Changes in Physical Activity and Sedentary Behavior During Cardiac Rehabilitation

Changes in Physical Activity and Sedentary Behavior During Cardiac Rehabilitation

Accepted Manuscript Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation Nienke ter Hoeve, MSc, Madoka Sunamura, MD, Myrn...

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Accepted Manuscript Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation Nienke ter Hoeve, MSc, Madoka Sunamura, MD, Myrna E. van Geffen, MSc, Malou H.J. Fanchamps, MSc, Herwin L.D. Horemans, PhD, Johannes B.J. Bussmann, PhD, Henk J. Stam, MD, Prof, Ron T. van Domburg, PhD, Rita J.G. van den Berg-Emons, PhD PII:

S0003-9993(17)30384-2

DOI:

10.1016/j.apmr.2017.05.008

Reference:

YAPMR 56911

To appear in:

ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Received Date: 15 August 2016 Revised Date:

11 April 2017

Accepted Date: 16 May 2017

Please cite this article as: Hoeve Nt, Sunamura M, van Geffen ME, Fanchamps MHJ, Horemans HLD, Bussmann JBJ, Stam HJ, van Domburg RT, van den Berg-Emons RJG, Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation, ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION (2017), doi: 10.1016/j.apmr.2017.05.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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(2) TITLE PAGE

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Title:

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Changes in Physical Activity and Sedentary Behavior during Cardiac Rehabilitation

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Running head:

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Physical behavior and cardiac rehabilitation

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Authors:

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Nienke ter Hoeve1,2*, MSc; Madoka Sunamura1, MD; Myrna E. van Geffen1,2, MSc; Malou H.J.

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Fanchamps2, MSc; Herwin L.D. Horemans2, PhD; Johannes B.J. Bussmann2, PhD; Henk J.

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Stam2, MD, Prof; Ron T. van Domburg3, PhD; Rita J.G. van den Berg-Emons2, PhD

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Institutional affiliations:

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performed)

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Netherlands

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Capri Cardiac Rehabilitation, Rotterdam, The Netherlands (institution where study was

Erasmus University Medical Centre, Department of Rehabilitation Medicine, Rotterdam, The

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Erasmus University Medical Centre, Department of Cardiology, Rotterdam, The Netherlands

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*Corresponding author: Address: P.O. Box 2040, 3000 CA Rotterdam, The Netherlands

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Tel: +31 107044599, Fax: +31 107033843, Email: [email protected]

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Acknowledgement of presentation:

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Nothing to declare

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Acknowledgement of financial support:

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No financial support.

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Acknowledgement article

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No acknowledgements

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Nothing to declare

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Conflicts of interest:

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation

Changes in Physical Activity and Sedentary Behavior during Cardiac

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Rehabilitation

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation ABSTRACT

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Objective: To objectively measure changes in both moderate-to-vigorous physical activity (MVPA) and

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sedentary behavior (SB) during and after standard cardiac rehabilitation (CR).

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Design: Prospective cohort study

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Participants: 135 patients with acute coronary syndrome (ACS) who completed CR.

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Intervention: Multi-disciplinary CR according to current guidelines

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Main outcome measures: The proportion of time spent in MVPA and SB was objectively measured with

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an accelerometer. The distribution of time in MVPA and SB was also determined (e.g. average length of

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time periods spent in MVPA and SB). All measurements were obtained prior to CR, following CR and at

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one-year follow-up.

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Results: Patients‘time in MVPA during waking hours increased by 0.65% (≈5 min) during CR (p=0.002),

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and remained increased at one-year follow-up (p=0.037). The MVPA distribution did not change. During

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CR, time spent in SB decreased by 2.49% (≈22 min; p<0.001), and SB time became more fragmented

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with more breaks and shorter SB periods (p<0.001). These SB improvements were maintained at one-

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year follow-up (p<0.001).

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Conclusions: Patients with ACS achieved a small improvement in MVPA time during CR but MVPA

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distribution remained unchanged. More substantial improvements occurred for SB time and

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distribution. However, by the end of CR, patients still spent relatively little time in MVPA and a long time

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in SB, which is known to be detrimental to cardiovascular health. Although CR programs have the

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potential to improve physical behavior, our findings highlight the need to develop adjusted CR targets

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that address amount and distribution of MVPA and SB.

