Target Step Count for the Secondary Prevention of Cardiovascular Disease
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1 Circ J 2008; 72: Target Step Count for the Secondary Prevention of Cardiovascular Disease Makoto Ayabe, PhD*, **; Peter H. Brubaker, PhD ; Devon Dobrosielski, PhD ; Henry S. Miller, MD ; Akira Kiyonaga, MD**; Munehiro Shindo, MS**; Hiroaki Tanaka, PhD** Background Obtaining an accurate measure of physical activity energy expenditure (PAEE) can be difficult, so the simple measurement of steps per day has become widely promoted and accepted in the general population. However, the relationship between PAEE and steps per day has not been evaluated in patients with cardiovascular disease. Methods and Results A total of 77 (53 men, 24 women) cardiac rehabilitation program participants aged between 46 and 88 years were enrolled. By means of an accelerometer the step count per day, amount of PAEE, as well as time per day spent in physical activity at light (<3 metabolic equivalents (METs)), moderate (3 6 METs) and vigorous (>6 METs) intensity were evaluated for each subject. The number of daily step counts strongly correlated with total PAEE (r=0.92, p<0.001) and time spent in moderate to vigorous intensity physical activity (r=0.85, p<0.001). The mean (95% confidence intervals) step counts associated with 214 and 314 kcal/day (ie, 1,500 and 2,200 kcal/week) were 6,470 and 8,496 steps/day, respectively. Conclusion To achieve the total amount of PAEE generally recommended for the secondary prevention of cardiovascular disease, patients should be encouraged to accumulate 6,500 8,500 steps/day. (Circ J 2008; 72: ) Key Words: Accelerometer; Cardiac rehabilitation; Pedometer The inverse dose response relationship between physical activity and cardiovascular disease progression is well established, 1 4 but the common physical activity recommendation of min of moderate-intensity physical activity, 3 4 times per week will generally result in a physical activity energy expenditure (PAEE) of less than 1,000 kcal/week. This level of PAEE is associated with a high likelihood for of atherosclerotic cardiovascular disease progression. 4 A goal of 1,500 kcal/week is thought to be necessary to prevent disease progression and should be recognized as the minimal physical activity goal for secondary prevention. 1 4 Furthermore, a more aggressive PAEE goal of 2,200 kcal/week may be desirable in this population as it has been associated with cardiovascular disease regression. 4 Unfortunately, it appears that participation in traditional cardiac rehabilitation programs (CRP, ie, thrice weekly) alone will not provide enough PAEE to meet these goals and must be supplemented with additional unstructured PAEE. 5 9 Although there are several approaches for estimating PAEE during structured exercise and leisure-time physical (Received April 3, 2007; revised manuscript received October 2, 2007; accepted October 11, 2007) *Department of Exercise Physiology, School of Health and Sports Science, Juntendo University, Chiba, **Faculty of Sports Science, Fukuoka University, Fukuoka, Japan and Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA Mailing address: Makoto Ayabe, PhD, Department of Exercise Physiology, School of Health and Sports Science, Juntendo University, 1-1 Hiragagakuendai, Inba, Chiba , Japan. All rights are reserved to the Japanese Circulation Society. For permissions, please cj@j-circ.or.jp activity, the accelerometer appears to be the most useful method. Unfortunately, for many the cost of an accelerometer is prohibitive and therefore the less expensive and simpler pedometer has become a more popular option for monitoring physical activity levels. 10,11 Pedometers simply measure step counts, but this basic information is highly correlated with other physical activity parameters (caloric expenditure, time spent distribution) as well as quality of life and overall prognosis Numerous researchers have recommended that individuals should accumulate 10,000 steps per day to prevent cardiovascular disease, as well as diabetes, obesity, and certain cancers. 10,11 Although this is a very practical and reasonable goal for most, 10,000 steps per day may be inappropriate for sedentary individuals, older individuals, and/or those with chronic health conditions such as cardiac disease. 10 To our knowledge, no study to date has examined the relationship between step counts and PAEE in the adult, cardiac disease population. Consequently, our objective was to determine the number of daily steps that correspond to the minimal and optimal levels of PAEE (1,500 and 2,200 kcal/week, respectively) in order to establish practical target levels of physical activity for secondary prevention. Methods Subjects A total of 77 participants (53 men, 24 women) in the Wake Forest University CRP aged between 46 and 88 years participated in this investigation. After explanation of the study design and requirements, all participants signed a consent form that was approved by the universities institutional review board.
