Accepted Manuscript Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation Nienke ter Hoeve, MSc, Madoka Sunamura, MD, Myrna E. van Geffen, MSc, Malou H.J. Fanchamps, MSc, Herwin L.D. Horemans, PhD, Johannes B.J. Bussmann, PhD, Henk J. Stam, MD, Prof, Ron T. van Domburg, PhD, Rita J.G. van den Berg-Emons, PhD PII:
S0003-9993(17)30384-2
DOI:
10.1016/j.apmr.2017.05.008
Reference:
YAPMR 56911
To appear in:
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 15 August 2016 Revised Date:
11 April 2017
Accepted Date: 16 May 2017
Please cite this article as: Hoeve Nt, Sunamura M, van Geffen ME, Fanchamps MHJ, Horemans HLD, Bussmann JBJ, Stam HJ, van Domburg RT, van den Berg-Emons RJG, Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2017), doi: 10.1016/j.apmr.2017.05.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
(2) TITLE PAGE
2
Title:
4
Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation
6
Running head:
7
Physical behavior and cardiac rehabilitation
8
Authors:
M AN U
9
SC
5
RI PT
3
10
Nienke ter Hoeve1,2*, MSc; Madoka Sunamura1, MD; Myrna E. van Geffen1,2, MSc; Malou H.J.
11
Fanchamps2, MSc; Herwin L.D. Horemans2, PhD; Johannes B.J. Bussmann2, PhD; Henk J.
12
Stam2, MD, Prof; Ron T. van Domburg3, PhD; Rita J.G. van den Berg-Emons2, PhD
14
Institutional affiliations:
15
1
16
performed)
17
2
18
Netherlands
19
3
EP
Capri Cardiac Rehabilitation, Rotterdam, The Netherlands (institution where study was
Erasmus University Medical Centre, Department of Rehabilitation Medicine, Rotterdam, The
AC C
20
TE D
13
Erasmus University Medical Centre, Department of Cardiology, Rotterdam, The Netherlands
21
*Corresponding author: Address: P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
22
Tel: +31 107044599, Fax: +31 107033843, Email:
[email protected]
23
ACCEPTED MANUSCRIPT
24
Acknowledgement of presentation:
25
Nothing to declare
27
Acknowledgement of financial support:
28
No financial support.
30
Acknowledgement article
31
No acknowledgements
SC
29
34
Nothing to declare
AC C
EP
TE D
Conflicts of interest:
M AN U
32 33
RI PT
26
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation
Changes in Physical Activity and Sedentary Behavior during Cardiac
2
Rehabilitation
AC C
EP
TE D
M AN U
SC
RI PT
1
1
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation ABSTRACT
4
Objective: To objectively measure changes in both moderate-to-vigorous physical activity (MVPA) and
5
sedentary behavior (SB) during and after standard cardiac rehabilitation (CR).
RI PT
3
6 7
Design: Prospective cohort study
8 Setting: Outpatient CR center
SC
9 10
Participants: 135 patients with acute coronary syndrome (ACS) who completed CR.
M AN U
11 12 13
Intervention: Multi-disciplinary CR according to current guidelines
14
Main outcome measures: The proportion of time spent in MVPA and SB was objectively measured with
16
an accelerometer. The distribution of time in MVPA and SB was also determined (e.g. average length of
17
time periods spent in MVPA and SB). All measurements were obtained prior to CR, following CR and at
18
one-year follow-up.
EP
19
TE D
15
Results: Patients‘time in MVPA during waking hours increased by 0.65% (≈5 min) during CR (p=0.002),
21
and remained increased at one-year follow-up (p=0.037). The MVPA distribution did not change. During
22
CR, time spent in SB decreased by 2.49% (≈22 min; p<0.001), and SB time became more fragmented
23
with more breaks and shorter SB periods (p<0.001). These SB improvements were maintained at one-
24
year follow-up (p<0.001).
AC C
20
25
2
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Conclusions: Patients with ACS achieved a small improvement in MVPA time during CR but MVPA
27
distribution remained unchanged. More substantial improvements occurred for SB time and
28
distribution. However, by the end of CR, patients still spent relatively little time in MVPA and a long time
29
in SB, which is known to be detrimental to cardiovascular health. Although CR programs have the
30
potential to improve physical behavior, our findings highlight the need to develop adjusted CR targets
31
that address amount and distribution of MVPA and SB.