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Keywords:

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physical activity, sedentary behavior, cardiac rehabilitation, acute coronary syndrome

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List of abbreviations

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ACS- Acute Coronary Syndrome

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CR- Cardiac Rehabilitation

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MVPA- Moderate-to-Vigorous Physical Activity

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PA- Physical Activity

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SB- Sedentary Behavior

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Physical behavior comprises both physical activity (PA) and sedentary behavior (SB).1 PA is

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defined as any bodily movement produced by skeletal muscles that requires energy expenditure.2 SB is

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defined as behavior that consist mainly of sitting or lying and that requires very low energy

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expenditure.3 Recent studies show that PA and SB should be considered as distinct behaviors related to

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health outcomes.4, 5 In a general population, low levels of moderate-to-vigorous intensity PA (MVPA)

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have been identified as a leading risk factor for mortality and cardiovascular disease.6 Increased levels of

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SB are independently related to an increased risk of diabetes, cardiovascular disease, and mortality.3-5, 7

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In addition to volume (total time) of MVPA and SB, increasing evidence suggests that the distribution of

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this behavior over time may also be important. For example, the health benefits of daily, short bursts of

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MVPA may be smaller than those of less frequent, longer periods of MVPA.8, 9 Taking regular active

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breaks during sedentary time can counteract the harmful effects of prolonged sedentary periods.10, 11

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In patients with Acute Coronary Syndromes (ACS), it has been shown that more MVPA is related

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to a better cardiovascular risk profile12, 13 and lower cardiac mortality.14 Standard Cardiac Rehabilitation

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(CR) generally addresses MVPA, but not SB. Few studies have focused on SB in patients following ACS.

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Cross-sectional studies show that patients with cardiovascular disease spend more time sedentary per

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day compared to healthy individuals,15 and that longer sedentary time at CR completion is associated

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with poorer fitness and higher body mass index.16

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Studies using objective measurement tools to evaluate changes in MVPA and SB volume and

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distribution during standard CR are lacking. Knowledge of these changes may help formulate

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recommendations on future PA and SB targets. Therefore, the objective of the present study was to

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evaluate longitudinal changes in PA and SB volume and distribution in patients with ACS during and after

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CR participation.

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 66 METHODS

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Study sample

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The cohort investigated in the current study was originally recruited for a randomized controlled trial

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(RCT) in which they were assigned to the control group, receiving treatment as usual (standard CR).

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Patients with ACS who were referred to Capri CR between September 2011 and August 2014 were

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invited to participate in this study. Inclusion criteria were: diagnosis of ACS; age >18 years; proficiency in

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Dutch; and absence of physical and cognitive impairments that could limit CR participation. Only

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patients who completed standard CR were included in the current study. Additionally, patients needed

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at least two valid physical behavior measurements (of which one baseline) for inclusion in the analysis.

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All participants provided written informed consent. The study protocol was approved by the Medical

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Ethics Committee of the Erasmus Medical Center in Rotterdam, The Netherlands.

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Physical behavior

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Physical behavior (PA and SB) was measured with a tri-axial accelerometer (ActiGraph GT3X+a). Patients

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were asked to wear the accelerometer on the right side of their waist for eight consecutive days during

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waking hours, except when showering or swimming. Patients recorded the times they wore the

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accelerometer in a logbook.

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Data processing

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Consensus in accelerometer data processing is lacking. There is wide variability in the choices made for

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epoch length, wear time validation and intensity cut-off points, for example. We made our choices after

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extensively reviewing the literature.17-25

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Accelerometer data were sampled with a frequency of 30 Hz. The ActiGrapha measures raw

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accelerations on three axes and converts this into activity counts and steps. Step numbers were

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processed using Actilife software.26 Counts were summed over 15s time sampling intervals (epochs)

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using Actilife software and converted to Matlab format for further processing (Matlab version R2011b).