2 300 AYABE M et al. Table 1 Characteristics of the Study Subjects All (n=77) Men (n=53) Women (n=24) Mean ± SD 95%CI Mean ± SD 95%CI Mean ± SD 95%CI Age (years) 68.1±9.2 ( ) 66.8±9.6 ( ) 70.9±7.7 ( ) Height (cm) 170.7±8.3 ( ) 174.3±7.0 ( ) 162.8±4.7 ( ) Weight (kg) 79±13.5 ( ) 83.9±12.2 ( ) 68.0±9.3 ( ) BMI (kg/m 2 ) 27.0±3.4 ( ) 27.6±3.4 ( ) 25.6±3.1 ( ) CI, confidence interval; BMI, body mass index. Significant difference between men and women at p<0.05. Table 2 Step Count Pattern in CRP Participants All (n=77) Men (n=53) Women (n=24) All (steps/day) 6,752±2,659 (6,148 7,355) 7,046±2,785 (6,279 7,814) 6,101±2,277 (5,140 7,063) CRP days (steps/day) 8,499±3,173 (2,662 18,777) 8,850±3,298 (3,827 18,777) 7,724±2,790 (2,662 12,757) Non-CRP days (steps/day) 5,491±2,805 (1,460 18,759) 5,731±2,998 (1,568 18,759) 4,963±2,290 (1,460 11,501) All, data were averaged over all experimental days. CRP days, data were averaged over the 3 days comprising the CRP. Non-CRP days, data were averaged over the 4 days not attending the CRP. CRP, cardiac rehabilitation program. Other abbreviation see in Table 1. Significant difference between CRP days and non-crp days at p<0.01 All participants were clinically stable during this study, and all were New York Heart Association class II or I. Furthermore, based on the classification of the severity of heart failure according to maximal oxygen uptake, established by Weber et al, (87%) subjects were categorized as class A (>20 ml kg 1 min 1 ) and 10 (13%) were categorized as class B (16 20 ml kg 1 min 1 ). They had been participating in the CRP at Wake Forest University for more than 3 months, and the average period was 5.4±5.3 years. In this program, participants undergo annual measurement of maximal aerobic capacity, as well as blood pressure, blood cholesterol and blood glucose. In the latest results, the mean maximal aerobic capacity, estimated by the incremental treadmill test, was 9.1±2.8 metabolic equivalents (METs). The mean values for systolic blood pressure, diastolic blood pressure, total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, and blood glucose were 137±17 mmhg, 78±10 mmhg, 175±35 mg/dl, 47± 13 mg/dl, 97±30 mg/dl and 108±22 mg/dl, respectively. The program consisted of supervised endurance exercise 3 times per week on Monday, Wednesday and Friday mornings. After a 10-min warm-up that included slow walking and light stretching, patients walked on an indoor track (160 meter per lap) for approximately 40min at a pace needed to maintain a target heart rate range. The exercise intensity was set at 50 85% of heart rate reserve from data generated during a symptom-limited graded exercise test performed prior to starting the program based on general CRP guidelines. 1 3 Although the present investigation did not evaluate medications, some can affect the heart rate response, 1,2 so each patient exercised to achieve 50 85% of the actual measured heart rate reserve. A 10-min cool-down period of stretching and light weight training completes the exercise training session. Physical Activity Assessment All subjects wore a 1-axial accelerometer (Lifecorder, Suzuken Co, Tokyo, Japan) on a belt at waist level just above the leg except while sleeping or bathing. After 10 days of continuous wear, the device was retrieved and the data were downloaded into a computer with Microsoft Excel software. In order to assess the usual daily physical activity level, this investigation used the final 7 days of continuous data from the 10-day collection period. The Lifecorder is a small ( cm), lightweight (40 g) activity monitor that samples vertical acceleration ranges between 0.06 and 1.94 G (1 G is equal to earth s gravity acceleration) at 32 Hz. From the magnitude and frequency of acceleration, the Lifecorder determines a level of movement intensity every 4s on a scale of 1 (minimal intensity of movement) to 9 (maximal intensity of movement). As shown in previous studies, 17,18 the intensity levels as described above are closely related and approximate the METs between 2 and 9. Consequently, based on body weight and the acceleration pattern, the device determines the PAEE (PAEE in kcal/day), time spent in light (<3 METs), moderate (3 6 METs) and vigorous (>6 METs) intensity physical activity (min/day), as well as the step count (steps/day). The validity of this device has been well documented and compares favorably with doubly labeled water 19 and indirect calorimetry. 