SC
32
RI PT
26
Keywords:
34
physical activity, sedentary behavior, cardiac rehabilitation, acute coronary syndrome
35
M AN U
33
List of abbreviations
37
ACS- Acute Coronary Syndrome
38
CR- Cardiac Rehabilitation
39
MVPA- Moderate-to-Vigorous Physical Activity
40
PA- Physical Activity
41
SB- Sedentary Behavior
AC C
EP
TE D
36
3
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Physical behavior comprises both physical activity (PA) and sedentary behavior (SB).1 PA is
43
defined as any bodily movement produced by skeletal muscles that requires energy expenditure.2 SB is
44
defined as behavior that consist mainly of sitting or lying and that requires very low energy
45
expenditure.3 Recent studies show that PA and SB should be considered as distinct behaviors related to
46
health outcomes.4, 5 In a general population, low levels of moderate-to-vigorous intensity PA (MVPA)
47
have been identified as a leading risk factor for mortality and cardiovascular disease.6 Increased levels of
48
SB are independently related to an increased risk of diabetes, cardiovascular disease, and mortality.3-5, 7
49
In addition to volume (total time) of MVPA and SB, increasing evidence suggests that the distribution of
50
this behavior over time may also be important. For example, the health benefits of daily, short bursts of
51
MVPA may be smaller than those of less frequent, longer periods of MVPA.8, 9 Taking regular active
52
breaks during sedentary time can counteract the harmful effects of prolonged sedentary periods.10, 11
M AN U
SC
RI PT
42
53
In patients with Acute Coronary Syndromes (ACS), it has been shown that more MVPA is related
55
to a better cardiovascular risk profile12, 13 and lower cardiac mortality.14 Standard Cardiac Rehabilitation
56
(CR) generally addresses MVPA, but not SB. Few studies have focused on SB in patients following ACS.
57
Cross-sectional studies show that patients with cardiovascular disease spend more time sedentary per
58
day compared to healthy individuals,15 and that longer sedentary time at CR completion is associated
59
with poorer fitness and higher body mass index.16
61
EP
AC C
60
TE D
54
Studies using objective measurement tools to evaluate changes in MVPA and SB volume and
62
distribution during standard CR are lacking. Knowledge of these changes may help formulate
63
recommendations on future PA and SB targets. Therefore, the objective of the present study was to
64
evaluate longitudinal changes in PA and SB volume and distribution in patients with ACS during and after
65
CR participation.
4
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 66 METHODS
68
Study sample
69
The cohort investigated in the current study was originally recruited for a randomized controlled trial
70
(RCT) in which they were assigned to the control group, receiving treatment as usual (standard CR).
71
Patients with ACS who were referred to Capri CR between September 2011 and August 2014 were
72
invited to participate in this study. Inclusion criteria were: diagnosis of ACS; age >18 years; proficiency in
73
Dutch; and absence of physical and cognitive impairments that could limit CR participation. Only
74
patients who completed standard CR were included in the current study. Additionally, patients needed
75
at least two valid physical behavior measurements (of which one baseline) for inclusion in the analysis.
76
All participants provided written informed consent. The study protocol was approved by the Medical
77
Ethics Committee of the Erasmus Medical Center in Rotterdam, The Netherlands.
M AN U
SC
RI PT
67
TE D
78 Measures
80
Physical behavior
81
Physical behavior (PA and SB) was measured with a tri-axial accelerometer (ActiGraph GT3X+a). Patients
82
were asked to wear the accelerometer on the right side of their waist for eight consecutive days during
83
waking hours, except when showering or swimming. Patients recorded the times they wore the
84
accelerometer in a logbook.
AC C
85
EP
79
86
Data processing
87
Consensus in accelerometer data processing is lacking. There is wide variability in the choices made for
88
epoch length, wear time validation and intensity cut-off points, for example. We made our choices after
89
extensively reviewing the literature.17-25
5
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Accelerometer data were sampled with a frequency of 30 Hz. The ActiGrapha measures raw
91
accelerations on three axes and converts this into activity counts and steps. Step numbers were
92
processed using Actilife software.26 Counts were summed over 15s time sampling intervals (epochs)
93
using Actilife software and converted to Matlab format for further processing (Matlab version R2011b).