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A composite measure called vector magnitude was calculated (√(x2+y2+z2)) and used for analysis. Non-

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wear time was defined as a > 60 min of consecutive zeros, with no allowance of epochs with counts

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above zero. Data were analyzed only for patients who wore the accelerometer for ≥4 days and 660 min

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per day. After subtracting the non-wear time from the data, each epoch was categorized as:

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MVPA: activities of ≥672.5 counts 17

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Light activity: activities of >37.5 and < 672.5 counts17

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SB: activities of ≤37.5 counts18

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Outcome measures

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Volume of physical behavior

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Total activity counts were calculated by summation of counts in epochs, and expressed as counts per

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minute. Total time spent in MVPA, light activity, and SB was calculated and expressed as a percentage of

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total daily wear time. The amount of steps was expressed as steps per minute.26 In addition, we

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calculated the percentage of patients meeting a step target of at least 6500 steps/day. According to a

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recent study, 6500 steps/day is needed to prevent cardiovascular disease progression.27, 28

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Distribution of physical behavior

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The mean length of all uninterrupted bouts (time periods) of MVPA and SB with a minimum length of

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15s (1 epoch) was calculated. Because the lengths of these bouts were not normally distributed, the

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natural logarithm of lengths was taken and geometric means were calculated. A fragmentation index for

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation both MVPA and SB was calculated as the total number of bouts divided by the total volume in minutes.

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A higher fragmentation index indicates that the number of bouts was high and time in MVPA or SB

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relatively low. In other words, time is more fragmented in frequent, shorter bouts than in fewer

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prolonged periods. 19, 20

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Also, we were interested in prolonged bouts of MVPA and SB. In accordance with

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recommendations6, 12, 29-31, prolonged MVPA was defined as periods ≥10 min. Short MVPA interruptions

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may occur in daily life situations such as waiting for a traffic light.21-23 The exact length of MVPA

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interruptions to consider the bout as continuous remains unclear.23 We chose to allow a maximum of

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four interruptions (not necessarily consecutive) of 15s epochs with counts below 672.5 during a single

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bout of MVPA. Likewise, because there is no standard definition of prolonged SB, we defined prolonged

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SB as those bouts >30 min. During a sedentary period, we chose to allow a maximum of three

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consecutive interruptions of 15s epochs with counts above 37.5 during a single bout of SB. Thus, we

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analyzed a prolonged SB bout as ending after at least 1 min of continuous non-SB. In making this choice,

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we considered that interrupting SB every 30 min with a 1 min break of non-SB seems a feasible target

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for interventions. The total time spent in prolonged MVPA and SB was calculated and expressed as a

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percentage of total wear time. We also calculated whether participants met the American College of

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Sports Medicine (ACSM) target of ≥150 min of prolonged MVPA bouts per week.30 This guideline is

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consistent with those addressing secondary prevention of cardiovascular disease.6,

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accelerometer was not always worn for a full week, we calculated the percentage of participants

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reaching an average 21.4 min prolonged MVPA/day (150 min/ 7 days). There are no guidelines currently

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for recommended volume of SB.

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Because the

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Procedures

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Cardiac rehabilitation

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation All patients participated in multi-disciplinary outpatient CR lasting 10-13 weeks, as per Dutch

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guidelines.32 The program was terminated when individual physical and psychosocial goals were met, as

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evaluated by an exercise stress test and consultation by a multidisciplinary team consisting of physical

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therapists, social workers, and cardiologists. The program consisted of a 75-min group exercise sessions

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(twice weekly with a strength and aerobic program); and group educational sessions about the medical

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background and risk factors for cardiovascular disease, dietary advice, and emotional coping. If indicated

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each patient could participate in group counseling sessions on smoking cessation, healthy diet, and

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stress management. If needed, patients were referred for individual consultations with a psychologist,

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social worker, psychiatrist, or dietician. During CR, there was no specific MVPA coaching, but general

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information was given on the health benefits of an active lifestyle. There was no specific focus on

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changing SB.

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Patients also attended usual follow-up appointments with their cardiologist, during which

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general information on the health benefits of PA might be given. We do not have exact information on

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this aspect

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Data collection

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Data on physical behavior were obtained the week before CR (T0), during the last week of CR (T1), and

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at follow-up one year after the start of CR (T2). Data on age, gender, and working status were collected

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at T0.

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Statistical analysis

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Descriptive statistics were used to present baseline characteristics. Independent t-tests and Chi-square

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tests were used to test for differences in baseline characteristics between the original study sample and

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the sample with sufficient valid physical behavior measures.

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation For continuous variables, mean differences between T0 and T1 and between T0 and T2 were

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analyzed using paired t-tests, after checking whether the within-subject changes met the assumptions of

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normality. For dichotomous variables, chi-square tests were used to test for mean differences between

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T0 and T1 and between T0 and T2

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A two-sided p-value <0.05 was considered significant. All analyses were performed using SPSS (version 20).

