Low levels of daily physical activity (DPA) in individuals with heart disease have worse clinical outcomes compared with those with higher levels of DPA, including (1) a poorer prognosis1–7; (2) a lower aerobic capacity1; (3) lower health-related quality of life8–10; (4) increased sympathetic nervous system activity11,12; (5) more hospitalizations13–16; (6) a higher prevalence of obesity, metabolic syndrome, and risk factors for cardiovascular disease17–19; and (7) a reduced ability to participate in activities of daily living.8–10 Given that DPA is such a strong determinant of health outcomes, the American Association of Cardiovascular and Pulmonary Rehabilitation includes an assessment of DPA as a core competency for cardiac rehabilitation/secondary prevention professionals.20
The US Department of Health and Human Services’ “Physical Activity Guidelines for Americans”21 focuses mainly on exercise (ie, structured DPA) and only tangentially addresses sedentary time. However, decreasing overall duration and individual bouts of sedentary time may decrease mortality risk22,23 and should be considered as an important clinical outcome. Reductions in sedentary time and increases in total daily energy expenditure (EE) are accomplished not just through the use of exercise (ie, structured physical activity [PA]), but through increases in all other activities of daily living (ie, unstructured PA) as well.24 The use of the term “DPA” in this manuscript refers to the total daily EE (ie, the sum of unstructured and structured PA).
With regard to the measurement of DPA, subjective and objective measures of DPA and sedentary behavior are used in clinical and research settings.20 Compared with objective measures, subjective measures may be affected by self-reporting bias or recall memory issues.25,26 However, the advantages of subjective measures include the ease and efficiency of administration in the clinical setting, a minimal patient burden, a low cost, the provision of immediate feedback, and feasibility for use in population surveillance efforts.27
Subjective measures of DPA have different emphases with regard to the PA behavior measured. Some measure overall DPA/EE (ie, total of structured and unstructured DPA), and some emphasize structured PA behavior, while others measure sedentary time (ie, the inverse of total DPA). The American Heart Association recommends that subjective measures of DPA account for the various dimensions (mode, frequency, duration, and intensity of a PA) and domains (occupational, domestic, transportation, and leisure time) of PA.28
The optimal subjective measure of DPA for individuals with heart disease has not yet been established. Three prior literature reviews considered subjective measures in patients with heart disease29–31 but were limited by the methodology, focus of the review, and/or populations considered. No prior review has specifically commented on the methodological limitations of existing validity studies of subjective daily PA measures in heart disease.
The review by Le Grande et al29 was limited in several important ways. Of the 23 listed measures included in the review, only 13 had been used in patients with heart disease, and only 9 of those 13 were validity studies.
Ahlarbi et al30 conducted a narrative literature review of studies that examined both self-report and direct PA measures and restricted their review to only patients undergoing cardiac rehabilitation. They ultimately included 8 studies covering 8 subjective PA measures. Only 4 of the 8 studies measured reliability, and the validity coefficients were generally low, especially when compared with direct/objective measures of PA.30 They concluded that, although most subjective measures of PA allow for an estimation of the metabolic equivalents of task (METs) or EE, the standard MET calculations of 3.5 mL oxygen·kg−1·min−1 may be an overestimate in patients with heart disease.30,31
Panguntalan and Gregoski32 performed an integrative literature review of studies that examined self-report and direct measures of PA in African American women “in the context of the risk for [coronary heart disease].” The review included 7 studies covering 9 self-report questionnaires estimating METs, EE, or other measures of PA. The authors observed that the included studies did not exclusively or even primarily include African American women with coronary heart disease and concluded that reliability was understudied (only 3 studies) and that only modest validity coefficients were observed.32
In summary, the measurement of DPA is important for the prognosis and quantifying clinical outcomes in individuals with heart disease. The measurement of DPA is more feasible using subjective measures compared with objective measures. Previously published reviews of subjective measures of DPA in individuals with heart disease are limited by either the methodology (ie, not a systematic review) or focus on a narrow population (ie, only cardiac rehab). Therefore, the purpose of this paper was to conduct a systematic review of the literature to identify the subjective measures of DPA that have established reliability and validity in individuals with heart disease to assist clinician and researcher instrument selection. The authors hypothesize that there will be few subjective measures of DPA that have been validated against objective measures of EE in individuals with heart disease.
Methods
Literature Search
The literature search was performed using 4 different databases: PubMed, CINAHL Complete, PsycInfo, and Web of Science Core Collection. The searches were performed on July 11, 2019. The following Medical Subject Headings (MeSH) terms and keywords were used for the search strategy: ((((((((((((((((((((“physical activity”) OR “activities of daily living”) OR “motor activities”) OR walking) OR exercise) AND “heart failure”) OR “heart disease”) OR “cardiovascular disease”) AND “surveys”) OR “questionnaire”) OR “interview”) OR “log”) OR “self-report”) OR “diary, health”) OR “subjective”) AND “validation”) AND “validation studies”) AND validity) AND reliability)).