94
A composite measure called vector magnitude was calculated (√(x2+y2+z2)) and used for analysis. Non-
95
wear time was defined as a > 60 min of consecutive zeros, with no allowance of epochs with counts
96
above zero. Data were analyzed only for patients who wore the accelerometer for ≥4 days and 660 min
97
per day. After subtracting the non-wear time from the data, each epoch was categorized as:
SC
RI PT
90
•
MVPA: activities of ≥672.5 counts 17
99
•
Light activity: activities of >37.5 and < 672.5 counts17
100
•
SB: activities of ≤37.5 counts18
101
M AN U
98
Outcome measures
103
Volume of physical behavior
104
Total activity counts were calculated by summation of counts in epochs, and expressed as counts per
105
minute. Total time spent in MVPA, light activity, and SB was calculated and expressed as a percentage of
106
total daily wear time. The amount of steps was expressed as steps per minute.26 In addition, we
107
calculated the percentage of patients meeting a step target of at least 6500 steps/day. According to a
108
recent study, 6500 steps/day is needed to prevent cardiovascular disease progression.27, 28
EP
AC C
109
TE D
102
110
Distribution of physical behavior
111
The mean length of all uninterrupted bouts (time periods) of MVPA and SB with a minimum length of
112
15s (1 epoch) was calculated. Because the lengths of these bouts were not normally distributed, the
113
natural logarithm of lengths was taken and geometric means were calculated. A fragmentation index for
6
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation both MVPA and SB was calculated as the total number of bouts divided by the total volume in minutes.
115
A higher fragmentation index indicates that the number of bouts was high and time in MVPA or SB
116
relatively low. In other words, time is more fragmented in frequent, shorter bouts than in fewer
117
prolonged periods. 19, 20
RI PT
114
Also, we were interested in prolonged bouts of MVPA and SB. In accordance with
119
recommendations6, 12, 29-31, prolonged MVPA was defined as periods ≥10 min. Short MVPA interruptions
120
may occur in daily life situations such as waiting for a traffic light.21-23 The exact length of MVPA
121
interruptions to consider the bout as continuous remains unclear.23 We chose to allow a maximum of
122
four interruptions (not necessarily consecutive) of 15s epochs with counts below 672.5 during a single
123
bout of MVPA. Likewise, because there is no standard definition of prolonged SB, we defined prolonged
124
SB as those bouts >30 min. During a sedentary period, we chose to allow a maximum of three
125
consecutive interruptions of 15s epochs with counts above 37.5 during a single bout of SB. Thus, we
126
analyzed a prolonged SB bout as ending after at least 1 min of continuous non-SB. In making this choice,
127
we considered that interrupting SB every 30 min with a 1 min break of non-SB seems a feasible target
128
for interventions. The total time spent in prolonged MVPA and SB was calculated and expressed as a
129
percentage of total wear time. We also calculated whether participants met the American College of
130
Sports Medicine (ACSM) target of ≥150 min of prolonged MVPA bouts per week.30 This guideline is
131
consistent with those addressing secondary prevention of cardiovascular disease.6,
132
accelerometer was not always worn for a full week, we calculated the percentage of participants
133
reaching an average 21.4 min prolonged MVPA/day (150 min/ 7 days). There are no guidelines currently
134
for recommended volume of SB.
14, 29
Because the
AC C
EP
TE D
M AN U
SC
118
135 136
Procedures
137
Cardiac rehabilitation
7
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation All patients participated in multi-disciplinary outpatient CR lasting 10-13 weeks, as per Dutch
139
guidelines.32 The program was terminated when individual physical and psychosocial goals were met, as
140
evaluated by an exercise stress test and consultation by a multidisciplinary team consisting of physical
141
therapists, social workers, and cardiologists. The program consisted of a 75-min group exercise sessions
142
(twice weekly with a strength and aerobic program); and group educational sessions about the medical
143
background and risk factors for cardiovascular disease, dietary advice, and emotional coping. If indicated
144
each patient could participate in group counseling sessions on smoking cessation, healthy diet, and
145
stress management. If needed, patients were referred for individual consultations with a psychologist,
146
social worker, psychiatrist, or dietician. During CR, there was no specific MVPA coaching, but general
147
information was given on the health benefits of an active lifestyle. There was no specific focus on
148
changing SB.
M AN U
SC
RI PT
138
Patients also attended usual follow-up appointments with their cardiologist, during which
150
general information on the health benefits of PA might be given. We do not have exact information on
151
this aspect
152
TE D
149
Data collection
154
Data on physical behavior were obtained the week before CR (T0), during the last week of CR (T1), and
155
at follow-up one year after the start of CR (T2). Data on age, gender, and working status were collected
156
at T0.
AC C
157
EP
153
158
Statistical analysis
159
Descriptive statistics were used to present baseline characteristics. Independent t-tests and Chi-square
160
tests were used to test for differences in baseline characteristics between the original study sample and
161
the sample with sufficient valid physical behavior measures.
8
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation For continuous variables, mean differences between T0 and T1 and between T0 and T2 were
163
analyzed using paired t-tests, after checking whether the within-subject changes met the assumptions of
164
normality. For dichotomous variables, chi-square tests were used to test for mean differences between
165
T0 and T1 and between T0 and T2
166 167
RI PT
162
A two-sided p-value <0.05 was considered significant. All analyses were performed using SPSS (version 20).