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Subjects

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A flow diagram of inclusion is shown in Figure 1. A total of 245 patients were randomized to standard CR

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and included in this study. Data from 45 patients who did not complete CR, for reasons such as lack of

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time and unwillingness, were excluded. An additional 54 patients were excluded because fewer than

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two valid physical behavior measurements were available, and 11 patients because baseline physical

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behavior measurements were lacking. These 65 patients with insufficient physical behavior

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measurements were on average four years younger (p=0.001). Most of the remaining 135 participants

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were male (80%), mean age was 59 years and attendance rate was 23 CR exercise sessions. (Table 1).

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ActiGrapha wear time increased between T0 and T1 and between T0 and T2 (Table 2). Data from

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logbooks showed that at T0, during which patients are still in the acute phase after their cardiac event,

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patients go to bed earlier and wake up later. To compensate for these differences, all physical behavior

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outcomes were expressed relative to wear time.

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Changes in physical behavior during cardiac rehabilitation

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Table 2 shows the observed data and outcomes of the paired t-tests for mean changes over time in the

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volume of physical behavior (graphically depicted in Figure 2).

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Total activity counts per minute significantly increased between T0 and T1 (mean

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difference=50.56 counts/min, p<0.001), and between T0 and T2 (mean difference=55.04 counts/min,

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p<0.001). The step count also increased between T0 and T1 (mean difference=0.67 steps/min, p=0.002)

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and between T0 and T2 (mean difference=0.55 steps/min, p=0.017). At T0, 39.3% of participants were

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compliant with a daily step target of 6500. This compliance increased to 51.4% (p<0.001) at T1 and was

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46.5% at T2 (p<0.001 vs T0).

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Between T0 and T1, the time spent in MVPA and light activity increased (mean difference=0.65%

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of waking hours, p=0.002 and mean difference=1.84%, p=0.001 respectively) and time in SB decreased

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(mean difference=-2.49%, p<0.001). During an average day with a wear time of 14.5 hours, this equals a

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change of +5.7 min in MVPA, +16.0 min in light activities and -21.7 min in SB. Differences remained

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significant between T0 and T2.

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Distribution of physical behavior

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Table 3 shows the observed data and the outcomes of the paired t-tests for mean changes over time in

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the distribution of physical behavior.

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With regard to MVPA, there were no significant changes in distribution outcomes. Compliance

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with the ACSM guidelines decreased over time from 17.8% of participants at TO to 13.5% at T1

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(p<0.001) and 13.2% at T2 (p<0.001 vs T0).

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SB bout distribution changed between T0 and T1. The mean length of bouts decreased (mean

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difference=-0.05 min, p<0.001), the fragmentation index increased (mean difference=0.04, p=0.001),

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and time spent in prolonged SB bouts >30 min decreased (mean difference=-3.10%, p=0.001). These

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changes were also significant between T0 and T2. For an average day with a wear time of 14.5 hours, the

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change in time spent in prolonged SB was -26.0 min/day between T0 and T1 and -44.4 min/day between

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T0 and T2.

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 210 DISCUSSION

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Our results show a small, but lasting, increase in MVPA time during CR. Distribution measures revealed

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that patients with ACS tend to break up their MVPA time into short bouts. This pattern did not change

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during CR. SB volume and distribution changed. During CR, SB time decreased nearly 22 min and

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sedentary time became more fragmented with shorter bouts. These improvements were maintained.

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The exact changes in MVPA and SB required to gain health benefits are unclear, making it

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difficult to determine the clinical relevance of our findings. Nevertheless, our results indicate that MVPA

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remains low despite CR. For example, at the end of CR, only half of the participants achieved a daily step

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target of 6500.27, 28 Recognizing that PA volume, intensity and distribution are all important8, the ACSM

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guidelines recommend 150 min of MVPA per week, in bouts of 10 min or longer. Again, only a minority

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of our participants attained this level and compliance to this guideline even decreased over time.

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Compliance rates might be underestimated, because these guidelines are based on questionnaires,

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whereas our data were objectively measured.23 However, the MVPA volume was also relatively low at

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the end of CR compared to that of healthy adults measured by objective accelerometers (7.0% vs 10.2%

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MVPA, respectively).20 Moreover, although MVPA time improved during CR, there were no

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improvements in the distribution of this behavior.