Article Selection
Included articles met the following inclusion criteria: (1) written in English, (2) included subjects with heart disease, and (3) assessed the validity and/or reliability of subjective measures of DPA. Heart disease was defined as heart failure, coronary artery disease, congenital heart defects, cardiovascular disease, a history of myocardial infarction, and valvular disease. The subjective measures of DPA were defined as instruments that provided a derived measure of EE or quantified some aspect of DPA. Articles were excluded if they (1) were not peer reviewed, (2) did not include adults in the sample, or (3) did not provide the results of the subgroup analyses for the subjects with heart disease when subjects without heart disease were included in the sample. There was no limit to the year of article publication. Following removal of duplicates, article titles were reviewed, followed by a review of the abstracts and full text, if appropriate. Article selection bias was addressed using 2 authors (each article assigned to 2 of the following authors: M.M., H.S., and J.Z.) who independently completed the screening process and a third author (S.G. or M.J.S.) resolving any conflicts.
Evaluation of Included Articles
The Quality Appraisal of Reliability Studies was used to assess the quality and applicability of the diagnostic reliability studies.33 The Quality Appraisal of Reliability Studies is an 11-item appraisal tool that was developed according to epidemiologic principles, current quality assessment checklists, and the Standards for Reporting of Diagnostic Accuracy and Quality Assessment of Diagnostic Accuracy Studies guidelines.33 The methodological quality of validity studies was assessed using the Quality Appraisal tool for Validity Studies.34 The Quality Appraisal tool for Validity Studies is a 24-item instrument that examines content, concurrent, and construct validity, as well as numerous principles of methodological quality.34 The Strengthening the Reporting of Observation Studies in Epidemiology Statement was used to assess the quality of reporting of observational studies.35 The Strengthening the Reporting of Observation Studies in Epidemiology Statement is a 22-item checklist that provides recommendations to authors about how to enhance the reporting of observational studies and also aides in the critical evaluation and analysis of studies by reviewers.35 Therefore, the assessment of methodological rigor using the Quality Appraisal of Reliability Studies, Quality Appraisal tool for Validity Studies, and Strengthening the Reporting of Observation Studies in Epidemiology allowed the authors to identify the risk of bias in individual studies as part of the overall synthesis of data from the included studies. Consensus on scoring was reached by 3 authors (M.M., H.S., and J.Z.), with a fourth author confirming the assigned scores (M.J.S. or S.G.)
Data Extraction
The primary data used in this review included validity and reliability metrics for the various subjective DPA measures. The characteristics of each measure were recorded, including the method of administration, number of items, length of recall, and type/quantification of DPA measured. Sample sizes, sample selection, and sample demographic information, including the diagnosis, type and severity of heart disease, age, sex, and comorbidities, when reported, were used to assist in the assessment of risk of bias across studies. The data were extracted by the authors (M.M., H.S., M.J.S., and J.Z.) working in consultation with one another to ensure accuracy.
Results
The initial search produced 3758 results, with 2351 articles remaining after the removal of duplicates (Figure 1). Two researchers independently screened all titles/abstracts. A third author adjudicated differences. The full text was independently reviewed for 42 articles by 4 authors (M.J.S., M.M., J.Z., and H.S.), who reached agreement on the inclusion of 19 articles. Fifteen articles were excluded for not meeting the inclusion criteria, one was excluded for only being an abstract, and one was excluded for not being peer reviewed. Four additional articles were screened after a review of the included articles’ references. Of note, 2 separate papers by Garet et al36,37 reported on the same study/data set. Therefore, only 22 unique studies are represented in this review.
