scarce and we need to ensure that there are not
more effective ways of achieving the health outcomes we want.
References:
1.) Ogilvie D, Foster C, Rothnie H, Cavill N, Hamilton V, Fitzsimons
C, Mutrie N; on behalf of the Scottish Physical Activity Research
Collaboration (SPARColl). Interventions to promote walking: systematic
review. BMJ 2007 doi: 10.1136/bmj.39198.722720.BE
2.) Gray J. Evidenced-based healthcare. Edinburgh: Churchill
Livingstone 2nd ed, 2001.
3.) Sackett D, Rosenberg W, Gray J, Haynes R, Richardson W. Evidence
based medicine: what it is and what it isn't. BMJ 1996;312: 71-2.
4.) Blackman T. Statins, saving lives, and shibboleths. BMJ
2007;334:902.
5.) Rose G. Sick individuals and sick populations. International
Journal of Epidemiology 1985; 14: 32-38.
6.) Truby H, Baic S, deLooy A, Fox KR, Livingstone MBE, Logan CM, et
al. Randomised controlled trial of four commercial weight loss programmes
in the UK: initial findings from the BBC "diet trials". BMJ 2006; 332:1309
-11.
7.) Normand C. Ten popular health economic fallacies. Journal of
Public Health Medicine. 1998; 20: 2:129-132.
Competing interests:
None declared
Competing interests: No competing interests
We read with interest the recent review of walking interventions by
Ogilvie et al1 and wholeheartedly support their efforts in further
eliciting the “compelling reasons to encourage people to walk more”.1
Whilst there is indeed a need for further studies, we wish to highlight
current evidence of positive health benefits which we have found in
randomised controlled trials of home-based walking programmes among
populations with low levels of physical activity.
The authors conclude that few studies found unequivocal improvements
in health and risk factors for disease.1 Though not clear from the text,
further investigation of the search strategy on
http://sparcoll.org.uk/images/bmjsupp.pdf indicated that studies were
excluded if their aim was to “evaluate the effects of a prescribed walking
regime on clinical or physiological outcomes” which may explain their
failing to find a relationship between walking and health outcomes.
Due to the strategy employed by Ogilvie et al,1 our study of the
effects of brisk walking on fitness and cardiovascular fitness was
excluded from the review. We found that an increase in walking of 30
minutes 5 days per week led to significant improvements in blood pressure,
reduction in Framingham risk and increase in functional capacity in
primary care patients.2 In a more recent study (in press), we have found
improvements in blood pressure and functional capacity from walking for 30
minutes on either three of five days per week, in a group of 106 healthy,
sedentary adults.3
The results of these studies and others demonstrate clear
improvements in health and cardiovascular risk factors which we feel
should not be ignored.
1. Ogilvie D, Foster CE, Rothnie H, et al. Interventions to promote
walking: systematic review. BMJ 2007;334:1204-7.
2. Tully MA, Cupples M, Chan W, McGlade K, Young I. Brisk walking,
fitness, and cardiovascular risk: a randomized controlled trial in primary
care. Prev Med 2005;41:622-8.
3. Tully MA, Cupples M, Hart ND et al. Randomised controlled trial of
home based walking programmes at and below current recommended levels of
exercise in sedentary adults. J Epidemiol Community Health 2007;000:1–6.
doi: 10.1136/jech.2006.053058
Competing interests:
None declared
Competing interests: No competing interests
I would never choose to have cyclists on the same track/road/way as
pedestrians. A cycle with a say 80 kgs person aboard, and travelling at
the relatively fast speed needed to counteract the cycle’s efficiency yet
raise the heart rate, is in fact a missile. I’ve seen several cases of
cyclists crashing both into each other, and into pedestrians, and causing
hospital stays of several months. Pedestrians need to have an environment
relatively free of threat. Otherwise it just becomes another stress.
Competing interests:
None declared
Competing interests: No competing interests
The article by Ogilvie et al provided conclusive evidence that tailor
made and targeted interventions are most effective in promoting walking
and that new behavioral interventions are needed to promote walking. (1)
One intervention that has universal appeal irrespective of age, gender,
culture or socio-economic status is music. Nearly every one has a passion
for music of some sort or the other. Music has been shown to improve
functional performance, decrease the perception of dyspnea and increase
adherence to walking regimens. (2) Soft, slow, easy listening music has
also been shown to increase endurance. (3) The fact that musical motor
feedback has resulted in increased walking speeds in patients with strokes
clearly illustrates the subtle yet concrete affects of music. (4)
The increasing popularity and easy availability of portable music
devices such as iPods is clearly a big advantage that healthcare
professionals should take advantage of in promoting “mobile music for
walking”. Undoubtedly, promoting walking while listening to music or an
audio book is something that can go a long way in making a community wide
change in walking patterns.
1. Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons
CF, et al. Interventions to promote walking: systematic review. BMJ 2007;
Jun 9;334(7605):1204.
2. Bauldoff GS, Hoffman LA, Zullo TG, Sciurba FC. Exercise
maintenance following pulmonary rehabilitation: effect of distractive
stimuli. Chest 2002; Sep;122(3):948-54.
3. Copeland BL, Franks BD. Effects of types and intensities of
background music on treadmill endurance. J Sports Med Phys Fitness 1991;
Mar;31(1):100-3.
4. Schauer M, Mauritz KH. Musical motor feedback (MMF) in walking
hemiparetic stroke patients: randomized trials of gait improvement. Clin
Rehabil 2003; Nov;17(7):713-22.