SC
168 RESULTS
170
Subjects
171
A flow diagram of inclusion is shown in Figure 1. A total of 245 patients were randomized to standard CR
172
and included in this study. Data from 45 patients who did not complete CR, for reasons such as lack of
173
time and unwillingness, were excluded. An additional 54 patients were excluded because fewer than
174
two valid physical behavior measurements were available, and 11 patients because baseline physical
175
behavior measurements were lacking. These 65 patients with insufficient physical behavior
176
measurements were on average four years younger (p=0.001). Most of the remaining 135 participants
177
were male (80%), mean age was 59 years and attendance rate was 23 CR exercise sessions. (Table 1).
178
ActiGrapha wear time increased between T0 and T1 and between T0 and T2 (Table 2). Data from
179
logbooks showed that at T0, during which patients are still in the acute phase after their cardiac event,
180
patients go to bed earlier and wake up later. To compensate for these differences, all physical behavior
181
outcomes were expressed relative to wear time.
TE D
EP
AC C
182
M AN U
169
183
Changes in physical behavior during cardiac rehabilitation
184
Table 2 shows the observed data and outcomes of the paired t-tests for mean changes over time in the
185
volume of physical behavior (graphically depicted in Figure 2).
9
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Total activity counts per minute significantly increased between T0 and T1 (mean
187
difference=50.56 counts/min, p<0.001), and between T0 and T2 (mean difference=55.04 counts/min,
188
p<0.001). The step count also increased between T0 and T1 (mean difference=0.67 steps/min, p=0.002)
189
and between T0 and T2 (mean difference=0.55 steps/min, p=0.017). At T0, 39.3% of participants were
190
compliant with a daily step target of 6500. This compliance increased to 51.4% (p<0.001) at T1 and was
191
46.5% at T2 (p<0.001 vs T0).
RI PT
186
Between T0 and T1, the time spent in MVPA and light activity increased (mean difference=0.65%
193
of waking hours, p=0.002 and mean difference=1.84%, p=0.001 respectively) and time in SB decreased
194
(mean difference=-2.49%, p<0.001). During an average day with a wear time of 14.5 hours, this equals a
195
change of +5.7 min in MVPA, +16.0 min in light activities and -21.7 min in SB. Differences remained
196
significant between T0 and T2.
197
M AN U
SC
192
Distribution of physical behavior
199
Table 3 shows the observed data and the outcomes of the paired t-tests for mean changes over time in
200
the distribution of physical behavior.
TE D
198
With regard to MVPA, there were no significant changes in distribution outcomes. Compliance
202
with the ACSM guidelines decreased over time from 17.8% of participants at TO to 13.5% at T1
203
(p<0.001) and 13.2% at T2 (p<0.001 vs T0).
AC C
204
EP
201
SB bout distribution changed between T0 and T1. The mean length of bouts decreased (mean
205
difference=-0.05 min, p<0.001), the fragmentation index increased (mean difference=0.04, p=0.001),
206
and time spent in prolonged SB bouts >30 min decreased (mean difference=-3.10%, p=0.001). These
207
changes were also significant between T0 and T2. For an average day with a wear time of 14.5 hours, the
208
change in time spent in prolonged SB was -26.0 min/day between T0 and T1 and -44.4 min/day between
209
T0 and T2.
10
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 210 DISCUSSION
212
Our results show a small, but lasting, increase in MVPA time during CR. Distribution measures revealed
213
that patients with ACS tend to break up their MVPA time into short bouts. This pattern did not change
214
during CR. SB volume and distribution changed. During CR, SB time decreased nearly 22 min and
215
sedentary time became more fragmented with shorter bouts. These improvements were maintained.
RI PT
211
SC
216
The exact changes in MVPA and SB required to gain health benefits are unclear, making it
218
difficult to determine the clinical relevance of our findings. Nevertheless, our results indicate that MVPA
219
remains low despite CR. For example, at the end of CR, only half of the participants achieved a daily step
220
target of 6500.27, 28 Recognizing that PA volume, intensity and distribution are all important8, the ACSM
221
guidelines recommend 150 min of MVPA per week, in bouts of 10 min or longer. Again, only a minority
222
of our participants attained this level and compliance to this guideline even decreased over time.
223
Compliance rates might be underestimated, because these guidelines are based on questionnaires,
224
whereas our data were objectively measured.23 However, the MVPA volume was also relatively low at
225
the end of CR compared to that of healthy adults measured by objective accelerometers (7.0% vs 10.2%
226
MVPA, respectively).20 Moreover, although MVPA time improved during CR, there were no
227
improvements in the distribution of this behavior.
