How Many Steps/day Are Enough? For Older Adults and Special Populations

Tudor-Locke et al.
International Journal of Behavioral Nutrition and Physical Activity 2011, 8:80

http://www.ijbnpa.org/content/8/1/80
REVIEW Open Access
How many steps/day are enough? For older

adults and special populations
Catrine Tudor-Locke1,2*, Cora L Craig2,3, Yukitoshi Aoyagi4, Rhonda C Bell5, Karen A Croteau6,
Ilse De Bourdeaudhuij7, Ben Ewald8, Andrew W Gardner9, Yoshiro Hatano10, Lesley D Lutes11,
Sandra M Matsudo12,13, Farah A Ramirez-Marrero14, Laura Q Rogers15, David A Rowe16, Michael D Schmidt17,18,
Mark A Tully19 and Steven N Blair20
Abstract
Older adults and special populations (living with disability and/or chronic illness that may limit mobility and/or
physical endurance) can benefit from practicing a more physically active lifestyle, typically by increasing ambulatory
activity. Step counting devices (accelerometers and pedometers) offer an opportunity to monitor daily ambulatory
activity; however, an appropriate translation of public health guidelines in terms of steps/day is unknown. Therefore
this review was conducted to translate public health recommendations in terms of steps/day. Normative data
indicates that 1) healthy older adults average 2,000-9,000 steps/day, and 2) special populations average 1,200-8,800
steps/day. Pedometer-based interventions in older adults and special populations elicit a weighted increase of
approximately 775 steps/day (or an effect size of 0.26) and 2,215 steps/day (or an effect size of 0.67), respectively.
There is no evidence to inform a moderate intensity cadence (i.e., steps/minute) in older adults at this time.
However, using the adult cadence of 100 steps/minute to demark the lower end of an absolutely-defined
moderate intensity (i.e., 3 METs), and multiplying this by 30 minutes produces a reasonable heuristic (i.e., guiding)
value of 3,000 steps. However, this cadence may be unattainable in some frail/diseased populations. Regardless, to
truly translate public health guidelines, these steps should be taken over and above activities performed in the
course of daily living, be of at least moderate intensity accumulated in minimally 10 minute bouts, and add up to
at least 150 minutes over the week. Considering a daily background of 5,000 steps/day (which may actually be too
high for some older adults and/or special populations), a computed translation approximates 8,000 steps on days
that include a target of achieving 30 minutes of moderate-to-vigorous physical activity (MVPA), and approximately
7,100 steps/day if averaged over a week. Measured directly and including these background activities, the evidence
suggests that 30 minutes of daily MVPA accumulated in addition to habitual daily activities in healthy older adults
is equivalent to taking approximately 7,000-10,000 steps/day. Those living with disability and/or chronic illness (that
limits mobility and or/physical endurance) display lower levels of background daily activity, and this will affect
whole-day estimates of recommended physical activity.
Introduction concluded that, in addition to the well known cardiovas-

The profound and multiple benefits of living a physically cular and metabolic health benefits, there was “strong
active lifestyle extend to older adults and special popula- evidence” that physically active older adults have higher
tions (living with disability and/or chronic illness that levels of functional health, lower risks of falling, and
may limit mobility and/or physical endurance) [1]. In improved cognitive health [2]. A recent systematic
reviewing their 2008 release of federal physical activity review further confirmed that greater aerobic physical
guidelines, the U.S. Advisory Committee Report activity was associated with reduced risk of functional
limitations and disability with age [3]. A systematic
review of the benefits of physical activity for special
* Correspondence: Tudor-Locke@pbrc.edu
1
Walking Behaviour Laboratory, Pennington Biomedical Research Center, populations is lacking, but it is presumed that similar
Baton Rouge, LA, USA returns are reasonable to expect.
Full list of author information is available at the end of the article
© 2011 Tudor-Locke et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Tudor-Locke et al. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:80 Page 2 of 19
Evidence-based guidelines for older adults communi- Methods

cate the benefits of a physically active lifestyle using The Public Health Agency of Canada (PHAC) commis-
frequency-, duration-, and intensity-based parameters. sioned a literature review in February 2010 to inform an
Similar to what is typically communicated to younger evidence-based approach to converting step count data
adults, public health physical activity guidelines pro- into minutes of active time congruent with public health
mote at least 150 minutes/week of moderate-to-vigor- guidelines. An English-language search strategy identi-
ous physical activity (MVPA) for older adults and fied 1,594 articles published since 2000 using the key-
include “brisk walking” as a primary example of an words (pedomet* or acceleromet*) and step* and
appropriate activity [3]. Variations on the message ((physical activity) or walk*) within the following search
exist: the World Health Organization promotes at least engines: CINAHL, ERIC, MEDLINE, PsycINFO, SocIN-
30 minutes of moderate intensity physical activity 5 DEX, and SPORTDiscus. The list was subsequently
days per week for older adults [4]. All older adults reduced to 837 articles after duplicates, remaining non-
should avoid inactivity and some physical activity is English language articles, dissertations, non-peer
considered better than none [5]; however, public health reviewed articles, and those obviously not dealing with
recommendations answer a pragmatic need to provide step-defined human physical activity were removed.