—PRISMA flow diagram.
Citation: Journal of Physical Activity and Health 18, 4; 10.1123/jpah.2020-0661
Summary of Included Studies
The demographics of the samples studied in the included articles were as follows: the age ranged from 15 to 83 years old, with both men and women included (Tables 1 and 2). With regard to the diagnoses and settings studied, the most common setting was cardiac rehabilitation, with a large majority of the studies including patients with coronary artery disease (11 studies).38,39,41,43–45,48–52,55 Other diagnoses were cardiac transplant,53 cardiovascular disease,46 cardiomyopathy,54 congenital heart disease,42,47 and individuals with heart failure.36,37,40,56–58
Characteristics of the Study Population
| Author | Diagnosis (es) | Sample size; sample location | Gender (male/female) | BMI mean (SD) | Age, y mean (SD) | LVEF, NYHA, or other index of severity |
|---|---|---|---|---|---|---|
| Bahler et al38 | MI CAD | 48 Switzerland | 37/11 | 27.00 (4.00) | 60.00 (8.00) | NR |
| Tayor-Piliae et al39 | MI CAD | 500 United States | 197/303 | 31.50 (7.20) | 45.90 (6.40) | NR |
| Chien et al40 | HF | 111 Taiwan | 69/42 | 25.70 (4.93) | 63.20 (11.50) | LVEF: 48.90% (16.40) NYHA: I–III |
| Gruner et al41 | CAD | 233 Switzerland | 186/47 | NR | 63.00 (10.00) | NR |
| Garet et al36,37 | HF | 105 France | 87/18 | 25.80 (4.00) | 55.80 (12.40) | LVEF: 33.20% (6.10) NYHA: I–IV VO2peak: 17.50 (4.80) |
| Larsson et al42 | Congenital heart disease | 75 Sweden | 46/29 | 24.40 (4.30) | 37.50 (15.50) | NYHA: I–III Severity class: simple (39)/complex (36) |
| Prince et al43 | CAD | 35 Canada | 19/16 | 30.10 (5.20) | 61.50 (9.80) | VO2peak: 19.60 (6.00) |
| Orrell et al44 | CAD | 73 England | 58/15 | NR | 66.23 (7.74) | NR |
| Orrell et al45 | CAD | 72 England | 58/14 | NR | 65.90 (7.45) | NR |
| Pfaeffli et al46 | CVD | 30 New Zealand | 26/4 | NR | 65.60 (8.80) | NR |
| Muller et al47 | Congenital heart disease | 786 NR | 451/335 | 23.70 (4.00) | 31.10 (11.60) | Severity class: simple (100)/moderate (243)/complex (397) VO2peak of predicted: 80.50 (21.50) |
| Nowak et al48 | MI CAD | 207 NR | NR | NR | 59.00 (9.00) | VO2peak: 29.23 (9.98) LVEF: 51.64% (9.13) |
| Satge et al49 | CHF CAD | 30 NR | 24/6 | 26.20 (4.00) | 55.00 (11.00) | LVEF < 45% = 9 (30%) |
| Gremeaux et al50 | MI/CAD | 52 France | Non-CR: 28/3 CR: 31/5 | Non-CR: 27.30 (4.40) CR: 25.90 (3.50) | Non-CR: 58.30 (11.10) CR: 61.10 (11.80) | NR |
| Sundal Holen et al51 | CAD | 217 Norway | 176/41 | NR | 54.90 (9.30) | NR |
| Guiraud et al52 | CAD | 70 France | 58/12 | 27.50 (3.80) | 57.60 (11.60) | NR |
| Myers et al53 | Heart transplant | 47 United States | 41/6 | 30.00 (5.40) | 46.70 (11.60) | VO2peak: 17.20 (5.20) |
| Mezzani et al54 | Cardiomyopathy | ALVD: 40 Chronic HF: 153 Italy | ALVD: 39/1 Chronic HF: 135/18 | ALVD: 22.00 (5.00) Chronic HF: 23.00 (5.00) | ALVD: 55.00 (11.00) Chronic HF: 57.00 (9.00) | NYHA ALVD: I NYHA chronic HF: I–III LVEF ALVD: 29.00% (8.00) LVEF chronic HF: 25.00% (8.00) VO2peak ALVD: 20.00 (4.00) VO2peak chronic HF: 14.70 (3.70) |
| Allison et al55 | CR | 32 United States | 19/13 | NR | 72.00 (4.24) | NR |
| Borland et al56 | HF | 53 Sweden | Intervention: 20/5 Control: 18/5 | NR | Intervention: 70.00 (6.00) Control: 71.00 (9.00) | Intervention group: NYHA II/III: 10/14 (n = 24) LVEF: 26% (10) Control group: NYHA II/III: 11/12 LVEF: 27% (11) |
| Oka et al57 | HF | 41 United States | 32/9 | NR | 56.00 (12.00) | LVEF: 23.60% (7.40) NYHA II: 37% NYHA III: 63% VO2peak: 17.70 (3.50) |
| Ribeiro-Samora et al58 | HF | 62 Brazil | 44/18 | 25.6 (3.6) | 47.98 (10.84) | LVEF: 31.80% (10.4) NYHA I: 7 (11.3) NYHA II: 24 (38.7) NYHA: 31 (50.0) |
Abbreviations: ALVD = asymptomatic left ventricular dysfunction; BMI = body mass index; CAD = coronary artery disease; CR = cardiac rehabilitation; HF = heart failure; LVEF = left ventricular ejection fraction; MI = myocardial infarction, NR = not reported; NYHA = New York Heart Association Functional Class; VO2peak, peak oxygen uptake.