Competing interests:
None declared
Competing interests: No competing interests
‘Much of the research currently provides evidence of efficacy rather
than effectiveness’. This is the main lesson of the review by David
Olgivie et al of studies assessing the effects of interventions to promote
walking.(1) The authors and editors should keep in mind that many readers
of BMJ use English as a second language and cannot easily digest certain
linguistic subtleties. I feel unable to translate the conclusions of this
article into French, my mother tongue.
1 - Ogilvie D, Foster CE, Rothnie H, et al. Interventions to promote
walking: systematic review. BMJ 2007;334:1204-7
Competing interests:
None declared
Competing interests: No competing interests
Walking is an important mode of active life styles of our communities
(1).The consultation document from the Health of the Nation physical
activity taskforce more than a decade ago concluded that activities of
moderate intensity, such as brisk walking and cycling, offer the greatest
potential of health gain for most of the population (2). The benefits of
physical activity for public health are widely accepted.
Many studies have shown that environmental modifications are
important to promote walking and the challenge now is to make policymakers
work for an environment that promotes walking (3). However, we have been
extremely slow to recognize the impact that decisions about transport,
land use and infrastructure have on health.
As there are many public health benefits of active life styles and
pedestrians safe walking rights should be promoted to increase the
pleasure, safety and likeness of walking in our neighborhoods. A recent
study explored the question why children don’t walk to school more often
and 40% of parents reported traffic danger among the multiple barriers
that inhibit walking and biking to school (4). If traffic danger continues
to propagate avoidance of walking and cycling among children, youth and
older citizens then the disease burden (with inactivity as a risk factor
for other diseases) will increase, and the total burden of disease will be
much larger than the WHO predicts in 2020 (5).
We need to advocate a systematic environmental approach to reduce
pedestrian injuries: complete separation of pedestrians and cyclists from
traffic and traffic calming in residential areas as well as provision of
safe outdoor areas in which people can be both independent and mobile.
Benefit of such measures could promote walking and cycling habits of our
communities.
REFERENCES:
(1). Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V,
Fitzsimons CF, et al; on behalf of the Scottish Physical Activity Research
Collaboration (SPARColl). Interventions to promote walking: systematic
review. BMJ 2007 doi: 10.1136/bmj.39198.722720.BE
(2). Physical Activity Task Force. The health of the nation. More
people, more active, more often: physical activity in England, a
consultation paper. London: Department of Health, 1995.
(3). Andersen, L. B. Physical activity and health. BMJ 2007; 334:
1173-1173
(4).Barriers to children walking and biking to school—United States.
MMWR 2002; 51(32); 701–4.
(5). Desapriya E.B., Pike I., Basic A., Subzwari S. Deterrent to
healthy lifestyles in our communities. Pediatrics. 2007; 119(5):1040-2
Competing interests:
None declared
Competing interests: No competing interests
Inactivity in Secondary Care Doctors
The interventions suggested by Ogilvie et al to increase the amount
of walking by individuals can, and perhaps should, be applied to secondary
care doctors.(1)
The epidemic of obesity driven by inactivity is accentuated by
obstacles in the workplace such as calorie-saving lifts and escalators.
Hospitals are not exempt from such temptations and doctors as a profession
face challenges to maintain adequate levels of physical activity. Physical
activity is essential for long-term weight control and avoiding the
phenomenon of ‘middle-aged spread.’(2) Even the suggested daily thirty
minutes of moderate physical activity recommended may be inadequate to
control body weight in some cases. Thirty minutes of moderate physical
activity uses approximately two-hundred kilocalories and equates to
approximately 3000-4000 steps.(3)
We assessed whether all members of a hospital Cardiology team
experienced similar levels of physical activity in the workplace, or
whether seniority, which brings with it higher levels of sedentary
sessions, predisposes to physical inactivity. Pedometers of the same brand
and type were given to each member of the Cardiology team, comprising the
House Officer, Senior House Officer, Clinical Fellow, Specialist Registrar
and Consultant, in a Teaching Hospital, to be worn during the working day,
for five days. In order of seniority, the most junior team member (39354
steps) amassed the greatest number of steps each day, and over the five
day period was found to walk more than the senior house officer (21148),
who walked more than the Clinical Fellow (18567), who walked more than the
Registrar (14393), who walked more than the Consultant (7291).
In conclusion, there is a clear and significant trend towards
decreased levels of activity with increasing seniority within the
Cardiology team. Some would argue that it is not the role of the
workplace to offer physical activity, yet many would argue that the
workplace should encourage physical activity in all its members for the
well-being of its workforce. Extra activities, where provided, should be
encouraged, such as fitness classes and on-site recreational clubs, and
more senior doctors should be encouraged to avoid lifts and use stairs.
This may be one of the effective means of intervention in an attempt to
increase physical activity amongst doctors, which will provide a leading
example to the remainder of the population.
(1) Ogilvie D, Foster CE, Rothnie H, Cavill N, Hamilton V, Fitzsimons
CF, et al. Interventions to promote walking: systematic review. BMJ 2007;
Jun 9;334(7605):1204.
(2) Jakicic, J. M. & Otto, A. D. Physical activity considerations
for the treatment and prevention of obesity. American Journal Of Clinical
Nutrition 2005, 82(1), Supplement, S226-S229
(3) British Heart Foundation – Think Fit! Be Active! www.bhf.org.uk
Competing interests:
None declared
Competing interests: No competing interests