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Interpreting the SB outcomes is even more difficult, as there are no existing guidelines for

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comparison. The improvements in volume and distribution of SB during CR seem quite substantial and

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lasting. Less time was spent in SB and this time was more fragmented with shorter periods, as is

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suggested to gain health benefits.10, 11 This improvement in SB is surprising, as interventions without an

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SB focus usually do not result in SB changes.34 However, despite the SB improvements during CR, time in

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SB was still long (62.8% which equals approximately 9 hours) when compared to that of healthy adults

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(57.5%).20 Moreover, a meta-analysis has shown that every hour increase in SB beyond seven hours is

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associated with a 5% increase in all-cause mortality.

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spent in prolonged SB also seemed long (> 5 h/day).

Although no reference data are available, time

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The results of our study are in line with those of other studies showing that cardiac patients

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tend to be sedentary and inactive.35-37 Studies focusing on the effects of CR and using objective

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measurement tools are scarce. A recent longitudinal study reported comparable small improvements in

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MVPA after eight weeks of CR;38 however, in contrast to our study, patients showed no improvement in

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SB. Another cross-sectional study showed post-CR, step counts and MVPA levels comparable to ours; for

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SB, lower values were found (56% vs 62.8% in our study).34 Differences can partly be explained by

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differences in choices related to data processing of accelerometers. This general issue of methodological

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differences in PA and SB research limits comparisons between studies.21, 24, 39, 40

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Our findings highlight the need to focus on further improvements in PA and SB in patients with

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ACS. Multidisciplinary CR teams that specialize in directing lifestyle changes can have an important role

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of helping to improve physical behavior. The focus of CR should be to reach more substantial and lasting

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changes to total MVPA time, but also to accrue MVPA time in longer-lasting bouts. Targets for SB

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improvement should be to lower total SB time and frequently interrupt this time. Behavioral

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interventions containing self-regulation components (e.g. self-monitoring, goal-setting) seem

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promising.31, 34, 41

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Study Limitations

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation Our study has some limitations. Firstly, the ActiGrapha cutt-off points we used for the PA intensity

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categories were developed for a healthy population. Patients entering CR often have lower

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cardiovascular fitness levels compared to healthy individuals, which may result in under classification of

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PA intensity.42 Furthermore, the ActiGrapha is not water-resistant and could not be worn during

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swimming activities. Because our participants rarely swam, we made no attempt to correct for this

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limitation. Finally, although the ActiGraph GT3X+a was found to fairly accurately detect SB,

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misclassifications such as designating “standing still” as “SB” cannot be ruled out.18 Despite these

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limitations, the use of accelerometers is still a major strength of our study.

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Another limitation is that our study was performed at a single-center with no control group.

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Caution is required when attributing the observed effects to the CR program. Baseline measurements

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were taken after hospital discharge, when patients had not yet returned to their daily life activities. The

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observed improvements might, therefore, partly reflect a return to participants’ physical behavior

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situations that existed before the cardiac incident.

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Lastly, patients who did not have sufficient physical behavior measurements to be included in

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the analysis were younger on average, which may have biased the results. In addition, the cohort may

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consist of higher motivated patients that were willing to participate in this trial. Information on patients

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who did not provide informed consent is lacking.

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CONCLUSIONS

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Patients with ACS achieved small, but lasting, improvements in the MVPA volume during CR. More

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substantial and lasting improvements in SB volume and distribution were observed. However, at the end

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CR participants still spent a relatively short time in MVPA and a long time in SB, which has been shown

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to be detrimental to cardiovascular health. Although CR programs have the potential to improve

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physical behavior, our findings highlight the need to develop adjusted CR targets focusing on volume

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and distribution of MVPA and SB.

