Can consumer wearable activity tracker-based interventions improve physical activity and cardiometabolic health in patients with chronic diseases? A systematic review and meta-analysis of randomised controlled trials

Classified as probably not a substantial claim. May combine two claims.

Increased physical activity has significant health benefits and is associated with the prevention and delayed onset of many chronic diseases.

“On the other hand, it is well known that increased physical activity has significant health benefits and is associated with the prevention and delayed onset of many chronic diseases [4, 6].”

• cites [4] Lee I-M, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–29. sourcePartly supported

  The Introduction and Discussion (page numbers unavailable) describe substantial health benefits of physical activity and estimate that becoming active could avert cases of coronary heart disease, type 2 diabetes, and breast and colon cancers. Our copy does not establish that physical activity delays the onset of those diseases specifically; its life-expectancy findings concern mortality, not age at disease onset. (LLM, conf=0.82)

  Experimental — accuracy not yet measured
• cites [6] Pedersen BK, Saltin B. Exercise as medicine–evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25(S3):1–72. sourceNot checked — no full text of the source

May combine two claims.

Structured behaviour change strategies are often resource-intensive and time-consuming, factors that limit long-term adherence and are usually not feasible in routine clinical care.

“However, these strategies are often resource-intensive and time-consuming, factors that limit long-term adherence and usually not feasible in routine clinical care [15].”

• cites [15] Coughlin SS, Stewart J. Use of Consumer Wearable Devices to Promote Physical Activity: A Review of Health Intervention Studies. Journal of environment and health sciences. 2016;2(6). sourcePartly supported

  The Introduction (page unavailable) says established physical-activity and weight-loss interventions are resource-intensive and time-consuming, limiting full participation and widespread dissemination. It does not say these factors limit long-term adherence or make the strategies usually infeasible in routine clinical care. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim.

Recent reviews have shown that CWATs have potential to increase physical activity.

“Although recent reviews have shown that CWATs have potential to increase physical activity, they included only one type of chronic disease [19, 20] or solely pedometers [14, 21].”

• cites [19] Baskerville R, Ricci-Cabello I, Roberts N, Farmer A. Impact of accelerometer and pedometer use on physical activity and glycaemic control in people with type 2 diabetes: a systematic review and meta-analysis. Diabetic medicine : a journal of the British Diabetic Association. 2017;34(5):612–20. sourceNot checked — no full text of the source
• cites [20] de Vries HJ, Kooiman TJ, van Ittersum MW, van Brussel M, de Groot M. Do activity monitors increase physical activity in adults with overweight or obesity? A systematic review and meta-analysis. Obesity (Silver Spring). 2016;24(10):2078–91. sourceNot checked — no full text of the source
• cites [14] Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. Jama. 2007;298(19):2296–304. sourceNot checked — no full text of the source
• cites [21] Qiu S, Cai X, Chen X, Yang B, Sun Z. Step counter use in type 2 diabetes: a meta-analysis of randomized controlled trials. BMC Med. 2014;12:36. sourceSupported

May combine two claims.

Recent reviews of CWATs included only one type of chronic disease or solely pedometers.

“Although recent reviews have shown that CWATs have potential to increase physical activity, they included only one type of chronic disease [19, 20] or solely pedometers [14, 21].”

• cites [19] Baskerville R, Ricci-Cabello I, Roberts N, Farmer A. Impact of accelerometer and pedometer use on physical activity and glycaemic control in people with type 2 diabetes: a systematic review and meta-analysis. Diabetic medicine : a journal of the British Diabetic Association. 2017;34(5):612–20. sourceNot checked — no full text of the source
• cites [20] de Vries HJ, Kooiman TJ, van Ittersum MW, van Brussel M, de Groot M. Do activity monitors increase physical activity in adults with overweight or obesity? A systematic review and meta-analysis. Obesity (Silver Spring). 2016;24(10):2078–91. sourceNot checked — no full text of the source
• cites [14] Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. Jama. 2007;298(19):2296–304. sourceNot checked — no full text of the source
• cites [21] Qiu S, Cai X, Chen X, Yang B, Sun Z. Step counter use in type 2 diabetes: a meta-analysis of randomized controlled trials. BMC Med. 2014;12:36. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The systematic review was registered in PROSPERO (CRD42019124126) and performed in accordance with PRISMA.

“This systematic review, including an explorative meta-analysis, was registered in the PROSPERO international prospective register of systematic reviews (registration number: CRD42019124126) and was performed in accordance with The Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement [24, 25].”