17,18 Additionally, the reported error in step counts for this device is less than 3%. 20,21 Details of the device have been described previously Statistical Analysis Data are presented as mean and standard deviation (mean ± SD) and 95% confidence intervals (CI). Independent T-test was used to determine if gender differences exist across any variable. The correlation between 2 variables was assessed by the Pearson correlation coefficient (r). The variables related to physical activity were classified according to the 25 th, 50 th and 75 th percentiles for the distribution of step counts. ANOVA was used to determine the differences in the variables related to physical activity across the quartiles of step counts. The effect size was calculated as the differences between the highest and lowest quartiles means, divided by the group standard deviation. A p-value <0.05 was considered statistically significant for all analy-
3 Target Step Goals 301 Table 3 Comparison of Energy Expenditure and Time Spent on Light, Moderate and Vigorous Physical Activity Across Quartiles of Daily Step Counts Quartiles of daily step count I II III IV F (p value) Effect size Energy expenditure (kcal/day) 120.4± ± ± ± ( ) ( ) ( ) ( ) (<0.0001) Light-intensity physical activity (min/day) 35.4± ± ± ± ( ) ( ) ( ) ( ) (<0.0001) Moderate-intensity physical activity (min/day) 5.2± ± ± ± ( ) ( ) ( ) ( ) (<0.0001) Vigorous-intensity physical activity (min/day) 0.2± ± ± ± ( ) ( ) ( ) ( ) (0.0165) F (p value) are the result of ANOVA. I, 2,541 5,087 steps/day (n=20; 13 men, 7 women); II, 5,174 6,567 steps/day (n=19; 11 men, 8 women); III, 6,571 8,362 steps/day (n=19; 15 men, 4 women); IV, 8,369 16,450 steps/day (n=19; 14 men, 5 women). Abbreviation see in Table 1. ses. Results Subject Characteristics The characteristics of the subjects are presented in Table 1 and are reflective of typical CRP participants. As expected, there were significant differences in height and body weight between men and women in this sample. As shown in Table 2, the step counts were not significantly difference between men and women evaluated in this study. As would be expected, the step counts were significantly higher (for the combined sample, as well as for men and women independently) on the days that subjects attended the CRP (Mon, Wed and Fri) vs non-program days (Tue, Thurs, and weekends). Relationship Between Step Count, PAEE and Time Spent in Moderate to Vigorous Intensity Physical Activity (MVPA) The daily amount of energy expenditure through physical activity, and the MVPA were categorized according to the step counts, as shown in Table3. The mean (range) step rate in the 4 quartiles (I IV) was 3,769 (2,542 5,087), 5,872 (5,174 6,567), 7,863 (6,571 8,362) and 10,160 (8,369 16,450) steps/day. There were significant differences in energy expenditure related to physical activity (F=35.942, p<0.0001), in time spent in light (F=24.633, p<0.0001), moderate (F=30.266, p<0.0001) and vigorous intensity physical activity (F=3.647, p<0.0001) across the quartiles of daily step counts. The differences of these variables across the quartiles exhibited a clear distinction (effect size >0.80), except for the time spent in vigorous intensity physical activity (effect size <0.80). Target Step Counts The step count significantly correlated with the MVPA (r=0.85) and total PAEE (r=0.92) (Fig 1). The correlation between time spent in light intensity physical activity was modest (r=0.69), although still significant. The mean (95% CI) step rate corresponding to 144, 214 and 314 kcal/day (reflective of weekly values of 1,000, 1,500 and 2,200 kcal, respectively), were 5,046 (4,256 5,836), 6,485 (5,555 7,414) and 8,510 (7,385 9,636) steps/day, respectively. Based on these results, the target step count needed for this cohort to obtain the minimal and optimal levels of PAEE appears to be 6,500 8,500 steps/day. Fig 1. Relationship of the step counts with physical activity energy expenditure (PAEE) and the time spent in moderate to vigorous intensity physical activity (MVPA) by participants in a cardiac rehabilitation program. Discussion The data from this investigation indicate that in order to achieve the PAEE goals generally accepted for secondary prevention of cardiovascular disease, patients should seek to accumulate 6,500 8,500 steps/day. Achieving 5,000 or fewer steps/day would be associated with a PAEE of less than 1,000 kcal/week, a level thought to promote coronary disease progression. 