THE PHYSICIAN AND SPORTSMEDICINE - VOL 29 - NO. 1 - JANUARY 2001

Can Exercise Gadgets Motivate Patients?

From Pedometers to High-Tech Tools

Walking is likely the most palatable exercise option for sedentary patients resolving to step up activity. But physicians often wonder how they can motivate patients to adopt a walking program. Increasingly, physicians, exercise professionals, and major health organizations are turning to a simple device—a pedometer—as a tool to help patients increase activity. Patients who are already active may benefit from more sophisticated feedback tools.

Pedometers Basics

Catrine Tudor-Locke, PhD, at the Prevention Research Center at the University of South Carolina in Columbia, says a pedometer, an inexpensive device (between $20 and $50) worn at the waist, contains an internal lever that deflects with each vertical acceleration of the hip (figure 1). Each acceleration is interpreted as a step. She notes that pedometers have been used in Japan for more than 30 years to increase walking, and the average Japanese family today owns 3.2 pedometers. "But in North America we are only now beginning to discover that the pedometer can assess walking behaviors," she says, "and it may be a good motivational device in goal-setting and self-monitoring programs."

Tudor-Locke says that under laboratory conditions, pedometers are extremely accurate, but they may be less precise in free-living conditions because walking speeds vary and movements such as bending and weight shifting may be interpreted as steps. "However, the magnitude of these errors is likely to be small when individuals use pedometers to monitor their own behavior," she says.

Some pedometer models claim to measure distance walked and calories expended; however, physicians and their patients should be aware that those data are less accurate than steps taken, Tudor-Locke says. Those two measures are based on manufacturer computations, which assume, for example, a standardized stride length. Also, data on calories burned are based on users entering their weight, sex, and age into the pedometer. "These equations are based on fallible assumptions, making it difficult to compare activity levels between individuals," she says. (Several pedometer models are available from Walk4Life, Inc, a manufacturer and distributor of pedometers. The Web address for the Plainfield, Illinois-based company is http://www.walk4life.com, and the toll-free phone number is 888/422-1806.)

How Many Steps?

One of the most notable changes in the most recent public health recommendation (1) was that individuals could accumulate 30 minutes or more of moderate intensity activity on most days of the week. A pedometer may help patients take advantage of this new recommendation.

Tudor-Locke says that the Japanese recommend taking 10,000 steps a day for health benefits, but she adds that no evidence supports this slogan and that it suggests a threshold for health benefits. "Blindly imposing the 10,000 steps a day would frustrate many individuals," she says, noting that average daily totals for obese people or those who have chronic health conditions are reported to be 3,500 to 5,000 steps per day. A more realistic goal for these groups to achieve 30 minutes of daily activity may be to take 2,400 to 3,600 extra steps each day, Tudor-Locke says. (This assumes that most people will take between 800 to 1,200 steps in 10 minutes of moderate-intensity walking.) "Once more active, additional benefits will accrue from either walking faster and/or adding more steps," she says.

The "10,000 steps" concept, however, provides an attractive marketing slogan that may attract many patients who are open to becoming more active. HealthPartners, a health maintenance organization based in Minneapolis, unveiled its "10,000 Steps" program in the spring of 1999. For $20, participants receive a pedometer, a personal action planner, a step log, and motivational mailings (biweekly for 8 weeks, and then bimonthly for 6 months). Prize drawings are held for patients who register, mail in their completed exercise logs, and/or complete a program evaluation form. Rebecca Lindberg, MPH, RD, lifestyle program adviser for HealthPartners, says the 10,000 Steps program has been the company's most successful health promotion initiative. "We're overwhelmingly pleased. More than 10,000 people have enrolled," she says. "People love the pedometer and the simplicity of the program. They love that they can sneak in physical activity and get immediate feedback."

Exercise Gadgets Go High-Tech

Pedometers represent the simplest of the portable exercise gadgets on the market. Nike, Inc, based in Beaverton, Oregon, recently released a shoe-mounted accelerometer that provides runners with speed and distance information, along with other training data. Reebok International, based in Canton, Massachusetts, is expected to release a shoe-based training system this summer (2). A heart rate monitor is another portable monitoring tool that has benefited from technological improvements (see "Heart Rate Monitors: Advances and Practical Points," page 17).