• cites [24] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. sourceSupported
• cites [25] Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Physical inactivity is one of the major contributing factors for the development of chronic diseases and is highly correlated with mortality and hospitalization.

“Physical inactivity is one of the major contributing factors for the development of chronic diseases and is highly correlated with mortality and hospitalization [4, 5].”

• cites [4] Lee I-M, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–29. sourcePartly supported

  The Findings and Discussion report that physical inactivity contributes to coronary heart disease, type 2 diabetes, breast and colon cancers, and premature mortality. The paper examines disease burden and mortality, but our copy does not report an association with hospitalization (searched: hospitalization, hospitalisation, hospital admissions). (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites [5] Garcia-Aymerich J, Lange P, Benet M, Schnohr P, Antó JM. Regular physical activity reduces hospital admission and mortality in chronic obstructive pulmonary disease: a population based cohort study. Thorax. 2006;61(9):772–8. sourcePartly supported

  The Results and Conclusions report that, among people with COPD, lower physical activity was associated with more COPD hospital admissions and higher mortality. The paper does not establish that inactivity contributes to the development of chronic diseases generally; it studies outcomes in people who already have COPD. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

The NAVIGATOR study has shown that for every additional 2000 steps/day the risk of developing cardiovascular events decreased by 10%, T2DM by 5.5%, and the metabolic syndrome risk score reduced by 0.29 z-score.

“In addition, the NAVIGATOR study, which consisted of 9000 individuals with high cardiovascular risk or impaired glucose tolerance, has shown that for every additional 2000 steps/day the risk of developing cardiovascular events decreased by 10%, T2DM by 5.5%, and the metabolic syndrome risk score redcued by 0.29 z-score [70–72].”

• cites [70] Yates T, Haffner SM, Schulte PJ, Thomas L, Huffman KM, Bales CW, et al. Association between change in daily ambulatory activity and cardiovascular events in people with impaired glucose tolerance (NAVIGATOR trial): a cohort analysis. Lancet (London, England). 2014;383(9922):1059–66. sourceNot checked — no full text of the source
• cites [71] Kraus WE, Yates T, Tuomilehto J, Sun JL, Thomas L, McMurray JJV, et al. Relationship between baseline physical activity assessed by pedometer count and new-onset diabetes in the NAVIGATOR trial. BMJ Open Diabetes Res Care. 2018;6(1):e000523. sourcePartly supported

  The Research design and methods section reports 9,306 participants with impaired glucose tolerance and cardiovascular disease or risk factors. The Conclusions report a 5.5% lower diabetes risk per 2,000 additional baseline steps per day. This paper does not report the claimed 10% reduction in cardiovascular events or 0.29 z-score reduction in metabolic syndrome risk; its Discussion mentions a cardiovascular association without that figure. Page numbers were unavailable in our copy. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites [72] Huffman KM, Sun JL, Thomas L, Bales CW, Califf RM, Yates T, et al. Impact of baseline physical activity and diet behavior on metabolic syndrome in a pharmaceutical trial: results from NAVIGATOR. Metab Clin Exp. 2014;63(4):554–61. sourceSupported

May combine two claims.

Dwyer et al. and Jefferis et al. both found an association between all-cause mortality and step count where every increment of 1000 steps per day led to a 6 and 14% risk reduction, respectively.

“Here, Dwyer et al. and Jefferis et al. both found an association between all-cause mortality and step count where every increment of 1000 steps per day led to a 6 and 14% risk reduction, respectively [68, 69].”

• cites [68] Dwyer T, Pezic A, Sun C, Cochrane J, Venn A, Srikanth V, et al. Objectively measured daily steps and subsequent long term all-cause mortality: the Tasped prospective cohort study. PLoS One. 2015;10(11):e0141274. sourceSupported
• cites [69] Jefferis BJ, Parsons TJ, Sartini C, Ash S, Lennon LT, Papacosta O, et al. Objectively measured physical activity, sedentary behaviour and all-cause mortality in older men: does volume of activity matter more than pattern of accumulation? Br J Sports Med. 2019;53(16):1013–20. sourceSupported

May combine two claims.

Other meta-analyses have shown increased physical activity among outpatient adults (+2500 steps/day) and patients with T2DM (+1822-2042 steps/day).

“These results are consistent with findings from other meta-analyses showing an increased physical activity among outpatient adults (+ 2500 steps/day) [14] and patients with T2DM (+ 1822–2042 steps/day) [21, 22].”