4 Given the difficulties associated with accurately quantifying PAEE (via accelerometry or estimated based on work rate), a target step count would be useful for patients to self-monitor physical activity that accumulates from a structured exercise program, as well as from non-structured physical activity. Although most CRP participants perform min of moderate-intensity physical activity 3 4 times per week in a rehabilitation facility, this dose of physical activity alone may be insufficient to obtain the 1,500 2,200 kcal of PAEE thought necessary to limit cardiovascular disease progression and for potential disease regression. Several investigations have demonstrated that most CRP participants fail to expend 300 kcal/day through standard CRP exercise sessions 6 8 and that the total weekly energy expenditure and/or the amount of moderate intensity physical activity are substantially lower than the desirable levels. 8,9 Several studies have evaluated step counts in a variety of
4 302 AYABE M et al. chronic disease populations and in general have found these levels to be significantly lower to those observed in apparently healthy populations. 10 The reported average daily step count for a group of peripheral arterial disease patients was nearly 4,500 steps/day 12 and it ranged from 3,500 4,300 steps/day in heart disease patients. 13,14,23 Hoodless et al demonstrated that chronic heart failure patients had a 60% reduction in step count compared with age-matched healthy controls. 23 In the present investigation, the mean observed step count was 5,491±2,805 steps/day for non-crp days, and 8,499±3,173 steps/day on CRP days. Consequently, the average step count (6,752±2,659 steps/day) in this investigation was slightly higher than that reported from earlier evaluations of a chronic disease population ,23 These findings are not surprising given that our participants regularly attended the CRP and they were also likely to have a greater functional capacity than the subjects observed in the aforementioned studies. Although the average step count for the subjects in the presents study corresponded to the minimal goal for PAEE in secondary prevention (1,500 kcal/week) (Table 2), 48% of patients failed achieve this minimal goal. Therefore, as previously reported, 8,9 nearly half of our CRP participants failed to reach the current exercise recommendation of 6,500 /steps or 215 kcal/day (1,500 kcal/week) for secondary prevention. As shown in Table 3, there was a clear distinction in the time spent in light and moderate intensity physical activity across the quartiles of daily step counts. In the most active quartile (IV), the step counts and MVPA were 10,160± 2,339 steps/day and 36±17min/day, respectively. Linear regression equation demonstrated that this step count equates to 35 min/day of MVPA. Walking 10,000 steps expends approximately 333 kcal in the average-size Japanese man, based on the assumption that 1 step of walking expends 0.55 calories/kg of body weight. 11 However, for the larger subjects observed in this study, walking 10,000 steps should, based on the aforementioned equation, result in approximately 385 kcal of PAEE. Interestingly, in the present study, the actual calorie expenditure and step counts determined from the accelerometer were 368.8±138.5 kcal/day and 10,160±2,339 steps/day, respectively, in the most active quartile (IV). Consistent with our findings, Sieminski et al found that in patients with peripheral arterial occlusive disease, 9,229±5,678 steps equated to 352±248 kcal over a 48-h period. 12 Thus, data from these 2 investigations suggest that recommending 10,000 steps/day to the typical chronic disease population (ie, cardiac rehabilitation patient) would be likely to yield a PAEE output >350 kcal/day. If performed 7 days/week, this would result in a PAEE >2,450 kcal/week. Although this level of PAEE would provide maximal protection against cardiovascular disease progression, it may be unnecessary and potentially excessive. One important consideration in the application of these findings is related to the reliability of the pedometer. There are a variety of pedometers available and there are measurable differences in the reported accuracy of these devices. 10,11 In general, most are reliable and can detect ambulatory activity with acceptable error. 