Characteristics of Subjective Daily PA Measures
| Name; author | Method of administration; no. of items; length of recall | Type of PA |
|---|---|---|
| SBAS; Tayor-Piliae et al39 | Self-report questionnaire mailed to participants prior to clinic visit; 2 items; up to 1-y recall | Occupational activities ranging from mostly sedentary to hard physical labor. Leisure-time activity, ranging from sedentary to vigorous activity. |
| DAQIHF; Garet et al36,37 and Chien et al40 | Self-report; 82 items; 1-wk recall | 7 dimensions, including sleeping/resting, everyday activities, housework activities, leisure-time activity, occupational activities, moving about, and miscellaneous activities. |
| IPAQ Long Form; Larsson et al42 and Prince et al43 | Self-report; 27 items; 7-d recall | Light, moderate, and vigorous activities including job-related, transportation, and housework/house maintenance/caring for family. Time spent sitting during typical week or weekend day. |
| IPAQ Short Form; Muller et al47 and Borland et al56 | Self-report; 7 items; 7-d recall | Vigorous, moderate, or walking activities, and 1 item on sitting time. |
| Self-reported exercise-induced sweating frequency; Gruner et al41 | Self-report; No information on number of items; 1-mo recall | Frequency and duration of different PA, as well as frequency of exercising vigorously enough to work up a sweat. |
| TAM1; Orrell et al44 | Self-report; 6 items; 7-d recall | Strenuous, moderate, and mild activities of mainly leisure- and work-related options. |
| TAM2; Orrell et al44 | Self-report 6 items; 7-d recall | Strenuous, moderate and mild activities of mainly leisure- and work-related options. |
| DPAQ; Guiraud52 and Gremeaux et al50 | Self-report/interview 9 items; no recall | Questions on daily activities, sports and leisure activities, and rest time. |
| Acti’MET; Satge et al49 | Interview; 3 items; immediate use | Intensity of activity, duration of activity, and weight of subject. |
| Selected questions; Sundal Holen et al51 | Self-report; 5 items; “Past few weeks” recall | Likert-type scale on frequency, intensity, and duration of exercise, as well as comparison of self to others and activity level compared to last year. |
| SWISSPAQ; Bahler et al38 | Self-report; 21 items; 2-mo recall | Household and leisure-time activities. |
| PPAQ; Myers et al53 | Self-report; 6 items; year recall and “adult life” recall | Walking, stairs, sports and recreational activities, and occupational activities. |
| PPAQ; Nowak et al48 | Interview; 8 items; 6 mo to a year recall | Walking, stairs, sports and recreational activities, questions about fatigue, tiredness, and level of exertion. |
| PASE; Allison et al55 | Self-report; 32 items; up to 7-d recall | Occupational, leisure, and household activities. |
| HSE; Orrell et al45 | Interview; Unclear number of items; 4-wk recall | Heavy home activities (household repairs, building work, walks >30 min, and sports/exercise > 15 min). Activity while at work for those who work. |
| GLTEQ; Prince et al43 | Self-report; 3 items; 7-d recall | Mild/light, moderate, and strenuous exercise with examples for each level. |
| MobilePAL; Pfaeffli et al46 | Self-report; 2 items 2 times per day; <1-d recall | PA level during work/daytime and during leisure time/evening. |
| PAS; Mezzani et al54 | Interview; 1 item; 6-mo recall | Asked to describe habitual leisure time and occupational activities. |
| HAP; Oka57 and Ribeiro-Samora et al58 | Unclear method of administration/interview; 94 items on activity, 8 items on dyspnea; “Current” activities | Leisure activity, ADLs, household activities, sports/recreation, and occupational activities. |
Abbreviations: ADLs, activities of daily living; DAQIHF, Daily Activity Questionnaire in Heart Failure Scale; DPAQ, Dijon Physical Activity Questionnaire; GLTEQ, Godin–Shephard Leisure-Time Exercise Questionnaire; HAP, Human Activity Profile; HSE, Health Survey of England; IPAQ, International Physical Activity Questionnaire; MobilePAL, Mobile Phone Physical Activity Logger; PA, physical activity; PAS, Physical Activity Score; PASE, Physical Activity Scale for the Elderly; PPAQ, Abridged Paffenbarger Physical Activity Questionnaire; SBAS, Standard Brief Activity Questionnaire; SWISSPAQ, SWISS Physical Activity Questionnaire; TAM1, Total Activity Measure 1; TAM2, Total Activity Measure 2.
A total of 19 subjective DPA measures were studied across the 22 unique included articles. Thirteen were self-report only,36–44,46,51,53,55,56 4 were interview only,45,48,49,54 1 was administered via interview and self-report in 2 different studies,50,52 and 1 was administered via interview.57,58 The length of recall for the questionnaires ranged from <1-day recall to “adult life” recall, with the most common recall period being 7 days (6 instruments).43,44,47,56,59 The types of DPA that were measured included leisure-, occupational-, housework-, and transportation-related activities. The majority of the questionnaires focused on the intensity level of DPA. The most common measurements obtained from these questionnaires were EE estimates in kilocalories or METs, minutes of moderate to vigorous PA (MVPA), and estimated peak oxygen uptake. Some questionnaires measured the frequency of exercise-induced sweating, categorized activities by intensity level, or used scale-specific scores.
All 22 unique included studies were observational studies, with 14 explicitly designed to test validity,36–38,41,42,44–46,50–52,54,55,58 5 that tested validity as a secondary purpose,39,43,48,53,57 and 3 that reported validity coefficients but did not have an explicitly stated purpose of establishing validity.40,47,56 (Table 3). They assessed a wide variety of validity types, including convergent, concurrent, divergent, construct, and content validity. The majority of studies assessed either convergent or concurrent validity, with 13 of the included studies assessing convergent39,42,43,46–48,50–54,56,57 and 8 assessing concurrent36–38,41,44,45,48,49,58 validity.