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation REFERENCES

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1. Bussmann JB, van den Berg-Emons RJ. To total amount of activity..... and beyond: perspectives on measuring physical behavior. Front Psychol 2013;4:463. 2. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public health reports 1985;100(2):126-31. 3. Wilmot EG, Edwardson CL, Achana FA, Davies MJ, Gorely T, Gray LJ et al. Sedentary time in adults and the association with diabetes, cardiovascular disease and death: systematic review and metaanalysis. Diabetologia 2012;55(11):2895-905. 4. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Annals of internal medicine 2015;162(2):123-32. 5. Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE et al. Daily sitting time and all-cause mortality: a meta-analysis. Plos One 2013;8(11):e80000. 6. Organization WH. Global Recommendations on Physical Activity for Health. 2010. 7. Healy GN, Wijndaele K, Dunstan DW, Shaw JE, Salmon J, Zimmet PZ et al. Objectively measured sedentary time, physical activity, and metabolic risk: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Diabetes Care 2008;31(2):369-71. 8. Strath SJ, Holleman RG, Ronis DL, Swartz AM, Richardson CR. Objective physical activity accumulation in bouts and nonbouts and relation to markers of obesity in US adults. Prev Chronic Dis 2008;5(4):A131. 9. Murphy M, Nevill A, Neville C, Biddle S, Hardman A. Accumulating brisk walking for fitness, cardiovascular risk, and psychological health. Medicine and science in sports and exercise 2002;34(9):1468-74. 10. Healy GN, Dunstan DW, Salmon J, Cerin E, Shaw JE, Zimmet PZ et al. Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care 2008;31(4):661-6. 11. Kim Y, Welk GJ, Braun SI, Kang M. Extracting objective estimates of sedentary behavior from accelerometer data: measurement considerations for surveillance and research applications. Plos One 2015;10(2):e0118078. 12. Balady GJ, Williams MA, Ades PA, Bittner V, Comoss P, Foody JM et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007;115(20):2675-82. 13. Warburton DE, Katzmarzyk PT, Rhodes RE, Shephard RJ. Evidence-informed physical activity guidelines for Canadian adults. Canadian Journal of Public Health Revue Canadienne de Sante Publique 2007;98 Suppl 2:S16-68. 14. Giannuzzi P, Mezzani A, Saner H, Bjornstad H, Fioretti P, Mendes M et al. Physical activity for primary and secondary prevention. Position paper of the Working Group on Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology. European Journal of Cardiovascular Prevention & Rehabilitation 2003;10(5):319-27. 15. Evenson KR, Butler EN, Rosamond WD. Prevalence of physical activity and sedentary behavior among adults with cardiovascular disease in the United States. J Cardiopulm Rehabil Prev 2014;34(6):406-19. 16. Prince SA, Blanchard CM, Grace SL, Reid RD. Objectively-measured sedentary time and its association with markers of cardiometabolic health and fitness among cardiac rehabilitation graduates. Eur J Prev Cardiol 2015.

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ACCEPTED MANUSCRIPT Running head: Physical behavior and cardiac rehabilitation 17. Sasaki JE, John D, Freedson PS. Validation and comparison of ActiGraph activity monitors. J Sci Med Sport 2011;14(5):411-6. 18. Carr LJ, Mahar MT. Accuracy of intensity and inclinometer output of three activity monitors for identification of sedentary behavior and light-intensity activity. J Obes 2012;2012:460271. 19. Tieges Z, Mead G, Allerhand M, Duncan F, van Wijck F, Fitzsimons C et al. Sedentary behavior in the first year after stroke: a longitudinal cohort study with objective measures. Arch Phys Med Rehabil 2015;96(1):15-23. 20. Blikman LJ, van Meeteren J, Horemans HL, Kortenhorst IC, Beckerman H, Stam HJ et al. Is physical behavior affected in fatigued persons with multiple sclerosis? Arch Phys Med Rehabil 2015;96(1):24-9. 21. Masse LC, Fuemmeler BF, Anderson CB, Matthews CE, Trost SG, Catellier DJ et al. Accelerometer data reduction: a comparison of four reduction algorithms on select outcome variables. Med Sci Sports Exerc 2005;37(11 Suppl):S544-54. 22. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008;40(1):181-8. 23. Chastin SF, Dall PM, Tigbe WW, Grant MP, Ryan CG, Rafferty D et al. Compliance with physical activity guidelines in a group of UK-based postal workers using an objective monitoring technique. Eur J Appl Physiol 2009;106(6):893-9. 24. Keadle SK, Shiroma EJ, Freedson PS, Lee IM. Impact of accelerometer data processing decisions on the sample size, wear time and physical activity level of a large cohort study. BMC Public Health 2014;14:1210. 25. Ayabe M, Kumahara H, Morimura K, Tanaka H. Epoch length and the physical activity bout analysis: an accelerometry research issue. BMC Res Notes 2013;6:20. 26. Lee JA, Williams SM, Brown DD, Laurson KR. Concurrent validation of the Actigraph gt3x+, Polar Active accelerometer, Omron HJ-720 and Yamax Digiwalker SW-701 pedometer step counts in lab-based and free-living settings. J Sports Sci 2015;33(10):991-1000. 27. Ayabe M, Brubaker PH, Dobrosielski D, Miller HS, Kiyonaga A, Shindo M et al. Target step count for the secondary prevention of cardiovascular disease. Circulation journal : official journal of the Japanese Circulation Society 2008;72(2):299-303. 28. Tudor-Locke C, Craig CL, Aoyagi Y, Bell RC, Croteau KA, De Bourdeaudhuij I et al. How many steps/day are enough? For older adults and special populations. Int J Behav Nutr Phys Act 2011;8:80. 29. Hamm LF, Sanderson BK, Ades PA, Berra K, Kaminsky LA, Roitman JL et al. Core competencies for cardiac rehabilitation/secondary prevention professionals: 2010 update: position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation. J Cardiopulm Rehabil Prev 2011;31(1):2-10. 30. Pate RR, Pratt M, Blair SN, Haskell WL, Macera CA, Bouchard C et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273(5):402-7. 31. Ferrier S, Blanchard CM, Vallis M, Giacomantonio N. Behavioural interventions to increase the physical activity of cardiac patients: a review. European Journal of Cardiovascular Prevention & Rehabilitation 2011;18(1):15-32. 32. Multidisciplinaire Richtlijn Hartrevalidatie 2011. Utrecht: Nederlandse