• cites [14] Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. Jama. 2007;298(19):2296–304. sourceNot checked — no full text of the source
• cites [21] Qiu S, Cai X, Chen X, Yang B, Sun Z. Step counter use in type 2 diabetes: a meta-analysis of randomized controlled trials. BMC Med. 2014;12:36. sourceSupported
• cites [22] Vaes AW, Cheung A, Atakhorrami M, Groenen MT, Amft O, Franssen FM, et al. Effect of 'activity monitor-based' counseling on physical activity and health-related outcomes in patients with chronic diseases: a systematic review and meta-analysis. Ann Med. 2013;45(5–6):397–412. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A systematic review showed a positive effect for CWATs, even when interventions were separated into CWAT-only and multifaceted interventions.

“This is in contrast with a systematic review that showed a positive effect for CWATs, even when interventions were separated into CWAT-only and multifaceted interventions [74].”

• cites [74] Brickwood KJ, Watson G, O'Brien J, Williams AD. Consumer-based wearable activity trackers increase physical activity participation: systematic review and meta-analysis. JMIR mHealth uHealth. 2019;7(4):e11819. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing).

Higgens et al. reported that almost one third of meta-analyses have moderate to considerable heterogeneity.

“Moreover, Higgens et al. reported that almost one third of meta-analyses have moderate to considerable heterogeneity [85].”

• cites [85] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ (Clinical research ed). 2003;327(7414):557–60. sourcePartly supported

  In “How much is too much heterogeneity?” (page not given), the paper tentatively calls I² values of 50% and 75% moderate and high, and reports that about a quarter of meta-analyses had I² values over 50%. That supports the general point, but not the claim’s “almost one third” proportion. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Probably not a substantial claim: may not pass S3 (load-bearing).

It has been suggested that regular physical activity may change the LDL cholesterol particle size, even when total LDL concentrations remain constant.

“However, it has been suggested that regular physical activity may change the LDL cholesterol particle size, even when total LDL concentrations remain constant [82, 83].”

• cites [82] Halle M, Berg A, Konig D, Keul J, Baumstark MW. Differences in the concentration and composition of low-density lipoprotein subfraction particles between sedentary and trained hypercholesterolemic men. Metab Clin Exp. 1997;46(2):186–91. sourceNot checked — no full text of the source
• cites [83] Williams PT, Stefanick ML, Vranizan KM, Wood PD. The effects of weight loss by exercise or by dieting on plasma high-density lipoprotein (HDL) levels in men with low, intermediate, and normal-to-high HDL at baseline. Metab Clin Exp. 1994;43(7):917–24. sourceCould not verify

  The Discussion and Results passages report changes in HDL cholesterol and its subfractions after exercise-induced weight loss, not changes in LDL particle size while total LDL remains constant. Searches for LDL particle size and low-density lipoprotein subfractions found only a related work listed in the References; our copy does not state the attributed claim. No page numbers were supplied for these passages. (LLM, conf=0.72)

  Experimental — accuracy not yet measured

May combine two claims.

All included studies were unable to blind participants and study personnel/physicians (n = 18) or to adequately report blinding (n = 17).

“All included studies were unable to blind the participants and the study personnel/physicians (n = 18) or to adequately report blinding (n = 17).”

May combine two claims.

The largest risk of bias was performance bias (lack of blinding of participants and personnel) and detection bias (minimal blinding of outcome assessors).

“The largest risk of bias was with regard to the performance bias (lack of blinding of participants and personnel) and detection bias (minimal blinding of those assessing outcomes).”

May combine two claims.

Among 35 included studies, 15 met five (n = 5) and four (n = 10) of six risk of bias criteria; 18 met three and two met only two.

“Fifteen studies met five (n = 5) [37, 42, 57, 59, 65] and four (n = 10) [18, 33, 38, 41, 49, 53, 55, 58, 64, 66] of the six risk of bias criteria. Eighteen studies met three criteria [32, 34–36, 39, 40, 43–45, 47, 50–52, 56, 60–63] and two studies met only two criteria [48, 54].”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Overall, 60% (range 13-89%) of participants were male, and one study included only male participants.

“Overall, 60% (range: 13–89%) of the participants were male and one study included only male participants.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Mean age of participants was 61.3 ± 7.3 years (range 45.4-75.7), with two studies not providing average age.

“Their mean age was 61.3 ± 7.3 years (range: 45.4–75.7 years) whereas two studies did not provide information of the average population age [41, 61].”

May combine two claims.