229
TE D
EP
AC C
228
M AN U
217
Interpreting the SB outcomes is even more difficult, as there are no existing guidelines for
230
comparison. The improvements in volume and distribution of SB during CR seem quite substantial and
231
lasting. Less time was spent in SB and this time was more fragmented with shorter periods, as is
232
suggested to gain health benefits.10, 11 This improvement in SB is surprising, as interventions without an
233
SB focus usually do not result in SB changes.34 However, despite the SB improvements during CR, time in
11
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 234
SB was still long (62.8% which equals approximately 9 hours) when compared to that of healthy adults
235
(57.5%).20 Moreover, a meta-analysis has shown that every hour increase in SB beyond seven hours is
236
associated with a 5% increase in all-cause mortality.
237
spent in prolonged SB also seemed long (> 5 h/day).
Although no reference data are available, time
RI PT
238
5
The results of our study are in line with those of other studies showing that cardiac patients
240
tend to be sedentary and inactive.35-37 Studies focusing on the effects of CR and using objective
241
measurement tools are scarce. A recent longitudinal study reported comparable small improvements in
242
MVPA after eight weeks of CR;38 however, in contrast to our study, patients showed no improvement in
243
SB. Another cross-sectional study showed post-CR, step counts and MVPA levels comparable to ours; for
244
SB, lower values were found (56% vs 62.8% in our study).34 Differences can partly be explained by
245
differences in choices related to data processing of accelerometers. This general issue of methodological
246
differences in PA and SB research limits comparisons between studies.21, 24, 39, 40
TE D
M AN U
SC
239
247
Our findings highlight the need to focus on further improvements in PA and SB in patients with
249
ACS. Multidisciplinary CR teams that specialize in directing lifestyle changes can have an important role
250
of helping to improve physical behavior. The focus of CR should be to reach more substantial and lasting
251
changes to total MVPA time, but also to accrue MVPA time in longer-lasting bouts. Targets for SB
252
improvement should be to lower total SB time and frequently interrupt this time. Behavioral
253
interventions containing self-regulation components (e.g. self-monitoring, goal-setting) seem
254
promising.31, 34, 41
AC C
EP
248
255 256
Study Limitations
12
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Our study has some limitations. Firstly, the ActiGrapha cutt-off points we used for the PA intensity
258
categories were developed for a healthy population. Patients entering CR often have lower
259
cardiovascular fitness levels compared to healthy individuals, which may result in under classification of
260
PA intensity.42 Furthermore, the ActiGrapha is not water-resistant and could not be worn during
261
swimming activities. Because our participants rarely swam, we made no attempt to correct for this
262
limitation. Finally, although the ActiGraph GT3X+a was found to fairly accurately detect SB,
263
misclassifications such as designating “standing still” as “SB” cannot be ruled out.18 Despite these
264
limitations, the use of accelerometers is still a major strength of our study.
SC
RI PT
257
Another limitation is that our study was performed at a single-center with no control group.
266
Caution is required when attributing the observed effects to the CR program. Baseline measurements
267
were taken after hospital discharge, when patients had not yet returned to their daily life activities. The
268
observed improvements might, therefore, partly reflect a return to participants’ physical behavior
269
situations that existed before the cardiac incident.
TE D
M AN U
265
Lastly, patients who did not have sufficient physical behavior measurements to be included in
271
the analysis were younger on average, which may have biased the results. In addition, the cohort may
272
consist of higher motivated patients that were willing to participate in this trial. Information on patients
273
who did not provide informed consent is lacking.
EP
270
AC C
274 275
CONCLUSIONS
276
Patients with ACS achieved small, but lasting, improvements in the MVPA volume during CR. More
277
substantial and lasting improvements in SB volume and distribution were observed. However, at the end
278
CR participants still spent a relatively short time in MVPA and a long time in SB, which has been shown
279
to be detrimental to cardiovascular health. Although CR programs have the potential to improve
13
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 280
physical behavior, our findings highlight the need to develop adjusted CR targets focusing on volume
281
and distribution of MVPA and SB.