Gregory Florez, CPT, as spokesperson for the American Council on Exercise, tracks exercise trends and as president of First Fitness, Inc, a Salt Lake City-based online personal training company, tests exercise equipment. He says that equipment advances satisfy a demand for more customized exercise feedback, "so exercisers know if they ran the same course faster, lengthened their stride, or burned more calories." The availability of portable devices seems to complement a trend toward exercise as being more lifestyle focused, Florez says. "In the '80s and '90s, people were more into burning calories for 30 minutes in the gym. Now people are more likely to walk, hike, or run when they can fit it in."

"My office is strewn with a lot of impressive-looking gadgets," he says. "But regardless of efficacy, the question is: Do they overcome exercise barriers and increase adherence?" A possible downside of high-tech exercise devices for some people is information overload. "Are you ever unplugged?" he asks.

Before recommending a pedometer or other device to a patient, physicians and other healthcare professionals should first make sure the patient wants to make use of the data such feedback instruments provide. He estimates, for example, that only about 30% of exercisers who use treadmills use the programming devices on the machines. "Make sure this is something they'll use on an ongoing basis. If it's too overwhelming, too complicated, or not digestible, it's not going to translate to real-life data," Florez says.

Florez has found that even if exercisers don't reach their physiologic goals, feedback devices can be useful for coaching and demonstrating progress. If a patient is interested in using a more complicated exercise device such as a shoe-based system or heart rate monitor, Florez recommends that physicians direct patients who are interested in high-tech feedback devices to a reputable specialty retailer that can demonstrate how to use the product. He also recommends having a personal trainer help the patient design an exercise program that makes the best use of the product.

Lisa Schnirring
Minneapolis

REFERENCES

1. Pollock ML, Gaesser GA, Butcher JD, et al: The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998;30(6):975-991
2. Marriott M: A shoe that will give runners and walkers instant feedback. New York Times. September 21, 2000:D10

Heart Rate Monitors: Advances and Practical Points

Heart rate monitors are perhaps the most widely used portable exercise devices, but they require considerably more user expertise than do pedometers. "They're like a window into your body, which is wonderful, but can be daunting," says Gregory Florez, CPT, spokesperson for the American Council on Exercise and president of First Fitness, Inc, a Salt Lake City-based online personal training company, where he tests exercise equipment.

Florez says technological advances have made heart rate monitors more user-friendly. Traditional heart rate monitors consist of a chest strap that transmits wirelessly to a wristband monitor. He notes that the chest strap is often uncomfortable, especially for women. Some new designs have eliminated the chest strap, enabling users to monitor their pulse by pressing their fingertips onto the wrist monitor. And he notes that another new design transmits heart rate information by human voice into earphones that are worn during exercise. Though Florez notes that the fingertip heart rate monitors are somewhat less accurate than chest-strap models, he applauds the trend toward user comfort. "The important consideration is likelihood of use," he says.

Warren Scott, MD, a sports medicine physician in private practice in Soquel, California, is closely familiar with heart rate monitors, not only professionally but personally—he's used them for triathlon training and running over the past 15 years. He advises two groups of patients to wear heart rate monitors during exercise: (1) competitive athletes who need heart rate information as a training guide and (2) athletes who have medical conditions and need to stay in a safe aerobic zone. "Even if patients with medical problems don't like the monitor, they should temporarily use one so they can learn the ratings of perceived exertion," he says. He adds that heart rate monitors may also be useful for newly exercising patients because the devices help them set limits and monitor progress.

Lewis G. Maharam, MD, a sports medicine specialist in private practice in New York City, says his active patients often ask if they should be wearing heart rate monitors. "My answer is usually yes, with the goal that they work at 65% to 85% of their maximal heart rate," says Maharam, who is medical director of the New York City Marathon. He says his answer is sometimes tailored to the patient's sport, and that walkers, swimmers, and cyclists are more likely than runners to exercise at a submaximal aerobic level.