Validity Design and Statistics of Subjective Daily PA Measures
| Questionnaire; author | Questionnaire measurement used for validity | Type of validity assessed; reference standard | Validity coefficients |
|---|---|---|---|
| SWISSPAQ; Bahler et al38 | Daily MET hours | Concurrent; ACTIHEART measuring heart rate and accelerometry, and PA diary | r = .41 with ACTIHEART (r = .61 without beta blockers; r = .33 with beta blockers) r = .41 with diary Overestimated activity by 1.26–1.37 average daily MET hours |
| TAM1 and TAM2; Orrell et al44 | TAM1/TAM2: number of minutes of PA at each activity level to yield total activity score in minutes to allow MET minutes calculation | Concurrent; RT3 measuring accelerometry | Correlations between activity score (MET per minutes) and time spent in activity (in minutes) with the accelerometer: r = −.09 to .27 for TAM1 total, light, moderate, and strenuous activities r = .02 to .39 for TAM2 total, light, moderate, and strenuous activities TAM1 overestimated activity by 2000–8000 MET minutes TAM2 overestimated activity by 2000–5000 MET minutes |
| MobilePAL Questionnaire; Pfaeffli et al46 | Ratio of total energy expenditure and resting energy expenditure during 24 h; average daily METs | Convergent; Actigraph GTIM measuring accelerometry and IPAQ-LF | Correlations between MobilePAL and accelerometer: r = .45 for PA counts per minute r = .45 for average daily MET r = .39 for daily minutes of activity Overestimated activity by 0.28 average daily METs Correlations between MobilePAL and IPAQ-LF: r = .49 for IPAQ estimated MET minutes per day r = .48 for IPAQ estimated minutes of PA Correlations for the IPAQ-LF with the accelerometer: r = .40 to .62 |
| IPAQ-LF; Larsson et al42 | Achievement of ≥150 min/wk of MVPA | Convergent; ACTIHEART measuring heart rate and accelerometry | r = .20 IPAQ significantly overestimated proportion of subjects exceeding ≥150 min of MVPA per week Sensitivity/specificity for detecting those with ≥150 min of MVPA per week was 83%/41% |
| IPAQ-SF; Borland et al56 | PA category (low, moderate, and high) and sitting time (in minutes) | Convergent; pedometer measuring steps per day, peak power measured by a maximal cycle ergometer test, and 6MWT | IPAQ sit time (in minutes) with steps per day: r = −.18 IPAQ sit time (in minutes) with watts: r = −.15 IPAQ sit time (in minutes) with 6MWT: r = −.11 IPAQ sit time (in minutes) with IPAQ category: r = −.02 IPAQ category with steps per day: r = .54 (P < .01) IPAQ category with watts: r = .24 IPAQ category with 6MWT: r = .35 (P < .05) |
| GLTEQ and IPAQ Long Form; Prince et al43 | Weekly totals converted for both questionnaires to average minutes per day of MVPA or sitting time | Convergent; ActivPAL3 accelerometer | Spearman correlation between sitting time and MVPA with ActivPAL3 (IPAQ rs = .05, GLTEQ rs = .20 not statistically significant) Change in MVPA when comparing baseline to follow-up, measured by both GLTEQ and ActivPAL3, was statistically significant but not correlated Change in sitting time when comparing baseline to follow-up, measured by both IPAQ and ActivPAL3, was not statistically significant and not correlated |
| HSE; Orrell et al45 | Activity classification of days with >30 min of MVPA as low (0), medium (1–5), or high (>5) | Concurrent; RT3 measuring accelerometry | Sensitivity/specificity, respectively Low PA: 0.35/0.92 Medium PA: 0.40/0.56 High PA: 1.00/0.76 Activity levels from HSE failed to agree with accelerometer data (κ = .08, 95% CI, −0.20 to 0.36) Sensitivity analysis on above data yielded similar results (κ = .04, 95% CI, −0.31 to 0.40) |
| Acti’MET calculator; Satge et al49 | Weekly energy expenditure in kilocalorie | Concurrent; 6MWT, peak power measured by a maximal cycle ergometer exercise test, and IPAQ-SF Dijon PAS | Acti’MET correlations: r = .54; r2 = .29 for 6MWT r = .27; r2 = .07 for max power r = .88; r2 = .77 for IPAQ r = .39; r2 = .15 for PAS |
Abbreviations: CI, confidence interval; GLTEQ, Godin–Shephard Leisure-Time Exercise Questionnaire; HSE, Health Survey of England; IPAQ, International Physical Activity Questionnaire; IPAQ-LF, IPAQ Long Form; IPAQ-SF, IPAQ Short Form; MET, metabolic equivalents or task; MVPA, moderately vigorous physical activity; PA, physical activity; PAS, Physical Activity Score; SWISSPAQ, SWISS Physical Activity Questionnaire; TAM1, Total Activity Measure 1; TAM2, Total Activity Measure 2; 6MWT, 6-minute walk test.
Subjective DPA measures were compared against a variety of reference standards. The most common reference standards used to assess validity of the questionnaires were cardiopulmonary exercise testing (peak oxygen uptake [7 instruments]36,37,41,47,48,53,54,57,58 and peak work [3 instruments]49,50,52,56) and triaxial accelerometry (8 instruments).38,42–46,52 Other reference standards used included the 6-minute walk test (4 instruments),49,50,56–58 uniaxial accelerometers/pedometers, other subjective questionnaires, quality of life instruments, and a variety of clinical characteristics.
Methodological Rigor
The scores for methodological rigor are presented in Supplementary Materials 1, 2, and 3 (available online), respectively. Limitations in methodological rigor included a lack of specificity of the type of validity investigated (17 articles, 74%) and not including a priori sample size calculations (17 articles, 74%). Only 9 articles (39%) included both the setting and time frame, and 13 articles (56%) included either the setting or time frame. Consultation with an expert panel was mentioned in 2 articles (8%). However, nearly all articles included a good description of the outcomes being validated, procedures, and rationale for use of their reference standards. Regarding methodological rigor for reliability testing, only 2 articles (8%) mentioned the blinding of raters, and those raters were blinded to the results of the reference standards or to information not intended to be provided as part of the testing procedure. However, nearly all studies used a representative sample of subjects, with the test applied correctly and using appropriate statistics.