10,11,20,21 However, previous studies have shown that many pedometers are unable to detect ambulation during slow walking, 15,20 common to an older, lower-functioning population, 26 as well as those with central obesity. In obese individuals, the abdominal adiposity appears to interfere with pedometer accuracy because of inappropriate positioning. So, while more expensive than pedometers, accelerometers are more accurate and reliable. 15,17 In 1 study, the pedometer detected just 75.0% of the actual step count taken while walking at 54m/min on a treadmill, whereas the accelerometer detected 98.9% of the step count taken during the same walk. 15 Consequently, there is a difference of 2,000 steps/day between the 2 devices (accelerometer>pedometer) over 24h in the free-living condition. 17 Thus, even the most accurate pedometers may be inappropriate for frail older adults, particularly those with slow gait. 26 In this context, as with obese subjects, the accelerometer may be more appropriate given its enhanced accuracy. Although we used the Lifecorder Ex (Suzuken) in the present study, there are several other accelerometers available. The Lifecorder Ex appears to an excellent device with a measurement error of less than 3% during usual walking. 20,21 Most accelerometers, including the Lifecorder Ex, cost $300 or more and require a computer for data analysis, which, while acceptable for research purposes, may limit the feasibility of its use for large field studies and/or individual use. Until the cost of accelerometers decreases, there are several less expensive pedometers, particularly the Digiwalker and NL-2000, that have been shown to have excellent accuracy. 18 There are several limitations in the present investigation. First, PAEE (calories) were estimated via the Lifecorder Ex according to the magnitude and frequency of the acceleration pattern and were not directly measured. Although PAEE assessed by the Lifecorder Ex is well correlated to indirect calorimetry, 17,18 the validity of this approach is not as well described during physical activity in obese individuals and/or those with a slow gait pattern. Furthermore, the present investigation did not measure specific outcomes related to coronary artery disease progression and/or regression. Consequently, the target step counts related to specific levels of PAEE associated with changes in coronary artery pathology is purely theoretical and based on previous investigations. 4 Finally, most of the subjects in the present investigation were classified as overweight or obese, and the calorie cost of 1 step depends on body weight. Thus the results of the present investigation should be confirmed in normal weight patients; however, we found that 6,500 8,500 steps/day indicated a meaningful level of moderate intensity physical activity. In summary, the purpose of this investigation was to determine the step count that corresponded to the minimal and optimal levels of PAEE recommended for the secondary prevention of cardiovascular disease. We observed a clear distinction in the PAEE and the time spent in light and moderate intensity physical activity across the daily step counts. Furthermore, the daily step count strongly correlated with PAEE and time spent in MVPA, with the mean (95%CI) step count corresponding to PAEE levels of 214 and 314 kcal/day (1,500 and 2,200 kcal/week), which corresponded to 6,470 (5,542 7,398) and 8,496 (7,372 9,620) steps/day, respectively. Thus, this finding indicates that 6,500 8,500 steps/day should be considered the minimal goal and optimal level, respectively, of physical activity for secondary prevention of cardiovascular disease. Of concern is that 48% of subjects evaluated in this investigation failed to accumulate 6,500 steps/day, which suggests that they are more likely to experience cardiovascular disease progression rather than regression. Because the average step count on CRP days was nearly 8,500 steps/day, increasing physical activity on non-crp days should be emphasized as the primary strategy to increase the PAEE of CRP participants.
