Table 1: Evidence Mapping Table Study Details Outcome measures Main findings Results Current Wales Evidence Grading NICE ,2010a Weight management in pregnancy – diet and physical activity National Institute for Health and Clinical Excellence Maternal health Diet, physical activity and indicators of weight management Health professionals At earliest opportunity health professionals should discuss physical activity (in context of weight management) with pregnant women. Give specific, practical and tailored advice about being physically active during pregnancy: − recreational exercise such as swimming or brisk walking and strength conditioning exercise is safe and beneficial − the aim of recreational exercise is to stay fit, rather than to reach peak fitness − if women have not exercised routinely they should begin with no more than 15 minutes of continuous exercise, three times per week, increasing gradually to daily 30-minute sessions − if women exercised regularly before pregnancy, they should be able to continue with no adverse effects -Explain to those women who would find this level of physical This guidance is based on a two systematic reviews and evidence statements drawn from them. The focus is on weight management through diet and physical activity combined. See PH27 for full details. Locally implemented in some areas but does not have a co-ordinated approach or national programme A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK
rights of way). Align all ‘planning gain’ agreements with the promotion of heart health to ensure there is funding to support physically active travel. NICE, 2008 Physical environment National Institute for Health and Clinical Excellence Whole population Active play, walking & cycling and other forms of physically active travel Strategies, policies, plans Involve all local communities and experts. Ensure planning applications for new developments always prioritise the need for people (including those whose mobility is impaired) to be physically active, including active play by children and that local facilities and services are easily accessible on active transport. Assess in advance what impact the proposals are likely to have on physical activity levels. Make the results publicly available and accessible. Transport Ensure pedestrians, cyclists and users of other modes of active transport are given the highest priority when developing or This guidance is based on 5 reviews of effectiveness. The relevant evidence statements are: Introduction of multi-use trails can lead to increases in levels of walking and cycling in both the short and long. Trails located closer to population centres may be better used. The evidence on the effect of traffic calming on walking or cycling and children playing outdoors is equivocal. Cycle infrastructure in both urban and rural areas can be effective in increasing cycling (evidence of lower reliability). Introduction of safe routes to schools schemes may lead to short-term increases in levels of walking and cycling within the These interventions are implemented locally in some areas but there is no consistent national programme or a co-ordinated approach A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK
maintaining streets and roads. Plan and provide a comprehensive network of routes for walking, cycling and using other modes of active transport which offer everyone (including people whose mobility is impaired) convenient, safe and attractive access to workplaces, homes, schools and other public facilities- built and maintained to a high standard. Public open spaces Ensure public open spaces and public paths can be reached by active transport and are accessible by public transport. Ensure public open spaces and public paths are maintained to a high standard - safe, attractive and welcoming to everyone. Buildings Ensure different parts of campus sites, including hospitals and universities, are linked by appropriate walking and cycling routes. area of the scheme. The composition of the built environment at the community level may have a positive impact upon levels of walking and cycling. Modification and promotion of parks may increase walking (1 moderate quality study only). The provision of facilities or trails for walking, jogging or cycling, and improvements to existing or provision of new facilities (such as new space, improved equipment, or improved aesthetics [painting, carpet]) may lead to increases in use and/or levels of physical activity in worksites. Physical improvements such as carpets, painting and addition of art work may lead to increases in stairwell usage in the short term. Colourful/fluorescent markings painted on a school playground can lead to objectively assessed increases in variables related to physical activity during playtime, such as time spent in moderate/vigorous physical activity, time spent in vigorous
promote physical activity. NICE 2006 continued. Exercise referral Schemes Increased physical activity Practitioners, policy makers and commissioners should only endorse exercise referral schemes to promote physical activity that are part of a properly designed and controlled research study to determine effectiveness. Measures should include intermediate outcomes such as knowledge, attitudes and skills, as well as measures of physical activity levels. Individuals should only be referred to schemes that are part of such a study. One systematic review of effectiveness was conducted: The evidence from two randomised controlled trials (1-) suggests that exercise referral schemes, involving a referral, either from or within primary care, can have positive effects on physical activity levels in the short term (6 to 12 weeks). However, evidence from four trials (one [1++], three [1-]) indicates that such referral schemes are ineffective in increasing physical activity levels in the longer term (over 12 weeks) or over a very long timeframe (over 1 year). Thus the evidence is inconsistent and insufficient to recommend the use of exercise referral schemes to promote physical activity, other than as part of research studies where their effectiveness can be evaluated. The intervention is funded for widespread national implementation in Wales F. The evidence is inconsistent and it is not possible to draw a conclusion but it tends towards no effect for longer-term outcomes NICE 2006 continued Pedometers and Increased physical activity Practitioners, policy makers and commissioners should only endorse pedometers and walking and cycling schemes to promote physical activity that Two systematic reviews of effectiveness were conducted. Insufficient evidence to recommend the use of pedometers and walking and cycling schemes This intervention is implemented locally in some areas but does Lack of evidence