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Vereniging Voor Cardiologie; 2011. 33. Twisk JW. Longitudinal data analysis. A comparison between generalized estimating equations and random coefficient analysis. European journal of epidemiology 2004;19(8):769-76.

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34. Prince SA, Saunders TJ, Gresty K, Reid RD. A comparison of the effectiveness of physical activity and sedentary behaviour interventions in reducing sedentary time in adults: a systematic review and meta-analysis of controlled trials. Obes Rev 2014;15(11):905-19. 35. Byun W, Ozemek C, Riggin K, Strath S, Kaminsky L. Correlates of objectively measured physical activity in cardiac patients. Cardiovasc Diagn Ther 2014;4(5):406-10. 36. Guiraud T, Granger R, Gremeaux V, Bousquet M, Richard L, Soukarie L et al. Accelerometer as a tool to assess sedentarity and adherence to physical activity recommendations after cardiac rehabilitation program. Ann Phys Rehabil Med 2012;55(5):312-21. 37. Evenson KR, Butler EN, Rosamond WD. Prevalence of Physical Activity and Sedentary Behavior Among Adults With Cardiovascular Disease in the United States. J Cardiopulm Rehabil 2014;34(6):40619. 38. Ribeiro F, Oliveira NL, Silva G, Campos L, Miranda F, Teixeira M et al. Exercise-based cardiac rehabilitation increases daily physical activity of patients following myocardial infarction: subanalysis of two randomised controlled trials. Physiotherapy 2015. 39. Gorman E, Hanson HM, Yang PH, Khan KM, Liu-Ambrose T, Ashe MC. Accelerometry analysis of physical activity and sedentary behavior in older adults: a systematic review and data analysis. Eur Rev Aging Phys A 2014;11(1):35-49. 40. Orme M, Wijndaele K, Sharp SJ, Westgate K, Ekelund U, Brage S. Combined influence of epoch length, cut-point and bout duration on accelerometry-derived physical activity. Int J Behav Nutr Phys Act 2014;11(1):34. 41. Gardner B, Smith L, Lorencatto F, Hamer M, Biddle SJ. How to reduce sitting time? A review of behaviour change strategies used in sedentary behaviour reduction interventions among adults. Health psychology review 2016;10(1):89-112. 42. Ozemek C, Cochran HL, Strath SJ, Byun W, Kaminsky LA. Estimating relative intensity using individualized accelerometer cutpoints: the importance of fitness level. BMC Med Res Methodol 2013;13:53.

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Suppliers ‘list

404

a

405

Manufacturer:

406

ActiGraph

407

48E Chase Street

408

Pensacola, FL 32502

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USA

410

Distributor:

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ProCare B.V.

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Zernikepark 16a

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9747 AN Groningen

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The Netherlands

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ActiGraph GT3X+:

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Figure 1. Flow diagram participants

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Figure 2. Percentage of waking hours spent in sedentary behavior (SB), light activities, and moderate-to-

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vigorous activities (MVPA).