Waist circumference, systolic BP, and LDL cholesterol results were homogeneous and had no significant publication bias.

“In addition, both waist circumference (Q = 20.0, p = 0.40; I2 = 12), systolic BP (Q = 7.5, p = 0.98; I2 < 0.001) and LDL cholesterol concentration (Q = 9.0, p = 0.44; I2 < 0.001) were all homogeneous results and no significant publication bias was found.”

May combine two claims.

Subgroup effects for chronic respiratory diseases, T2DM, overweight/obesity, and sedentary older adults were statistically heterogeneous.

“as well as the results from individual subgroups including chronic respiratory diseases (Q = 75.9, p < 0.001; I2 = 97), T2DM (Q = 95.3, p < 0.001; I2 = 86), overweight/obesity (Q = 4.4, p = 0.037; I2 = 77) and sedentary older adults (Q = 58.9, p < 0.001; I2 < 82).”

• AssumptionRests on an assumption: The pooled effect estimates from the included randomised controlled trials are valid despite the high statistical heterogeneity.

May combine two claims.

The included studies consisted of populations with chronic respiratory diseases (n = 7), impaired glucose tolerance or T2DM (n = 12), CVD (n = 6), overweight/obesity (n = 3), cognitive disorders (n = 1) and sedentary older adults (n = 6).

“The included studies consisted of populations with various chronic diseases including chronic respiratory diseases (n = 7) [32–38], impaired glucose tolerance or T2DM (n = 12) [39–50], CVD (n = 6) [51–56], overweight/obesity (n = 3) [57–59], cognitive disorders (n = 1) [60] and sedentary older adults (n = 6) [61–65].”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Control conditions varied and consisted of usual care (n = 21), maintaining normal physical activity levels (n = 7), encouragement to increase daily physical activity (n = 2), generic information brochures (n = 1), education sessions (n = 2), coaching sessions (n = 1) and one control group wore masked CWAT devices (n = 1).

“Control conditions varied between studies and consisted of usual care (n = 21) [32, 34–36, 38, 41–43, 46–50, 52–56, 58, 59, 61], maintaining normal physical activity levels (n = 7) [39, 57, 62–66], encouragement to increase daily physical activity (n = 2) [37, 40], generic information brochures (n = 1) [51], education sessions (n = 2) [33, 44], coaching sessions (n = 1) [45] and one control group”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The average dropout rate among studies was 17% (range 0-43%), with four studies having 100% completion.

“Furthermore, the average dropout rate among the studies was 17% (range: 0–43%) of which four studies had a 100% participants completion rate.”

May combine two claims.

Most studies provided complete outcome data (n = 31), three had high risk of attrition bias due to incomplete outcome data, and one reported insufficient information.

“Most of the studies provided complete outcome data (n = 31), whereas three studies had a high risk of attrition bias [38, 54, 60] due to incomplete outcome data and only one study reported insufficient information [48].”

May combine two claims.

Only eight studies blinded outcome assessors, whereas the majority did not adequately report blinding of outcome assessors (n = 22).

“Only eight studies blinded the outcome assessors, whereas the majority of the studies did not adequately report blinding of the outcome assessors (n = 22).”

May combine two claims.

Twenty-five studies reported daily step counts, and most participants in intervention (5105 ± 2591 steps/day; range 2031-9003) and control (5149 ± 2751 steps/day; range 2334-7539) groups were relatively physically inactive at baseline.

“Twenty-five studies reported daily step counts and most of the participants in the intervention (5105 ± 2591 steps/day; range: 2031–9003 steps/day) and control (5149 ± 2751 steps/day; range: 2334–7539 steps/day) groups were relatively physically inactive at baseline.”

Classified as probably not a substantial claim. May combine two claims.

Thirty-five full-text articles fulfilled inclusion criteria and were included in qualitative (n = 35) and quantitative (n = 33) synthesis.

“Thirty-five full-text articles fulfilled the inclusion criteria and were included in qualitative (n = 35) and quantitative (n = 33) synthesis (Table 1.).”

Probably not a substantial claim: may not pass S3 (load-bearing).

The CWAT-based interventions varied in duration (mean ± SD 22 ± 17 weeks; range 6-64 weeks).

“The CWAT-based interventions evaluated in the included studies varied considerably in intervention duration (mean ± SD; 22 ± 17 weeks; range: 6–64 weeks).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The majority of interventions consisted of CWAT use and individual counselling (n = 22), of which five also used additional telephone calls.