Validity of Subjective DPA Measures
This review identified 4 subjective DPA measures that estimated total daily MET minutes or EE per kilocalories that were compared against the reference standard of accelerometry (Table 3): Swiss Physical Activity Questionnaire (SWISSPAQ),38 Total Activity Measure version 1 (TAM1),44 Total Activity Measure version 2 (TAM2),44 and Mobile Phone Physical Activity Logger (MobilePAL).46 The MobilePAL demonstrated the strongest correlation values between estimated EE per kilocalories and accelerometry (r = .39 to .45).46 For the instruments that measured correlation values between the estimated MET minutes per day and accelerometry, the SWISSPAQ demonstrated the highest correlation (r = .41 overall, r = .61 for participants without beta blockers, and r = .33 for participants with beta blockers),38 followed by the TAM2 (r = .02 to .39) and the TAM1 (r = –.09 to .27).44 In addition, the SWISSPAQ was moderately correlated to a PA diary (r = .41).38
Other subjective DPA measures (Table 3) that were compared against accelerometer-based reference standards but which only estimated a narrow aspect of PA include the Godin–Shephard Leisure-Time Exercise Questionnaire (average minutes per day of moderately vigorous PA or sitting time43), the Health Survey of England (days with >30 min of moderately vigorous PA45), and the IPAQ (achievement of ≥150 min/wk of MVPA,42 general PA category, and sitting time56). Correlations with various accelerometer-derived measures were <.20, except for the IPAQ PA category and steps per day (r = .54).56
The Acti’MET estimates daily EE per kilocalories and was compared against another subjective DPA measure of EE per kilocalories. The Acti’MET demonstrated a strong correlation between daily EE per kilocalories and the IPAQ-SF estimation of EE (r = .88).49
Most subjective DPA measures were compared against other, non-DPA reference standards, such as peak oxygen uptake and anthropometric measures. The Physical Activity Score,54 Daily Activity Questionnaire in Heart Failure Scale,36,37 International Physical Activity Questionnaire (IPAQ) Short Form,47 Paffenbarger Physical Activity Questionnaire,48 and Abridged Paffenbarger Physical Activity Questionnaire53 estimated the MET minutes per day or daily EE per kilocalories, but were only compared against a reference standard of peak oxygen uptake. The correlation coefficients with peak oxygen uptake ranged from .30 to .71 and from .60 to .82 for anthropometric measures.
The most commonly studied subjective DPA measure was the IPAQ (Long Form [both the entire form and sitting time] and Short Form). The IPAQ was used both as a questionnaire under investigation and as a reference standard to establish the validity of another questionnaire. In studies seeking to validate the IPAQ, various IPAQ-reported and IPAQ-calculated measures were studied, including: 1) the achievement of ≥150 minutes per week of MVPA,42 2) MET minutes per week used to categorize as health-enhancing PA,47 3) categories of minimally active or inactive,56 4) PA categories of low, moderate, and high,56 and 5) sitting time (in minutes).43,56 These IPAQ-reported measures were compared with reference standards of accelerometry,42,43 peak oxygen uptake,47 health-related quality of life,47 the Medical Outcomes Study Short Form-36,47,56 pedometer,56 peak work,56 6-minute walk test,56 and muscle strength and endurance tests.56 When the IPAQ was used as a reference standard to establish the validity of other subjective DPA measures, it was compared with the EE per kilocalorie estimation from the MobilePAL46 and the Acti’MET.49 The highest correlation of all comparisons using the IPAQ was with the Acti’MET estimation of EE per kilocalories (r = .88), as noted above.49
With regard to the types of analyses, most studies used correlation coefficients, with few studies using other methods for measurement of agreement, such as the kappa statistic41,45 or Bland–Altman plots.38,44,46,58 Of those studies using an objective reference standard for DPA, the subjective questionnaires generally overestimated DPA based on the lower limits of agreement in Bland–Altman analyses. For example, overestimations of METs were as follows: TAM1 by 2000 to 8000 MET minutes,44 TAM2 by 2000 to 5000 MET minutes,44 SWISSPAQ by 1.26 to 1.37 MET hours,38 and the MobilePAL by 0.28 average daily METs.46
Reliability of Subjective DPA Measures