generalized guidance. Regardless of the message speci- Abstracts were reviewed, identified articles were
fics, as framed, time- and intensity-based guidelines assembled, and a report was written. Selected research-
imply that this dose of physical activity should be ers from around the world with first-hand experience
taken over and above a baseline level which is yet to collecting step data in the relevant population were
be quantified. This is problematic, since it is likely that invited to critically review the report, identify any gaps
this baseline level of non-exercise physical activity has or offer additional literature, check and verify data
been most susceptible to secular transitions in occupa- pulled from original sources, and intellectually contri-
tion in favour of desk jobs and reductions in physical bute to this consensus article.
demands of most other jobs, reliance on labour-saving For the purposes of this article, we defined older
devices to supplement or replace domestic tasks and adults as those older than 65 years of age, although
other activities of daily living, dependence on motor- much of the identified literature represents even older
ized transportation, and an insidious and pervasive individuals. At times we considered studies that
predilection for passive leisure time pursuits [6]. Since included at least some participants under 65 years of
self-reported leisure time physical activity (specifically age, for example, as low as 50 years of age if the sample
walking for exercise) increases in older adults with age mean age was over 65 years of age. The definition of
[7], yet objectively monitored physical activity special populations was purposely quite broad and
decreases [8], it is also likely that this baseline level of included studies of individuals living with disability and/
non-exercise physical activity is vulnerable to advan- or chronic illness that may limit mobility and/or physi-
cing age, disability, and chronic illness. cal endurance. Older adults with disabilities or chronic
Step counting devices (i.e., pedometers and acceler- health problems, and frail older adults would more
ometers) provide a means of objectively quantifying appropriately fit into the special populations category,
total daily activity, and their counting mechanisms are however, this category is not necessarily defined solely
particularly sensitive to detecting the recommended by age. The final product herein is centred on the litera-
intensities of walking believed to be associated with a ture relevant to older adults and special populations
host of healthful outcomes for older adults. Acceler- with regards to: 1) normative data (i.e., expected values);
ometers can provide additional data with regards to 2) changes expected from interventions; 3) controlled
time spent in various intensities of physical activity and studies that determine exact step-based conversions of
inactivity in addition to providing step data. However, timed behaviour; 4) computing a step translation of
due to their relative expense and associated intensive time- and intensity-based physical activity guidelines (e.
data management requirements their use is typically g., steps/day associated with time in moderate-to-vigor-
limited to research. In contrast, simple and inexpensive ous physical activity or MVPA); 5) directly measured
pedometers, even if they are less sensitive to very slow steps/day indicative of minimal time in MVPA taken
walking [9], are more likely to be adopted for clinical under free-living conditions; and, 6) steps/day associated
and real world applications, including direct use by with various health outcomes. Each section represents a
members of the public. Regardless of instrumentation ‘mini-review.’ At times the search strategy was exhaus-
choice, the utility of any step output is limited without tive and the exact number of articles identified is pre-
the ability to translate public health guidelines in terms sented under the appropriate heading below (e.g., direct
of steps/day. studies of step-equivalents of physical activity
guidelines). Where current reviews were identified (e.g., include those whose disability and/or chronic illness
normative data), the findings were simply summarized may or may not limit their mobility and/or physical
herein and select original articles were referred to only endurance.
to make specific points. Where appropriate, details of Tudor-Locke and Bassett [15] originally proposed a
studies were tabulated. Any apparent inconsistencies in graduated step index to describe pedometer-determined
reporting within tables (e.g., instrument brand, model, habitual physical activity in adults: 1) < 5,000 steps/day
manner in which participant age is reported, etc.) reflect (sedentary); 2) 5,000-7,499 steps/day (low active); 3)
reporting inconsistencies extracted directly from original 7,500-9,999 steps/day (somewhat active); 4) ≥ 10,000-
articles. The child/adolescent [10] and adult populations 12,499 steps/day (active); and 5) ≥12,500 steps/day
[11] literature is reviewed separately. (highly active). These incremental categories were rein-
forced in a second review in 2008 [16]. Recognizing a
Results considerable floor effect (i.e., insensitivity to the range
Normative data (expected values) of activity levels below the lowest threshold) when
An early review of normative data from studies pub- applied to low active populations, Tudor-Locke et al.