community walking and cycling schemes are part of a properly designed and controlled research study to determine effectiveness. Measures should include intermediate outcomes such as knowledge, attitude and skills, as well as measures of physical activity levels. to promote physical activity other than as part of research studies where their effectiveness can be evaluated. However, professionals should continue to promote walking and cycling (along with other forms of physical activity) as a means of incorporating regular physical activity into people's daily lives not have a consistent national programme or a co-ordinated approach NICE, 2006b Physical activity intervention in the workplace National Institute for Health and Clinical Excellence Adults of working age Not specified- increased physical activity Offer support to employers who want to implement this guidance to encourage their employees to be more physically active. Where appropriate and feasible, this should be provided on the employer’s premises. It could involve providing information on, or links to, local resources. It could also involve providing advice and other information or resources (for example, the services of physical activity experts). If initial demand exceeds the resources available, focus on: − enterprises where a high proportion of employees are from a disadvantaged background − enterprises where a high 1 systematic review of effectiveness conducted (of SRs & primary research including qualitative). Evidence statements from reliable sources included: Evidence on use of posters and signs to increase stair (instead of lift) use – inconclusive although there is some evidence to suggest that multi-component interventions that combine the provision of signs to encourage stair use with modifications to make stairwells more attractive can increase the frequency of stair use. Some evidence that workplace walking interventions using pedometers that focus on: facilitated goal setting, diaries and self-monitoring and walking routes Elements of this intervention are funded for national implementation but is dependent on local components which are variable A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK
including those from other countries, where appropriate. Messages and materials should highlight the need to reduce the amount of time spent being sedentary and the importance of being physically active. Other recommendations duplicate those from physical activity specific guidance above. NICE 2006c National Institute for Health and Clinical Excellence. Physical activity, prevention and management of overweight and obesity. Adults and children. Weight management through increased physical activity Recommendations draw from other guidelines and are thus duplicated with other NICE guidance above. Community Local authorities and partners should work together to create and manage more safe spaces or incidental and planned physical activity, addressing as a priority any concerns about safety, crime and inclusion, by: − providing facilities and schemes such as cycling and walking routes, cycle parking, area maps and safe play areas − making streets cleaner and safer, through measures such as traffic calming, congestion charging, pedestrian crossings, Evidence is drawn from a series of reviews and is summarised over 12 appendices. Evidence statements are not physical activity specific. Refer to the full guidelines for details. Some of these interventions are implemented locally in some areas but there is no consistent national programme or a co-ordinated approach The NERS Level 4 element includes people with obesity A. These interventions are supported by good evidence of its effectiveness and are recommended for use in the UK
activity interventions Cochrane Database of Systematic Reviews intervention approaches, intensity of actions delivered, the outcomes assessed and comparison communities. The overall quality of the studies was poor with the majority assessed as having a high risk of bias. There is a noticeable inconsistency of the findings of the available studies. The body of evidence in this review does not support the hypothesis that multi-component community wide interventions effectively increase population levels of physical activity. It could be postulated that, given the conflicting findings, community wide interventions lack efficacy, however we believe such a conclusion would be premature given the poor quality of studies. In particular, the tools used to measure physical activity were generally weak, inhibiting the ability to interpret the results and draw conclusions. There is a clear need for intervention studies and such studies should focus on the quality of the measurement of physical Only studies with a minimum follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded. Fifteen studies were identified as having a high risk of bias, 10 studies were unclear, and no studies had a low risk of bias. Selection bias was a major concern with these studies, with only one study using randomisation to allocate communities. 11 studies were at high risk of detection bias. Almost all of the interventions studies by included articles involved building partnerships with local governments or nongovernment organisations (NGOs) (22 studies). Others included some form of individual counselling by health professionals (18 studies), mass media campaigns (17 studies), or other communication strategies (19 studies). Some studies worked in specific settings (21 studies) and used environmental change programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis effect