AC C
EP
TE D
M AN U
SC
RI PT
282
14
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation REFERENCES
284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329
1. Bussmann JB, van den Berg-Emons RJ. To total amount of activity..... and beyond: perspectives on measuring physical behavior. Front Psychol 2013;4:463. 2. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public health reports 1985;100(2):126-31. 3. Wilmot EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ et al. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and metaanalysis. Diabetologia 2012;55(11):2895-905. 4. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Annals of internal medicine 2015;162(2):123-32. 5. Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE et al. Daily sitting time and all-cause mortality: a meta-analysis. Plos One 2013;8(11):e80000. 6. Organization WH. Global Recommendations on Physical Activity for Health. 2010. 7. Healy GN, Wijndaele K, Dunstan DW, Shaw JE, Salmon J, Zimmet PZ et al. Objectively measured sedentary time, physical activity, and metabolic risk: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Diabetes Care 2008;31(2):369-71. 8. Strath SJ, Holleman RG, Ronis DL, Swartz AM, Richardson CR. Objective physical activity accumulation in bouts and nonbouts and relation to markers of obesity in US adults. Prev Chronic Dis 2008;5(4):A131. 9. Murphy M, Nevill A, Neville C, Biddle S, Hardman A. Accumulating brisk walking for fitness, cardiovascular risk, and psychological health. Medicine and science in sports and exercise 2002;34(9):1468-74. 10. Healy GN, Dunstan DW, Salmon J, Cerin E, Shaw JE, Zimmet PZ et al. Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care 2008;31(4):661-6. 11. Kim Y, Welk GJ, Braun SI, Kang M. Extracting objective estimates of sedentary behavior from accelerometer data: measurement considerations for surveillance and research applications. Plos One 2015;10(2):e0118078. 12. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115(20):2675-82. 13. Warburton DE, Katzmarzyk PT, Rhodes RE, Shephard RJ. Evidence-informed physical activity guidelines for Canadian adults. Canadian Journal of Public Health Revue Canadienne de Sante Publique 2007;98 Suppl 2:S16-68. 14. Giannuzzi P, Mezzani A, Saner H, Bjornstad H, Fioretti P, Mendes M et al. Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. European Journal of Cardiovascular Prevention & Rehabilitation 2003;10(5):319-27. 15. Evenson KR, Butler EN, Rosamond WD. Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States. J Cardiopulm Rehabil Prev 2014;34(6):406-19. 16. Prince SA, Blanchard CM, Grace SL, Reid RD. Objectively-measured sedentary time and its association with markers of cardiometabolic health and fitness among cardiac rehabilitation graduates. Eur J Prev Cardiol 2015.
AC C
EP
TE D
M AN U
SC
RI PT
283
15
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 17. Sasaki JE, John D, Freedson PS. Validation and comparison of ActiGraph activity monitors. J Sci Med Sport 2011;14(5):411-6. 18. Carr LJ, Mahar MT. Accuracy of intensity and inclinometer output of three activity monitors for identification of sedentary behavior and light-intensity activity. J Obes 2012;2012:460271. 19. Tieges Z, Mead G, Allerhand M, Duncan F, van Wijck F, Fitzsimons C et al. Sedentary behavior in the first year after stroke: a longitudinal cohort study with objective measures. Arch Phys Med Rehabil 2015;96(1):15-23. 20. Blikman LJ, van Meeteren J, Horemans HL, Kortenhorst IC, Beckerman H, Stam HJ et al. Is physical behavior affected in fatigued persons with multiple sclerosis? Arch Phys Med Rehabil 2015;96(1):24-9. 21. Masse LC, Fuemmeler BF, Anderson CB, Matthews CE, Trost SG, Catellier DJ et al. Accelerometer data reduction: a comparison of four reduction algorithms on select outcome variables. Med Sci Sports Exerc 2005;37(11 Suppl):S544-54. 22. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40(1):181-8. 23. Chastin SF, Dall PM, Tigbe WW, Grant MP, Ryan CG, Rafferty D et al. Compliance with physical activity guidelines in a group of UK-based postal workers using an objective monitoring technique. Eur J Appl Physiol 2009;106(6):893-9. 24. Keadle SK, Shiroma EJ, Freedson PS, Lee IM. Impact of accelerometer data processing decisions on the sample size, wear time and physical activity level of a large cohort study. BMC Public Health 2014;14:1210. 25. Ayabe M, Kumahara H, Morimura K, Tanaka H. Epoch length and the physical activity bout analysis: an accelerometry research issue. BMC Res Notes 2013;6:20. 26. Lee JA, Williams SM, Brown DD, Laurson KR. Concurrent validation of the Actigraph gt3x+, Polar Active accelerometer, Omron HJ-720 and Yamax Digiwalker SW-701 pedometer step counts in lab-based and free-living settings. J Sports Sci 2015;33(10):991-1000. 27. Ayabe M, Brubaker PH, Dobrosielski D, Miller HS, Kiyonaga A, Shindo M et al. Target step count for the secondary prevention of cardiovascular disease. Circulation journal : official journal of the Japanese Circulation Society 2008;72(2):299-303. 28. Tudor-Locke C, Craig CL, Aoyagi Y, Bell RC, Croteau KA, De Bourdeaudhuij I et al. How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act 2011;8:80. 29. Hamm LF, Sanderson BK, Ades PA, Berra K, Kaminsky LA, Roitman JL et al. Core competencies for cardiac rehabilitation/secondary prevention professionals: 2010 update: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev 2011;31(1):2-10. 30. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-7. 31. Ferrier S, Blanchard CM, Vallis M, Giacomantonio N. Behavioural interventions to increase the physical activity of cardiac patients: a review. European Journal of Cardiovascular Prevention & Rehabilitation 2011;18(1):15-32. 32. Multidisciplinaire Richtlijn Hartrevalidatie 2011. Utrecht: Nederlandse
372 373 374
Vereniging Voor Cardiologie; 2011. 33. Twisk JW. Longitudinal data analysis. A comparison between generalized estimating equations and random coefficient analysis. European journal of epidemiology 2004;19(8):769-76.