5 Target Step Goals Acknowledgments This study was supported by grants from the Japanese Ministry of Health, Labour and Welfare, and Medical Frontier, Strategy Research (H11-Kenkou-018). References 1. American College of Sports Medicine. Guidelines for exercise testing and prescription, 7th edn. Philadelphia: Lippincott Williams & Wilkins; American Association of Cardiovascular and Pulmonary Rehabilitation. Guidelines for cardiac rehabilitation and secondary prevention, 4 th ed. Champaign: Human Kinetics; Smith SC Jr, Blair SN, Bonow RO, Brass LM, Cerqueira MD, Dracup K, et al. AHA/ACC Scientific Statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: A statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation 2001; 104: Hambrecht R, Niebauer J, Marburger C, Grunze M, Kälberer B, Hauer K, et al. Various intensities of leisure time physical activity in patients with coronary artery disease: Effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions. J Am Coll Cardiol 1993; 22: McConnell TR, Palm RJ, Shearn WM, Laubach CA Jr. Body fat distribution s impact on physiologic outcomes during cardiac rehabilitation. J Cardiopulm Rehabil 1999; 19: Schairer JR, Kostelnik T, Proffitt SM, Faitel KI, Windeler S, Rickman LB, et al. Caloric expenditure during cardiac rehabilitation. J Cardiopulm Rehabil 1998; 18: Savage PD, Brochu M, Scott P, Ades PA. Low caloric expenditure in cardiac rehabilitation. Am Heart J 2000; 140: Schairer JR, Keteyian SJ, Ehrman JK, Brawner CA, Berkebile ND. Leisure time physical activity of patients in maintenance cardiac rehabilitation. J Cardiopulm Rehabil 2003; 23: Ayabe M, Brubaker PH, Dobrosielski D, Miller HS, Ishi K, Yahiro T, et al. The physical activity patterns of cardiac rehabilitation program participants. J Cardiopulm Rehabil 2004; 24: Tudor-Locke CE, Myers AM. Methodological considerations for researchers and practitioners using pedometers to measure physical (ambulatory) activity. Res Q Exerc Sport 2001; 72: Bassett DR Jr, Strath SJ. Use of pedometer to assess physical activity. In: Welk GJ, editor. Physical activity assessments for health-related research. Champaign: Human Kinetics; 2002; Sieminski DJ, Cowell LL, Montgomery PS, Pillai SB, Gardner AW. Physical activity monitoring in patients with peripheral arterial occlusive disease. J Cardiopulm Rehabil 1997; 17: Walsh JT, Charlesworth A, Andrews R, Hawkins M, Cowley AJ. Relation of daily activity levels in patients with chronic heart failure to long-term prognosis. Am J Cardiol 1997; 79: Houghton AR, Harrison M, Cowley AJ, Hampton JR. Assessing exercise capacity, quality of life and haemodynamics in heart failure: Do the tests tell us the same thing? Eur J Heart Fail 2002; 4: LE Masurier GC, Tudor-Locke C. Comparison of pedometer and accelerometer accuracy under controlled conditions. Med Sci Sports Exerc 2003; 35: Weber KT, Kinasewitz GT, Janicki JS, Fishman AP. Oxygen utilization and ventilation during exercise in patients with chronic cardiac failure. Circulation 1982; 65: Kumahara H, Schutz Y, Ayabe M, Yoshioka M, Yoshitake Y, Shindo M, et al. The use of uniaxial accelerometry for the assessment of physical-activity-related energy expenditure: A validation study against whole-body indirect calorimetry. Br J Nutr 2004; 91: Higuchi H, Ayabe M, Sindo M, Yoshitake Y, Tanaka H. Comparison of daily energy expenditure in young and older Japanese using pedometer with accelerometer. Jpn J Phys Fitness Sports Med 2003; 52: Rafamantanantsoa HH, Ebine N, Yoshioka M, Higuchi H, Yoshitake Y, Tanaka H, et al. Validation of three alternative methods of measuring total energy expenditure against doubly labeled water method in older Japanese men. J Nutr Sci Vitaminol 2002; 48: Crouter SE, Schneider PL, Karabulut M, Bassett DR Jr. Validity of 10 electric pedometers for measuring steps, distance, and energy cost. Med Sci Sports Exerc 2003; 35: Schneider PL, Crouter SE, Lukajic O, Bassett DR Jr. Accuracy and reliability of 10 pedometers for measuring steps over a 400-m walk. Med Sci Sports Exerc 2003; 35: Tudor-Lock CE, Ainsworth BE, Thompson RW, Mattews CE. Comparison of pedometer and accelerometer measures of free-living physical activity. Med Sci Sports Exerc 2002; 34: Hoodless DJ, Stainer K, Savic N, Batin P, Hawkins M, Cowley AJ. Reduced customary activity in chronic heart failure: Assessment with a new shoe-mounted pedometer. Int J Cardiol 1994; 43: Brubaker PH, Warner JG Jr, Rejeski WJ, Edwards DG, Matrazzo BA, Ribisl PM, et al. Comparison of standard- and extended-length participation in cardiac rehabilitation program on body composition, functional capacity, and blood lipids. Am J Cardiol 1996; 78: Welk GJ, Differding JA, Thompson RW, Blair SN, Dziura J, Hart P. The utility of the Digi-walker step counter to assess daily physical activity patterns. Med Sci Sports Exerc 2000; 9(Suppl): S481 S Cyarto EV, Myers AM, Tudor-Locke C. Pedometer accuracy in nursing home and community-dwelling older adults. Med Sci Sports Exerc 2004; 36:
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