described basing interventions or components of interventions on multiple models. 9 studies were judged to be high intensity, 10 of medium intensity and six of low intensity. Foster, C, 2005 Physical activity interventions Cochrane Database of Systematic Reviews Change in self-reported physical activity between baseline and follow-up. fitness. Adverse events There is some evidence to suggest that interventions designed to increase physical activity can lead to moderate short and mid-term increases in physical activity, at least in middle age. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Nevertheless interventions which provide people with professional guidance about starting an exercise programme and then provide ongoing support may be more effective in encouraging the uptake of physical activity. There is no evidence that such interventions will reduce physical activity or cause other harm. There is only very limited evidence of the long-term 11,513 apparently healthy adults participated in the 29 included RCTs. The majority of studies recruited both genders with three studies recruiting men only, four studies recruiting women only). The stated age range of participants was from 18 to 95 years. Details on ethnic group of participants were reported in 13 studies, with proportions of participants in ethnic minorities ranging from 3% to 55%. Participants were recruited from four settings; primary healthcare, workplaces, university and the community. We found a marked heterogeneity in the interventions used in each study. Studies used one, or combination of, one-to-one counselling/advice or group counselling/advice; self-directed or prescribed physical activity; supervised or unsupervised physical activity; home-based or facility-based physical activity; Elements of this intervention are funded for national implementation but is dependent on local components which are variable C. There is some evidence supporting the use of this intervention but it is not conclusive respiratory
effectiveness of interventions. The review’s conclusions differed to earlier reviews which concluded that interventions that encouraged home-based activity were more effective than facility-based activity interventions. This review used more rigid inclusion criteria (eg outcome measures with at least 6 months follow-up) and subsequently excluded some studies included in these previous reviews. They also used unpublished data from study authors and performed a quantitative analysis using standardised mean differences for effects as opposed to just descriptions alone. The conclusions are similar to another published review (). The findings of this review are in contrast to the conclusions of a review produced by the Center for Disease Control () which examined the effectiveness of behavioural interventions for the promotion of physical activity and concluded that there was "good" evidence to ongoing face-to-face support; telephone support; written education/motivation material; self monitoring. The intervention was delivered by one or a number of practitioners with various professional backgrounds including physicians, nurses, health educators, counsellors, exercise leaders and peers. Only one study adopted a structured and supervised approach to their intervention, encouraging participants to cycle on a static bike for 10 to 25 minutes at a intensity, as part of a 2-hour exercise session. The majority of studies adopted an unstructured and independently performed physical activity regime. We found the majority of studies contacted participants on at least three or more occasions in the first 4 weeks of the intervention to support and encourage any adoption of physical activity. Studies offered a range of support and follow up to participants between week 5 and final outcome measure (a minimum of 6 months post baseline intervention). The types of follow-up offered to participants at any point ranged from postal
suggest that this type of intervention was effective in increasing physical activity. However the authors included studies with shorter periods of follow up, non randomised studies (including uncontrolled before and after studies), and did not take account of loss to follow up. Only one study was shared by both reviews. only, telephone only, face-to-face meetings, or a mixture of postal, telephone or face-to-face. The quality of the studies in this current review was limited by a lack of intention-to-treat analysis and failure to examine the interaction between baseline levels of physical activity and exposure to the intervention. Only six studies achieved all of the quality criteria. The observed effects were smaller but more consistent in studies with higher quality scores. Hillsdon, M, 2005 Physical activity interventions Health Development Agency [NICE] Reviews Individual Working age adults Many studies – different outcomes measures but all generally concerned with change to physical activity levels An important finding from this review is that relatively brief interventions, typically consisting of one short occasion of tailored advice with some follow-up, can lead to at least short-term changes in physical activity. Less is known about how to help people maintain changes in physical activity that might lead to future health benefits. Within each of the included reviews there are a considerable number of individual studies with positive effects. The wide diversity of the interventions employed in Synthesis of high-quality systematic reviews and of RCTs or studies - updates the first version published in February 2004. 16 included studies. 8 SRs examined the effectiveness of physical activity interventions in general practice and hospital outpatient departments. Evidence suggests: • Brief advice from a health professional, supported by written materials, is likely to be effective in producing a modest, short-term (6-12 weeks) effect on physical activity Elements of this intervention are funded for national implementation but is dependent on local components which are variable B. These interventions are supported by moderate to good quality evidence of its effectiveness analyses