lished between 1980 and 2000 [12] reported that we can [17] suggested that the original sedentary level could be
expect 1) healthy older adults to take 6,000-8,500 steps/ further divided into two additional incremental levels: <
day (based on 10 studies identified that included adults 2,500 steps/day (basal activity) and 2,500- 4,999 steps/
age 50+ years with no specifically reported disabilities or day (limited activity). As it stands, this graduated step
chronic conditions); and 2) special populations to take index represents an absolute classification scheme. For
3,500- 5,500 steps/day (based on 8 studies identified example, it does not take into consideration that advan-
representing a broad range of disabilities and chronic ill- cing age or the presence of chronic disease/disability
nesses). The authors acknowledged that these expected generally reduces levels of activity. As such older adults
values were derived from an amalgamation of few and and special populations will be always compared to
disparate studies published at that time. Further, they younger populations with less disability or illness.
anticipated that these normative data would and should Table 1 displays those studies of free-living behaviour
be modified and refined as evidence and experience reporting the percent meeting select step-defined cut
using pedometers to assess physical activity would inevi- points in older adults and special populations (specifi-
tably continue to accumulate. cally individuals living with HIV [18], as no other rele-
Since that time a number of studies focused on objec- vant article was located on special populations). These
tively monitored data have been published and the limited studies indicate that achieving > 10,000 steps/
expected values for healthy older adults have been day is likely to be challenging for some (e.g., those tak-
updated [13]. Specifically, 28 studies published between ing less than 2,500 steps/day), but not necessarily
2001 and 2009 focusing on adults ≥50 years of age not impossible for all older adults (e.g., those taking more
specifically recruited for illness or disability status were than 9,000 steps/day).
identified and assembled in a review article [13]. Step- In summary, the updated normative data indicate that
defined physical activity ranged from 2,000- 9,000 steps/ 1) apparently healthy older adults average 2,000-9,000
day, was (generally) lower for women than men, steps/day, and 2) special populations average 1,200-
appeared to decrease over reported age groups, and was 8,800 steps/day. The very broad ranges of habitual activ-
lower for those defined as overweight/obese compared ity reflect the natural diversity of abilities common to
to normal weight samples. A separate review article [14] older adults and special populations, especially given
summarized expected values from 60 studies of special that not all chronic conditions are expected to signifi-
populations including those living with heart and vascu- cantly impact physical mobility and/or endurance.
lar diseases, chronic obstructive pulmonary disease or Further, individuals with a chronic illness are not neces-
COPD, diabetes and dialysis, breast cancer, neuromus- sarily “older,” further exacerbating this wide variability.
cular diseases, arthritis, joint replacement, fibromyalgia, Normative data continue to be published. These norma-
and disability (impaired cognitive function/intellectual tive data provide an important set of reference values by
difficulties). Older adults with disabilities took the low- which individual or group data can be compared to
est number of steps/day (1,214 steps/day) followed by assumed peers. Use of a graduated step index permits
individuals living with COPD (2,237 steps/day). The classification of older adults and special populations by
highest number of steps/day (8,008 steps/day) were multiple step-defined physical activity categories. On-
taken by individuals with Type 1 diabetes, followed by going surveillance of step-defined physical activity is
those living with mental retardation/intellectual disabil- required to track progress, identify areas of concern,
ity (7,787 steps/day) and HIV (7,545 steps/day). It is and evaluate the efficacy and effectiveness of public
apparent that special populations, broadly defined, health strategies. The next step will be to improve
Table 1 Studies of free-living behaviour reporting percent meeting select step-defined cut points in older adults
First Sample Characteristics Instrument Monitoring Cut points % Meeting
Author Frame used Specified Cut Point
Tudor- 6 men, 12 women; Yamax Digiwalker SW-200, Yamax 9 days 10,000 50% never achieved 10,000 steps on any
Locke Community dwelling Corporation, Tokyo, Japan day of the monitoring frame
[37] older exercisers;
2002 59-80 years
Canada
Newton 54 women; Actigraph MTI Health Services, USA 6 days Adult Graded 24% > 10,000
[58] primary biliary cirrhosis Step Index
2006 patients
UK 63.0 ± 9.4 years
Rowe [55] 29 men, 60 women Yamax 7 days 10,000 9.6% of days > 10,000
2007 community dwelling Actigraph
UK 60+ years
Ewald 322 men, 362 women; Yamax Digwalker SW-200 7 days 8,000 [84] Overall: 42% > 8,000
[88] community-dwelling, 55-59 year olds: 62%
2009 urban; 80+ year olds: 12%
Australia 55 to 85 years
understanding about determinants of step-defined physi- representative of sedentary populations [15]. The mean
cal activity, including the impact of disability and delta (i.e., difference between pre- and post-intervention)
chronic illness on contexts (e.g., occupation, retirement, was 808 steps/day; adjusted for sample size the weighted
transport, leisure, home, living arrangements, etc.) mean delta was 775 steps/day. In comparison, a change
where older adults and special populations accumulate of 2,000-2,500 steps/day is typical of pedometer-based
(or do not accumulate) steps, especially those of at least interventions in younger adults [19,21]. Study-specific
moderate intensity (defined below). effect sizes (Cohen’s D) were computed where necessary
data were provided in the original article, and these also
Interventions appear in Table 2. Overall, the weighted effect size was
Although three previous reviews have documented the 0.26 (generally considered a small effect). This effect
effects of pedometer-based programming on physical size is also smaller than what is expected in younger
activity [19-21], weight loss [19,20], and blood pressure adult populations (i.e., 0.68) [21].