AC C
EP
TE D
M AN U
SC
RI PT
330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371
16
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation
RI PT
SC
M AN U
TE D
402
EP
401
34. Prince SA, Saunders TJ, Gresty K, Reid RD. A comparison of the effectiveness of physical activity and sedentary behaviour interventions in reducing sedentary time in adults: a systematic review and meta-analysis of controlled trials. Obes Rev 2014;15(11):905-19. 35. Byun W, Ozemek C, Riggin K, Strath S, Kaminsky L. Correlates of objectively measured physical activity in cardiac patients. Cardiovasc Diagn Ther 2014;4(5):406-10. 36. Guiraud T, Granger R, Gremeaux V, Bousquet M, Richard L, Soukarie L et al. Accelerometer as a tool to assess sedentarity and adherence to physical activity recommendations after cardiac rehabilitation program. Ann Phys Rehabil Med 2012;55(5):312-21. 37. Evenson KR, Butler EN, Rosamond WD. Prevalence of Physical Activity and Sedentary Behavior Among Adults With Cardiovascular Disease in the United States. J Cardiopulm Rehabil 2014;34(6):40619. 38. Ribeiro F, Oliveira NL, Silva G, Campos L, Miranda F, Teixeira M et al. Exercise-based cardiac rehabilitation increases daily physical activity of patients following myocardial infarction: subanalysis of two randomised controlled trials. Physiotherapy 2015. 39. Gorman E, Hanson HM, Yang PH, Khan KM, Liu-Ambrose T, Ashe MC. Accelerometry analysis of physical activity and sedentary behavior in older adults: a systematic review and data analysis. Eur Rev Aging Phys A 2014;11(1):35-49. 40. Orme M, Wijndaele K, Sharp SJ, Westgate K, Ekelund U, Brage S. Combined influence of epoch length, cut-point and bout duration on accelerometry-derived physical activity. Int J Behav Nutr Phys Act 2014;11(1):34. 41. Gardner B, Smith L, Lorencatto F, Hamer M, Biddle SJ. How to reduce sitting time? A review of behaviour change strategies used in sedentary behaviour reduction interventions among adults. Health psychology review 2016;10(1):89-112. 42. Ozemek C, Cochran HL, Strath SJ, Byun W, Kaminsky LA. Estimating relative intensity using individualized accelerometer cutpoints: the importance of fitness level. BMC Med Res Methodol 2013;13:53.
AC C
375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400
17
ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 403
Suppliers ‘list
404
a
405
Manufacturer:
406
ActiGraph
407
48E Chase Street
408
Pensacola, FL 32502
409
USA
410
Distributor:
411
ProCare B.V.
412
Zernikepark 16a
413
9747 AN Groningen
414
The Netherlands
M AN U
SC
RI PT
ActiGraph GT3X+:
TE D
415 Figure Legends
417
Figure 1. Flow diagram participants
418
Figure 2. Percentage of waking hours spent in sedentary behavior (SB), light activities, and moderate-to-
419
vigorous activities (MVPA).