applied. 25 studies were 4 months or less in duration. Priest, N, 2008 Interventions to increase participation in sport Cochrane Database of Systematic Reviews Whole population. Participation in sporting activities. The sport sector is viewed as a priority area for increasing rates of physical activity. Participation rates in organised sport have been shown to be lower in females and to decline with age, and are reduced in lower socio-economic and minority groups. There is an absence of high quality evidence to support interventions designed and delivered by sporting organisations to increase participation in sport. Interventions funded and conducted in this area must be linked to a rigorous evaluation strategy in order to examine overall effectiveness, differentials in participation and of these strategies. Despite a thorough review of the published and unpublished literature, no rigorous studies evaluating the effects of interventions organised through sporting organisations to increase participation in sport were found. U. Implementation status unknown. Lack of evidence Hosking, J, 2010 Primary outcomes: obesity, CVD & risk factors, There is insufficient evidence to determine whether organisational travel plans are effective for improving health or changing travel mode. Seventeen studies were included. Ten were conducted in a school setting, two in universities, and five in workplaces. One study directly measured health This intervention is implemented locally in some areas but does D. The evidence is inconsistent and it is not possible to
travel Cochrane Database of Systematic Reviews Working age adults, Children & young adults mental health, illness, injury rates Secondary outcome: physical activity Organisational travel plans should be considered as complex health promotion interventions, with considerable potential to influence community health outcomes depending on the environmental context in which they are introduced. Given the current lack of evidence, organisational travel plans should be implemented in the context of robustly-designed research studies, such as cluster randomised trials outcomes, and all included studies measured travel outcomes. Two cluster randomised controlled trials in the school setting showed either no change in travel mode or mixed results. A randomised controlled trial in the workplace setting, conducted in a group who were already contemplating or preparing for active travel, found improved health-related quality of life on some sub scales, and increased walking. Two controlled studies found that school travel interventions increased walking. No included studies were conducted in low- or countries, and no studies measured the social distribution of effects or adverse effects, such as injury. Overall risk of bias was judged to be high for most included studies. not have a consistent national programme or a co-ordinated approach draw a conclusion but there is some evidence of effect Dobbins, M, 2009 School-based physical activity programmes Leisure time physical activity rates, duration of physical activity, and time spent There is good evidence that school-based physical activity interventions have a positive impact on four of the nine outcome measures. Specifically positive effects were observed for duration of physical activity, television viewing, VO2 max, 26 studies were deemed of sufficient quality to be included in this review. Four were assessed as having very few methodological limitations and 22 as having more limitations but not sufficient enough to warrant their exclusion from the review. Elements of the intervention are funded for national implementation but implementation is dependent on B. This intervention is supported by moderate to good quality evidence of its effectiveness for some
Cochrane Database of Systematic Reviews School child, Children and young adults aged 6-18 watching television. Mean Systolic & diastolic blood pressure, cholesterol level ), bodymass index (BMI), VO2 max and pulse rate. and blood cholesterol. Generally school-based interventions had no effect on leisure time physical activity rates, systolic and diastolic blood pressure, body mass index, and pulse rate. At a minimum, a combination of printed educational materials and changes to the school curriculum that promote physical activity result in positive effects. Given that there are no harmful effects and that there is some evidence of positive effects on lifestyle behaviours and physical health status measures, ongoing physical activity promotion in schools is recommended at this time. The long term effects of interventions are unknown The most common methodological weakness was outcome assessors not being blinded and use of for outcomes. The majority of studies were conducted in the United States (16) with the remaining originating from European countries. Only seven of the 26 studies measured either leisure time physical activity rate or duration of leisure time physical activity. The results of this review are mixed with respect to the effectiveness of school-based interventions to increase leisure time physical activity rates among children and adolescents. While two of seven studies reported a significant increase in the percentage of grade school children who were physically active during leisure time in the short term, it is unknown if these results were maintained in the long (e.g. 1-3 years). A third study, which did not report a significant impact in leisure time physical activity immediately following the intervention, observed a significant difference in the number of participants who were physically active as adults. local components which are variable outcomes
Cochrane Database of Systematic Reviews Overweight and obese working age adults activities. TTM SOC combined with diet, PA and other interventions had a positive impact on fruit and vegetable consumption as well as increased exercise outcomes behaviour that were sustainable over longer periods (12 to 24 months). weight loss (about 2 kg or less). There was no conclusive evidence for sustainable weight loss. However, TTM SOC and a combination of physical activity, diet and other interventions tended to produce significant outcomes (particularly change in physical activity and dietary intake). TTM SOC was used inconsistently as a theoretical framework for intervention in the trials. Death and weight gain are the two adverse events reported by the included trials. None of the trials reported health-related quality of life, morbidity, and costs as outcomes. Foster, C, 2006 Environment interventions National Institute for Health and Clinical Excellence [Evidence Review] Changes to physical activity There are insufficient numbers of well-designed studies to draw conclusions about what is effective in relation to physical changes to working practices, policies and physical environment. There are insufficient studies to draw conclusions about what is effective in relation to use of newly developed cycling and walking paths. Changing the environment Systematic review . Physical & policy changes to environment Nineteen studies used health education materials to promote stair climbing in a variety of settings. Six studies made physical changes to an environment, with some interventions supporting this process with policy and regulatory changes. Most of the included studies contained significant methodological limitations such as lack of a control or comparator (all This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach F. The evidence is inconsistent and it is not possible to draw a conclusion but it tends towards no effect