“The majority of the interventions consisted of CWAT use and individual counselling (n = 22) of which five interventions also used additional telephone calls [48, 51, 59–61].”

May combine two claims.

Significant publication bias was found in subgroup analyses for patients with CVD (p = 0.012), overweight/obesity (p = 0.037), and sedentary older adults (p = 0.004).

“In addition, significant publication bias was found in subgroup analyses for patients with CVD (p = 0.012), overweight/obesity (p = 0.037) and sedentary older adults (p = 0.004).”

May combine two claims.

The included studies evaluated a total of 2858 participants (intervention n = 1567; control n = 1291), including 529 with chronic respiratory diseases (492 COPD), 704 with T2DM, 571 with CVD, 334 with overweight/obesity, 21 with Alzheimer's disease and 699 sedentary older adults.

“The included studies evaluated a total of 2858 participants (intervention: n = 1567; control: n = 1291) of which 529 participants with chronic respiratory diseases (492 with chronic obstructive pulmonary disease; COPD), 704 participants with T2DM, 571 participants with CVD, 334 participants with overweight/obesity, 21 participants with Alzheimer’s disease and 699 sedentary older adults.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Data were independently extracted by two reviewers using a predesigned data collection form adapted from the Cochrane Collaboration.

“Data were independently extracted by two of the reviewers (W.M.A.F. and J.S.). Data extraction was performed with the aid of a predesigned data collection form, adapted from the extraction form of the Cochrane Collaboration (Appendix II).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Studies were independently screened in three steps by two authors, with disagreements resolved by consensus with a third reviewer.

“Studies were independently screened in three different steps by two authors (W.M.A.F. and J.S.).”

• Also stated in: § Study selection · plain

  “Disagreements between authors were resolved by consensus with a third reviewer (B.O.E).”

May combine two claims.

CWAT-based interventions increase physical activity and have beneficial effects on systolic blood pressure, waist circumference and LDL cholesterol concentration in patients with chronic diseases.

“CWAT-based interventions increase physical activity and have beneficial effects on important health-related outcomes such as systolic blood pressure, waist circumference and LDL cholesterol concentration in patients with chronic diseases.”

• Also stated in: § Summary box · plain

  “Consumer wearable activity tracker-based interventions increase physical activity”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Goal setting may be a key motivational factor for increasing physical activity, but this conclusion was based on observational studies and healthy individuals.

“In addition, although Bravata et al. showed that goal setting may be a key motivational factor for increasing physical activity, this conclusion was based on observational studies and healthy individuals [14].”

• cites [14] Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, et al. Using pedometers to increase physical activity and improve health: a systematic review. Jama. 2007;298(19):2296–304. sourceNot checked — no full text of the source

Classified as probably not a substantial claim.

Risk of bias of included studies was assessed using the Cochrane Risk of Bias tool, covering sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting and other threats to validity.

“The risk of bias of the included studies was assessed by one reviewer (W.M.A.F.) as recommended by Higgins et al. (Cochrane ‘Risk of Bias’ assessment tool, the Cochrane Collaboration). Here, the following methodological criteria were assessed: sequence generation, allocation concealment, blinding of participants, personnel and outcome assessors, incomplete outcome data, selective outcome reporting”

• cites [27] Higgins JP, Green S. Cochrane handbook for systematic reviews of interventions. Version 5.2; 2017.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Sensitivity analyses were performed to assess heterogeneity and robustness of results.

“Sensitivity analyses were performed to assess heterogeneity of the studies and to evaluate the robustness of the results.”

May combine two claims.

The increase in step count from 5100 to 7200 steps/day could indicate a substantial reduction in all-cause mortality risk and the development of chronic diseases.

“Consequently and in accordance with Lee et al., who obeserved that hazard ratios of all-cause mortality declined progressively with higher mean steps per day until approximately 7500 steps/day after which they leveled in older adult women [73], this could indicate a substantial reduction in all-cause mortality risk and the development of chronic diseases.”

• cites [73] Lee IM, Shiroma EJ, Kamada M. Bassett DR. Buring JE. Association of Step Volume and Intensity With All-Cause Mortality in Older Women. JAMA internal medicine: Matthews CE; 2019.Not checked yet

  Not checked in the free run.

May combine two claims.

These studies all confirm that a CWAT-only, or included in a multi-component intervention, have a positive effect in favor of the intervention groups.

“These studies all confirm that a CWAT-only, or included in a multi-component intervention, have a positive effect in favor of the interventions groups.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Publication bias was assessed using funnel plots and the Egger test.

