Effects of Physical Activity Counseling in Primary Care: The Activity Counseling Trial - ACT (The Activity Counseling Trial)
The Activity Counseling Trial (ACT) was a multicenter randomized clinical trial to determine the effects of two patient education and counseling interventions compared with current recommended care, and with each other, on cardiorespiratory fitness and physical activity in inactive adult patients.
Counseling interventions differing in type and number of contacts would be equally effective in men or women in improving cardiorespiratory fitness over two years compared with recommended care provided by primary care physicians.
Patients Enrolled: 874
Mean Follow Up: 24 months
Participants were inactive (daily energy expenditure ≤35 kcal • kg-1 • day-1 from the seven-day PAR), 35 to 75 years old, and in stable health, defined as an absence of serious chronic disease. If the participants were taking medication for chronic disease, they had to be continuing a stable dosage for at least three months. Participants had to be planning or scheduled to see a study clinician during the recruitment phase, able to read and write English, independent in daily living, and able to increase their physical activity.
Patients with a history of coronary heart disease or findings of ischemia during the study treadmill test were excluded.
Cardiorespiratory fitness, measured by maximal oxygen uptake (VO2max) and self-reported total physical activity, measured by a seven-day PAR
Percentage of participants engaging in 30 minutes of moderate-to-vigorous physical activity at least five days a week or 30 minutes of vigorous activity at least three days a week and safety assessment (musculoskeletal injuries related to exercise, possible cardiovascular events, and physician visits and hospitalizations due to these)
Participants in the advice group received brief physician advice (2-4 minutes) consisting of assessing activity level, providing advice to increase activity and select a long-term goal and referring the participant to an on-site health educator who provided educational materials on physical activity, answered questions, and was available to be called with questions. At follow-up physician visits, the physician gave advice and the health educator briefly met with the participants.
Participants in the assistance group received the same physician advice and educational materials as those in the advice group. In addition, the health educator conducted an initial 30-40-minute behavioral counseling session and subsequently telephoned the participants one week after the initial visit. An interactive-mail component consisted of a monthly newsletter, which included a postage-paid mail-back card for reporting weekly physical activity, current goals, and barriers to participation. At the time of physician visits, participants received brief behavioral counseling from health educators.
Participants in the counseling group received all of the components of the assistance intervention and in addition received health educator–initiated telephone counseling biweekly, then monthly after six weeks during the first year, with telephone contacts during the second year at a negotiated frequency. Weekly classes were provided at the centers by the health educators on behavioral skills for adopting and maintaining physical activity.
All three groups were given the same physical activity targets based on current national recommendations: five or more days a week of 30 minutes of moderate-intensity physical activity (equivalent to brisk walking) or three or more days a week of 30 minutes of vigorous-intensity physical activity (equivalent to running).
Participants were randomly assigned to one of three groups: advice (n=292) (recommended care), assistance (n=293), and counseling (n=289). Baseline characteristics were similar in the three randomized groups. Follow-up measurement rates at 24 months were 91.4% for the seven-day physical activity recall (PAR) and 77.6% for VO2max, with rates of 90.7%, 93.9%, and 89.6% for the seven-day PAR and 80.1%, 78.5%, 74.0% for VO2max in the advice (n=133), assistance (n=132), and counseling groups (130), respectively.
For women, the primary analysis resulted in an adjusted difference of VO2max at 24 months between the assistance and advice groups of 80.7 ml/min (99.2% confidence interval [CI], 8.1-153.2; adjusted p=0.02), between the counseling and advice groups of 73.9 ml/min (99.2% CI, 0.9-147.0; adjusted p=0.046), and between the assistance and counseling groups of -6.7 ml/min (99.2% CI, -80.9 to 67.5; adjusted p=0.99). For men, there were no significant differences between groups in cardiorespiratory fitness at 24 months.
For both men and women, there were no significant differences in self-reported total physical activity, except for a significantly higher value of 0.54 kcal • kg-1 • day-1 in the counseling than in the assistance group (95% CI, 0.07-1.00; adjusted p=0.01) in women at six months. At 24 months, the secondary outcomes classifying participants according to physical activity recommendations showed that percentage of participants engaging in 30 minutes of moderate-to-vigorous physical activity at least five days a week or 30 minutes of vigorous activity at least three days a week for women were 25.7% (28/109) in the counseling group, 9.9% (12/121) in the assistance group, and 14.3% (17/119) in the advice group (counseling vs. assistance, p=0.005; other comparisons not significant), and for men were 18.5% (28/151) in the counseling group, 29.9% (46/154) in the assistance group, and 16.4% (24/146) in the advice group (assistance vs. advice, p=0.02; other comparisons not significant).
Musculoskeletal injuries, possible cardiovascular events, and physician visits and hospitalizations due to these were similar between the three randomized groups. There was approximately a 60% rate of musculoskeletal events during the two years. The difference in number of hospitalizations for possible cardiovascular events was significant across all three groups (p=0.04), with the pairwise comparison between the highest rate in the assistance group and the lowest rate in the counseling group also significant (p=0.05).
Two patient counseling interventions differing in type and number of contacts were equally effective in women in improving cardiorespiratory fitness over two years compared with recommended care. In men, neither of the two counseling interventions was more effective than recommended care.
Writing Group for the Activity Counseling Trial Research Group. Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial. JAMA 2001;286:677-87.
Keywords: Walking, Behavior Therapy, Chronic Disease, Exercise, Physicians, Primary Care, Health Educators, Telephone, Counseling, Running, Energy Metabolism, Hospitalization
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