might play an active role in promoting physical activity in a military setting. No conclusions can be reached about the effectiveness of using the environment as a point of active or sedentary choice (eg using stairs not the lift) with written media (eg stair posters, riser banners on steps). A variety of printed media in commercial, workplace and transport settings can increase use of stairs, but changes diminish over time. The efficacy of a stair intervention varied within the study populations, with different effects seen for different groups based on age, sex, observed body mass index and ethnicity. These effects were not consistent across the studies. but 2 studies). All the studies were subject to systematic error, including selection bias and measurement bias. Overall, the studies did not present any power calculations so it is difficult to determine if their response rates were adequate to answer the study questions. Most studies relied on self reported physical activity as their outcome and many did not report the validity and reliability of the method used. Few studies reported the potential modification of effects by gender or and socio-cultural factors. The recruitment and selection of participants to the studies limits the applicability of these interventions to a UK context. The study participants were generally well educated and white. Environment as a prompt Nineteen studies reported the results of using written media (eg posters, riser banners) to prompt stair use rather than escalators or lifts. A number of methodological limitations were present in the studies, such as a lack of comparator.
Publication bias may be an issue with this review. Shepherd, J, 2002 Physical activity interventions EPPI School child, Children & Young Adults Barriers to, and facilitators of, physical activity Little good quality research conducted in the UK (NB review conducted 2001/2). Schools, friends and family were both barriers and facilitator to physical activity. Complex issues arose re; ‘self’. Cost and transport were particular barriers. Recommendations: -Separate initiatives for young males & females where appropriate, tailored to their specific needs -School-based (whole school approach with peer-led component) initiatives which are integrated within initiative involving home/family, youth groups, wider community, show some promise -Rigorous evaluation is essential This report synthesises the results of three systematic reviews of the barriers to, and facilitators of, mental health, physical activity and healthy eating among young people with a view to making recommendations about how their health can be promoted Intervention and non-intervention studies of young people’s views were included. Of 38 studies of physical activity interventions only 4 met inclusion and quality criteria. These were all secondary school based and Little evidence of effectiveness was found and varied by gender (females more likely to benefit) and age (older children more likely to benefit). All included studies had additional methodological weaknesses which limited reliability. Elements of the intervention are funded for national implementation but implementation is dependent on local components which are variable D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect 4. Comparability of key messages with other evidence reviews: component.
U.S. Department of Health and Human Services Community Preventive Services Task Force. Guide to Community Preventive Services. Promoting good nutrition. Available at: Appendix 1: Evidence grading scheme A. This intervention is supported by good evidence of its effectiveness and is recommended for use in the UK NICE Recommended Intervention OR systematic review, of moderate to good quality studies, with meta-analysis of majority of studies favouring intervention effect B. This intervention is supported by moderate to good quality evidence of its effectiveness systematic review of moderate to weak studies with meta-analysis favouring intervention effect or narrative review including moderate to good quality studies with majority demonstrating positive effect C. There is some evidence supporting the use of this intervention but it is not conclusive systematic review of moderate to poor quality studies with majority favouring intervention D. The evidence is inconsistent and it is not possible to draw a conclusion but there is some evidence of effect Systematic review with significant weakness and high risk of bias (positive results) or review of moderate quality with inconsistent findings in favour of the intervention E. There is good evidence to suggest that this intervention has a sound theoretical basis or that work in this area is likely to have an impact but this has not been demonstrated in trials (this would apply particularly to pilot or novel interventions) Moderate to good quality systematic review of observational or qualitative studies which suggest that the intervention addresses a significant risk factor or determinant of the behaviour of interest F. The evidence is inconsistent and it is not possible to draw a conclusion but it tends towards no effect Systematic review with studies judged as significant weak/risk of bias (evidence of no effect) or review of moderate quality studies with inconsistent findings in favour of no effect G. There is some evidence suggesting that this intervention is ineffective but it is not conclusive systematic review of moderate to poor quality studies with majority favouring no effect H. There is moderate to good systematic review of moderate to weak