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ACCEPTED MANUSCRIPT Table 1. Baseline characteristics of the study population (n=135) Characteristics 78.5 58.8 (8.5) 28.0 (3.8) 45.1 12.4 42.5 23.1 (5.0)

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Displayed as percentage or mean (SD)

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Male Age (years) 2 Body Mass Index (kg/m ) Employment status Full time Part time Not employed Number of attended exercise sessions

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Table 2. Physical behavior over time

6.5 (1.1)

7.0 (1.1)

7.1 (1.1)

14.2 (1.0)

14.6 (1.0)

Total volume of physical activity 544.7 (169.6) Activity counts/min 7.3 (2.9) Steps/min Categories of physical behavior 6.3 (3.0) MVPA (% wear time) 28.1 (7.1) Light activity (% wear time) 65.6 (8.3) SB (% wear time)

P*

T0-T2 (n=114) Mean difference (SD)

P*

0.30 (0.95)

0.001

0.46 (0.98)

<0.001

14.7 (1.0)

0.43 (1.37)

0.001

0.52 (1.21)

<0.001

599.0 (152.0)

596.0 (164.2)

50.56 (128.2)

<0.001

55.04 (148.2)

<0.001

8.1 (2.6)

7.8 (2.8)

0.67 (2.21)

0.002

0.55 (2.44)

0.017

7.0 (2.7)

6.7 (3.0)

30.2 (6.4)

31.0 (7.6)

62.8 (7.4)

62.3 (8.4)

0.65 (2.21)

0.002

0.50 (2.51)

0.037

1.84 (5.65)

0.001

2.98 (6.49)

<0.001

-2.49 (6.57)

<0.001

-3.48 (7.75)

<0.001

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* t-tests

T0-T1 (n=111) Mean difference (SD)

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T2 (n=114) Mean (SD)

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T1 (n=111) Mean (SD)

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T0 (n=135) Mean (SD)

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Table 3. Distribution of physical behavior over time T2 (n=114) Mean (SD)

T0-T1 (n=111) Mean difference (SD)

0.39 (0.05)

0.39 (0.06)

0.008 (0.05)

1.73 (0.42)

1.86 (0.55)

-0.05 (0.42)

0.77 † (0-7.79)

0.49 † (0-6.87)

-0.03 (1.45)

0.87 (0.16)

0.82 (0.14)

0.80 (0.15)

0.49 (0.15)

0.53 (0.14)

0.54 (0.16)

39.0 (12.0)

35.2 (11.4)

34.5 (11.5)

a

Distribution of MVPA bouts Mean length MVPA 0.38 (0.06) a bouts (min) b 1.79 (0.53) Fragmentation index MVPA bouts >10 min (% 0.66 † c (0-8.26) of wear time)

P*

0.111

0.004 (0.05)

0.381

0.173

0.05 (0.46)

0.235

0.805

-0.21 (1.34)

0.096

-0.05 (0.14)

<0.001

-0.07 (0.16)

<0.001

0.04 (0.12)

0.001

0.06 (0.14)

<0.001

-3.10 (10.0)

0.001

-5.11 (10.7)

<0.001

a

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Distribution of SB bouts Mean length SB bouts a (min) b Fragmentation index SB bouts >30min (% of d wear time)

P*

T0-T2 (n=114) Mean difference (SD)

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T0 (n=135) Mean (SD)

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* t-tests a Uninterrupted bouts with a minimum length of 15 seconds (equal to epoch length) b Total number of bouts divided by total volume of MVPA/SB in minutes. A higher fragmentation index indicates that time is more fragmented with shorter periods of uninterrupted MVPA or SB. c Prolonged MVPA bouts with a minimum duration of 10 min with allowance for interruptions of 60 non-consecutive seconds of non-active time d Prolonged SB bouts with a minimum duration of 30 min with allowance for interruptions of 45 consecutive seconds of non-sedentary behavior † Since the outcomes violated normality assumptions, median (range) values are displayed

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Assessed for eligibility N=2039

In study N=731 Excluded from analysis Did not participate in standard CR: N= 486 Did not complete CR: N=45 <2 valid Actigraph measurements: N=54 No baseline Actigraph measurements: N=11

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In analysis N=135

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Volumes of physical behavior 6.3

7.0

6.7

28.1

30.2

31.0

65.6

62.8

80

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70 60 50

30

10 0

T0 (pre-CR)

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T1 (post-CR)

Light activity

T2 (1 year) MVPA

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Percentage of total daily wear time (%)

100

1