From a personal standpoint, Scott says he uses the data from the heart rate monitor to gauge his hydration level, glycogen stores, training response, recovery response, race pace, fatigue buildup, and fitness changes over time. "I like all the data. It keeps me interested," Scott says. But he says high-tech exercise gadgets aren't for everyone. "How about stopping and smelling the roses and stopping the electronic overload and relaxing during exercise?" he asks.

Field Notes

Exercise Predictions for 2001
Americans will be more active in 2001, and exercise options will be more creative and diverse, according to predictions released by the American Council on Exercise (ACE), a group that promotes exercise, certifies fitness instructors, and evaluates exercise products.

The group's report on the latest exercise trends includes:

• Outdoor fitness programs will become more popular because people spend so much time working indoors. Exercise classes will be held at parks and beaches, and more people will walk, jog, and hike.
• Children will be the focus of more fitness programs, based on public health reports of growing obesity and decreasing activity levels in this group. Gyms and community centers will offer more family exercise programs.
• Water aerobics will become more popular, especially for seniors and people who have physical disabilities.
• Corporations, because of the competitive employee market, will provide broader fitness benefits such as fitness centers, on-site personal trainers, Internet coaching, and golf and sport-specific training.
• Fitness devices such as personal digital assistants and heart rate monitors will become more popular for exercise training (see article above).
• Exercise classes will continue to diversify based on music and dance styles of other cultures, particularly Eastern.
• Yoga, Pilates, and other mind-body exercises will become more mainstream.
• Board sports such as snowboarding and skateboarding will draw new participants who are looking for thrills and fitness benefits.
• Strength training will draw more exercisers, particularly women who want to tap into its weight management, osteoporosis, and general health benefits.
• Exercise will be more fun—for example, "circus" workouts that incorporate elements of play by combining muscle strength, endurance, flexibility, and balance activities.
• Personal trainers will work with their clients on overall wellness and stress reduction, and the number of personal trainers will double in the next 3 to 5 years.

Safe Rolling With New Lightweight Scooters
Countless children and adults woke up Christmas morning and found new lightweight scooters under their trees. Though the devices might seem like safer alternatives to in-line skating or skateboarding, participants should be aware that preventable injuries do occur.

Even before the holiday buying season, sales of the scooters had increased 700%, according to the US Consumer Product Safety Commission (CPSC). Also on the rise were scooter-related injuries; CPSC data show that in August alone, hospital emergency department staff had treated 4,000 injuries. Nearly 90% were to children younger than age 15. Most injuries resulted from falls from the scooters. Fractures and dislocations (mostly to the arms and hands) accounted for 29% of the injuries.

The CPSC recommends the following precautions for safe scootering:

• Wear a safety-approved helmet, along with knee and elbow pads.
• Ride on smooth, paved surfaces that are not near traffic, and avoid surfaces with water, sand, gravel, or dirt on them.
• Do not ride the scooter at night.

Contaminated 'Andro' and Positive Drug Tests
Physicians and sports officials have known the athletes who take androstenedione can test positive for nandrolone, a banned steroid; however, they weren't sure why, because the urine byproduct that causes the positive test wasn't thought to be a metabolic byproduct of androstenedione. Now, a report in the November 22 issue of The Journal of the American Medical Association pinpoints the source: supplement contamination.

A group led by Donald Catlin, MD, director of the Olympic Analytical Laboratory at the University of California Los Angeles, tested the content of the androstenedione capsules after finding that groups of men who took either 300 mg or 100 mg of andro had 19-norandrosterone—the nandrolone byproduct—in their urine, while the control group did not.

The researchers then analyzed the content of the andro capsules and found that each contained trace amounts of 19-norandrostenedione, which was enough to produce a positive urine test. Catlin and his team analyzed nine additional brands of andro and found that the actual dose in each 100-mg capsule varies from 0 to 103 mg, and that some brands contained testosterone, another banned substance. They noted that not all andro is contaminated and that the amount of 19-norandrostenedione detected was far below the purity level set by the US Food and Drug Administration for pharmaceutical drugs. Still, Catlin said, "The only way to protect yourself from testing positive for steroid use is to not take drugs or health supplements at all."