Of the 22 unique studies included in this review, only 9 examined reliability (Table 4). The questionnaires assessed for reliability include the SWISSPAQ,38 Daily Activity Questionnaire in Heart Failure Scale,36,37,40 TAM1 and TAM2,44 MobilePAL,46 Acti’MET,49 Dijon Physical Activity Score,50 Physical Activity Score,54 and Physical Activity Scale for the Elderly.55 These studies examined a variety of reliability metrics, including test–retest, interrater and intrarater reliability, reproducibility with Bland–Altman plots, and day-to-day stability over a 7-day period. Of the 6 studies that assessed test–retest reliability, the test–retest intervals ranged from 8 days to greater than 6 weeks.36–38,40,44,54,55 Test–retest reliability was measured in a variety of ways, including intraclass correlation coefficients (ICCs), Pearson’s correlation coefficients, and repeated-measures analysis of variance. Of the 4 instruments whose test–retest reliability was measured by ICC, the Daily Activity Questionnaire in Heart Failure Scale, and the Physical Activity Score demonstrated the highest test–retest values (ICC = .99 and .97, respectively),40,54 followed by the TAM2 and TAM1 (ICC = .82 and .73, respectively).44 Of the 2 instruments whose test–retest reliability was measured using Pearson correlation coefficients, the Physical Activity Scale for the Elderly demonstrated the highest value (r = .72),55 followed by the SWISSPAQ (r = .62).38
Reliability Design and Statistics of Subjective Daily PA Measures
| Questionnaire; author | Type of reliability | Outcomes measured for reliability | Test–retest interval | Reliability measures |
|---|---|---|---|---|
| SWISSPAQ Bahler et al38 | Test–retest Reproducibility | Total MET hours | 14–51 d | Pearson r = .62 No difference between time points, Bland–Altman plot |
| DAQIHF; Garet et al36,37 | Interrater Test–retest | DEE | >6 wk | Interrater: no significant difference for DEE using paired t test Test–retest: no significant difference in DEE using paired t test |
| DAQIHF; Chien et al40 | Test–retest | DEE | Within 2 wk | ICC = .99 |
| TAM1 and TAM2; Orrell et al44 | Test–retest Reproducibility | Total activity in minutes of daily activity and METS per minute represented by total activity score | >8 d otherwise not specified | TAM1 total activity ICC = .73 TAM2 total activity ICC = .82 Bland–Altman plots for TAM1 and TAM2 |
| MobilePAL; Pfaeffli et al46 | Day-to-day stability over 7-d period | Ratio of total energy expenditure and resting energy expenditure during 24 h | 7-d period | No significant difference with repeated-measures analysis for both 7 d and any 2 d |
| Acti’MET; Satge et al49 | Interrater Intrarater | Weekly energy expenditure | Interrater: same day Intrarater: 3 d | Interrater: Pearson r = .87; r2 = .77 Intrarater: Pearson r = .98; r2 = .97 |
| DPAQ; Gremeaux et al50 | Interrater | PAS in points out of 30 where 0–10 = highly sedentary and 21–30 = highly active | 10 d | Cohen k for interrater reliability: cardiac rehabilitation group = 0.27, Noncardiac rehabilitation group = 0.68 |
| PAS; Mezzani et al54 | Test–retest Interrater | Activity score based upon intensity (MET) and frequency | 15 d | Test–retest: ICC = .97 Interrater: ICC = .98 |
| PASE; Allison et al55 | Test–retest | PASE score | Within 2–3 wk | Pearson r = .72 |
Abbreviations: DAQIHF, Daily Activity Questionnaire in Heart Failure Scale; DEE, Daily Energy Expenditure; DPAQ, Dijon Physical Activity Questionnaire; ICC = intraclass correlation coefficient; MET = metabolic equivalent or task; MobilePAL, Mobile Phone Physical Activity Logger; PAS, Physical Activity Score; PASE, Physical Activity Scale for the Elderly; SWISSPAQ, SWISS Physical Activity Questionnaire; TAM1, Total Activity Measure 1; TAM2, Total Activity Measure 2.
Discussion
Given the importance of DPA in prognosis and clinical outcomes in patients with heart disease, the clinical feasibility of subjective DPA measures, and limitations of previous reviews, the primary purpose of this review was to identify reliable and accurate subjective DPA measures in individuals with heart disease to help clinicians and researchers select an appropriate instrument. The most useful subjective DPA measure is that which provides a measure of actual activity levels in terms of METs, EE per kilocalories, or minutes per week of overall activity. This review revealed that there were 10 instruments across 10 studies that estimated either EE per kilocalories (5 instruments)36,37,40,46,48,49,53 or METs (5 instruments).38,44,47,54 No instrument measured the total minutes of overall activity per week, though 2 measured the minutes of MVPA per week42,43 and 2 measured the sedentary time.43,56 The validation of such measures would ideally use the most relevant reference standards of calorimetry,59,60 accelerometry,59–61 or detailed DPA diaries.62 This review observed that, of the instruments measuring EE, kilocalories, or METs, none were compared against calorimetry, 4 instruments were compared against acceleromety,38,44,46 and 1 against a detailed PA diary.38
The subjective DPA measures, which estimate EE per kilocalories and which were compared against accelerometry, include the SWISSPAQ,38 TAM1,44 TAM2,44 and MobilePAL.46 Despite moderate to high reliability, the SWISSPAQ, TAM1, TAM2, and MobilePAL demonstrated overall low to moderate validity (r = −.086 to .45)38,44,46 and tended to overestimate activity. These results related to validity for all 4 instruments have yet to be replicated, so it is not yet known whether these results are spurious or whether these questionnaires have significant limitations. For example, the TAM1, TAM2, and SWISSPAQ ask respondents to estimate the typical or average activity, rather than report on the actual activity measured in a specific timeframe.