“Publication bias was assessed using funnel plots and the Egger test (Appendix III).”

May combine two claims.

CWAT-based interventions increase physical activity and improve cardiometabolic health (waist circumference, systolic BP, LDL cholesterol) in populations with chronic diseases.

“In general, individuals with a CWAT increased their physical activity level and this may be associated with improvements in cardiometabolic health including waist circumference, systolic BP and LDL cholesterol concentration.”

• Also stated in: § Conclusion · hedged

  “These results suggest that populations with chronic diseases significantly increase physical activity using CWATs only, or as part of a multi-component intervention, and improve their cardiometabolic health such as a reduced waist circumference, systolic BP and LDL cholesterol concentration.”

• AssumptionRests on an assumption: The observed improvements in waist circumference, systolic BP, and LDL cholesterol are attributable to the CWAT-based interventions rather than other factors.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

A meta-analysis from The Cholesterol Treatment Trialists' Collaboration showed that with the aid of statins the 5-year incidence of major vascular events reduced by about 20% and all-cause mortality by 12% per 40 mg/dl in LDL cholesterol concentration.

“A meta-analysis from The Cholesterol Treatment Trialists’ Collaboration showed that with the aid of statins the 5-year incidence of major vascular events reduced by about 20% and all-cause mortality by 12% per 40 mg/dl in LDL cholesterol concentration.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A change of −10 mm Hg in systolic BP reduces the risk of developing CVD by 17% and overall mortality by 13%.

“It has been shown that a change of − 10 mm Hg in systolic BP reduces the risk of developing CVD by 17% and overall mortality by 13% [77].”

• cites [77] Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet (London, England). 2016;387(10022):957–67. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

The use of CWAT devices as both measurement and motivational instrument may affect the control group by increasing their physical activity by the thought that they were being monitored.

“As a result, this may affect the control group by increasing their physical activity by the thought that they were being monitored.”

May combine two claims.

Our findings are relevant for the general population and for those who cannot participate in high-intensity physical activities.

“As such, our findings are relevant for the general population and for those who cannot participate in high-intensity physical activities.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A decrease in systolic BP of 2 mm Hg is associated with a reduction of 10% in stroke mortality and a 7% reduction in mortality originating from CVD.

“In addition, a decrease in systolic BP of 2 mm Hg is associated with a reduction of 10% in stroke mortality and a 7% reduction in mortality originating from CVD [78].”

• cites [78] Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet (London, England). 2002;360(9349):1903–13. sourceNot checked — no full text of the source

May combine two claims.

All studies only measured physical activity but did not take into account sedentary time.

“Finally, all studies only measured physical activity but did not take into account sedentary time.”

May combine two claims.

No direct associations between increased physical activities (steps/day) and cardiometabolic risk factors could be made and no minimal amount of steps per day to improve cardiometabolic health could be determined.

“In this way, no direct associations between increased physical acitivities (steps/day) and cardiometabolic risk factors could be made and no minimal amount of steps per day to improve cardiometabolic health could be determined.”

May combine two claims.

Patient characteristics were all independently associated with an increased number of steps, which possibly explains the heterogeneity of the overall effect and subgroup analyses.

“Furthermore, patient characteristics were all independently associated with an increased number of step, which possibly explains the heterogeneity of the overall effect and subgroup analyses.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The lower increase in physical activity in COPD and CVD patients might be due to airflow and cardiac limitations and most of these studies were performed after a rehabilitation period where baseline physical activity levels were reduced.

“This might be due to airflow and cardiac limitations and most of these studies were performed after a rehabilitation period where baseline physical activity levels were reduced.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

Clinical and methodological diversity is always present in meta-analysis and statistical heterogeneity is inevitable.

“However, since clinical and methodological diversity is always present in meta-analysis statistical heterogeneity is inevitable.”

May combine two claims.

The obese population was younger of age compared to other populations and, as a result, probably showed a higher increase in physical activity.

“For example, the obese population was younger of age compared to other populations and, as a result, propably showed a higher increase in physical activity.”

May combine two claims.

The included studies had relatively small sample sizes and different intervention durations.

“First, studies with relatively small sample sizes and different intervention durations were included in the meta-analyses.”

May combine two claims.

CWATs can be effective on their own, but when combined with other behaviour change strategies, such as telephone support or group-based counselling, the improvement in physical activity is greater.

“This suggests that CWATs can be effective on their own, but when combined with other behaviour change strategies, such as telephone support or group-based counselling, the improvement in physical activity is greater.”