AC C
EP
416
18
ACCEPTED MANUSCRIPT Table 1. Baseline characteristics of the study population (n=135) Characteristics 78.5 58.8 (8.5) 28.0 (3.8) 45.1 12.4 42.5 23.1 (5.0)
AC C
EP
TE D
M AN U
SC
Displayed as percentage or mean (SD)
RI PT
Male Age (years) 2 Body Mass Index (kg/m ) Employment status Full time Part time Not employed Number of attended exercise sessions
1
ACCEPTED MANUSCRIPT
Table 2. Physical behavior over time
6.5 (1.1)
7.0 (1.1)
7.1 (1.1)
14.2 (1.0)
14.6 (1.0)
Total volume of physical activity 544.7 (169.6) Activity counts/min 7.3 (2.9) Steps/min Categories of physical behavior 6.3 (3.0) MVPA (% wear time) 28.1 (7.1) Light activity (% wear time) 65.6 (8.3) SB (% wear time)
P*
T0-T2 (n=114) Mean difference (SD)
P*
0.30 (0.95)
0.001
0.46 (0.98)
<0.001
14.7 (1.0)
0.43 (1.37)
0.001
0.52 (1.21)
<0.001
599.0 (152.0)
596.0 (164.2)
50.56 (128.2)
<0.001
55.04 (148.2)
<0.001
8.1 (2.6)
7.8 (2.8)
0.67 (2.21)
0.002
0.55 (2.44)
0.017
7.0 (2.7)
6.7 (3.0)
30.2 (6.4)
31.0 (7.6)
62.8 (7.4)
62.3 (8.4)
0.65 (2.21)
0.002
0.50 (2.51)
0.037
1.84 (5.65)
0.001
2.98 (6.49)
<0.001
-2.49 (6.57)
<0.001
-3.48 (7.75)
<0.001
AC C
EP
TE D
* t-tests
T0-T1 (n=111) Mean difference (SD)
RI PT
T2 (n=114) Mean (SD)
SC
T1 (n=111) Mean (SD)
M AN U
Wear time Valid days Daily wear time (hours)
T0 (n=135) Mean (SD)
1
ACCEPTED MANUSCRIPT
Table 3. Distribution of physical behavior over time T2 (n=114) Mean (SD)
T0-T1 (n=111) Mean difference (SD)
0.39 (0.05)
0.39 (0.06)
0.008 (0.05)
1.73 (0.42)
1.86 (0.55)
-0.05 (0.42)
0.77 † (0-7.79)
0.49 † (0-6.87)
-0.03 (1.45)
0.87 (0.16)
0.82 (0.14)
0.80 (0.15)
0.49 (0.15)
0.53 (0.14)
0.54 (0.16)
39.0 (12.0)
35.2 (11.4)
34.5 (11.5)
a
Distribution of MVPA bouts Mean length MVPA 0.38 (0.06) a bouts (min) b 1.79 (0.53) Fragmentation index MVPA bouts >10 min (% 0.66 † c (0-8.26) of wear time)
P*
0.111
0.004 (0.05)
0.381
0.173
0.05 (0.46)
0.235
0.805
-0.21 (1.34)
0.096
-0.05 (0.14)
<0.001
-0.07 (0.16)
<0.001
0.04 (0.12)
0.001
0.06 (0.14)
<0.001
-3.10 (10.0)
0.001
-5.11 (10.7)
<0.001
a
M AN U
Distribution of SB bouts Mean length SB bouts a (min) b Fragmentation index SB bouts >30min (% of d wear time)
P*
T0-T2 (n=114) Mean difference (SD)
RI PT
T1 (n=111) Mean (SD)
SC
T0 (n=135) Mean (SD)
AC C
EP
TE D
* t-tests a Uninterrupted bouts with a minimum length of 15 seconds (equal to epoch length) b Total number of bouts divided by total volume of MVPA/SB in minutes. A higher fragmentation index indicates that time is more fragmented with shorter periods of uninterrupted MVPA or SB. c Prolonged MVPA bouts with a minimum duration of 10 min with allowance for interruptions of 60 non-consecutive seconds of non-active time d Prolonged SB bouts with a minimum duration of 30 min with allowance for interruptions of 45 consecutive seconds of non-sedentary behavior † Since the outcomes violated normality assumptions, median (range) values are displayed
1
ACCEPTED MANUSCRIPT
Assessed for eligibility N=2039
In study N=731 Excluded from analysis Did not participate in standard CR: N= 486 Did not complete CR: N=45 <2 valid Actigraph measurements: N=54 No baseline Actigraph measurements: N=11
AC C
EP
TE D
M AN U
SC
In analysis N=135
RI PT
Declined to participate N=1308
ACCEPTED MANUSCRIPT
Volumes of physical behavior 6.3
7.0
6.7
28.1
30.2
31.0
65.6
62.8
80
RI PT
90
70 60 50
30
10 0
T0 (pre-CR)
M AN U
20
SC
40
T1 (post-CR)
Light activity
T2 (1 year) MVPA
EP
TE D
SB
62.3
AC C
Percentage of total daily wear time (%)
100
1