It is interesting to note that one of the most common reference standards used for validating DPA questionnaires was peak oxygen uptake. The theoretical basis for this choice of reference standard is the relationship between DPA and peak oxygen uptake. Individuals with greater activity levels typically have a greater peak oxygen uptake.63–65 Therefore, some studies selected peak oxygen uptake as a proxy objective measurement of activity level. The correlation coefficients of .30 to .71 with peak oxygen uptake36,37,48,53,54 were greater than the low to moderate coefficients of .09 to .45 reported for the instruments that were compared against accelerometry.38,44,46 Similarly, other reference standards, including anthropometric measurements, exercise duration, and the 6-minute walk test, also had stronger correlation coefficients than accelerometry.36,37,49,57 However, the use of reference standards that are not direct measures of DPA are not recommended.59–61,66,67
Although the IPAQ was the most frequently studied questionnaire (6 studies),42,43,46,47,49,56 only one study compared it against accelerometry (r = .20).42 Correlation coefficients with other reference standards were generally low to moderate. The strongest relationship was noted between the IPAQ activity category and pedometer-based steps per day (r = .54),56 which is consistent with previous research on the IPAQ in other populations.68 Despite the relatively low correlations between the IPAQ and objective DPA measures, it was used as a reference standard for validating the Mobile PAL46 and Acti’MET.49 None of the included studies assessed the IPAQ’s reliability.
It should be noted that a recent study of a subjective measure of DPA in individuals undergoing cardiac rehabilitation examined the Past-day Adults’ Sedentary Time (PAST) questionnaire.69 This study was not included in this review due to publication after our literature search was completed. The PAST measures the minutes of sedentary time in the past day and, similar to the other questionnaires included in this review, demonstrated low correlations with triaxial accelerometry. However, the authors observed improved overall agreement between the PAST and accelerometry over a 12-month period. The authors concluded that participants become better at estimating sedentary behavior and that the PAST may be useful for the measurement of changes in sedentary behavior at a group level following cardiac rehabilitation.
Similar to previous reviews,29,30,32 the authors of this review are unable to recommend a single subjective DPA measure for use with individuals with cardiovascular disease. However, this review is the most comprehensive to date with regard to search strategy, study populations, and recommendations and was focused solely on subjective DPA measures. Subjective DPA measures varied greatly with regard to the PA construct measured, length of recall, time/method of administration, and unit of measurement (Table 3). Test–retest reliability was generally good across the instruments in which it was studied, and therefore, these measures could be useful in identifying change in DPA. Unfortunately, relatively few questionnaires measuring METs, EE per kilocalories, or minutes of MVPA per week were compared against optimal reference standards of calorimetry, accelerometry, or DPA diaries. Of the questionnaires measuring METs, EE per kilocalories, or minutes of MVPA per week that were compared against the optimal reference standards of calorimetry, accelerometry, or DPA diaries (SWISSPAQ,38 TAM1/TAM2,44 and MobilePAL.46), the greatest differences were the recall period (ranging from less than 1 d to 2 mo) and construct measured/measurement units (MET hours of DPA vs minutes spent in different activity categories vs ratio of total daily EE to total resting EE). Therefore, the selection of a subjective measure of DPA would depend upon specific needs of the researcher or clinician in regard to the desired recall period (less than a day to 2 mo) and the construct measured (MET hours of DPA vs minutes spent in different activity categories vs ratio of total daily EE to total resting EE).
Future research on subjective DPA measures is clearly needed. The majority of the studies reviewed generally lacked high methodological rigor, and reliability testing was uncommon. Future studies should select reference standards most directly related to the DPA construct being measured and should seek to replicate results or prior studies.
This review was limited to peer-reviewed, English-only, full-text articles. In addition, this review included studies reporting on relationships between subjective DPA measures and reference standards, even when the primary objective of the included study was not to establish the validity of a given questionnaire. Finally, the conclusions of this review are limited to studies conducted in individuals with heart disease, and therefore, validity/reliability for a given instrument in other populations may be different.
Conclusions
Of the 19 questionnaires identified in this review, only the SWISS Physical Activity Questionnaire, Total Activity Measure 1 and 2, and Mobile Physical Activity Logger 1) provide an estimate of energy expenditure, metabolic equivalents, or minutes of DPA, 2) have established test–retest reliability, and 3) have been validated using accelerometry or a DPA diary.38,44,46 Test–retest reliability was good to excellent; however, the validity coefficients were moderate at best. Depending on the clinician or researcher needs, the selection of a subjective measure of DPA would depend on the desired recall period (less than 1 d to 2 mo) and the construct measured (MET hours of DPA vs minutes spent in different activity categories vs ratio of total daily EE to total resting EE).
Acknowledgments
The authors are grateful to Betsy Williams, reference librarian at Grand Valley State University, for her assistance with the design and execution of the database searches. There were no sources of funding for this work. All authors have no disclosures of funding or any potential conflicts of interest.
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In the original publication of this article, the list of databases searched was inaccurately listed as PubMed, CINAHL, MEDLINE, and ProQuest. The list of databases have been updated to correctly read PubMed, CINAHL Complete, PsycInfo, and Web of Science Core Collection. The authors apologize for this error.