[19] in samples that have included older adults and spe- Table 3 displays details from identified pedometer-
cial populations, no review has specifically examined based physical activity intervention studies in special
intervention effects in either of these groups at this populations that have reported any steps/day data. Spe-
time. Yet these are the groups that may be most cifically, we located 10 studies in cancer populations,
attracted to pedometer-based programming. Participants three in COPD populations, two in coronary heart dis-
in pedometer-based community interventions delivered ease and related disorders, 15 in diabetes populations,
in Ghent, Belgium [22] and Rockhampton, Australia and 3 in populations with joint or muscle disorders.
[23] were more likely to be older than younger. Across conditions, intervention durations have ranged
Although no actual pedometer data were reported, a from 4 weeks [28,29] to 12 months [30,31]. Some
library-based pedometer loan program delivered in researchers have chosen to intervene using a ped-
Ontario, Canada reported that older adults (55+ years of ometer but to assess outcomes using an accelerometer
age) were more likely to participate than other age [31-36]. Delta values and effect sizes were computed
groups. for each study where requisite data were reported.
Table 2 presents details from 13 identified pedometer- Additionally, we have presented unweighted and
based physical activity intervention studies that have weighted (taking into consideration sample size) deltas
focused on older adult samples ranging in age from 55 and effect sizes by condition. Mean weighted deltas
to 95 years. The majority of participants were commu- ranged from 562 steps/day for COPD to 2,840 steps/
nity-dwelling, however a few studies reported interven- day for coronary heart disease and related disorders.
tions with older adults living in continuing care [24], Weighted effect sizes ranged from 0.06 (small) for
congregate housing [25], or assisted living situations COPD to 1.21 (large) for coronary heart disease and
[26]. Interventions have lasted from 2 weeks [24] to 11 related disorders. Across conditions, unweighted mean
months [27] in duration. The mean baseline step- delta and effect size were 2,072 steps/day and 0.64,
defined physical activity was 4,196 steps/day (weighted respectively. Weighted values were 2,215 and 0.67
mean = 3,556 steps/day); a value that is considered (medium), respectively.
Table 2 Pedometer -based physical activity intervention studies with older adults
Reference Sample Intervention Instrument Intervention Intervention Delta Cohen’s
duration; study Group Group Steps/ D
duration and design Baseline Immediately day
Steps/day Post-
Intervention
Steps/day
Conn [89] 65-96 years; community- 3-month intervention; Yamax Digi-Walker 2,773 ± 1,780 2,253 ± 1,394 -520 -0.33
2003 dwelling; 3-month randomized
USA 190 participants controlled trial
Croteau [26] 68-95 years; living in assisted 4-week intervention; 4- Yamax Digi-Walker SW- 3,031 ± 2,754 2,419 ± 2,296 -612 -0.24
2004 living; 15 participants week quasi- 200
USA experimental
Jensen [90] 60-75 years; community 3-month intervention; Accusplit, San Jose, CA 4,027 ± 2,515 5,883 ± 3,214 1,856 0.65
2004 -dwelling; 18 participants 3-month quasi-
USA experimental
Croteau [25] 60-90 year olds; 4- month intervention; Accusplit AX120, San 4,041 ± 2,824 5,559 ± 3,866 1,518 0.45
2005 living in congregate housing 4-month quasi- Jose, California
USA or community-dwelling; 76 experimental
participants
Croteau [91] 55-94 years; community- 12-week intervention; Yamax Digi-Walker SW- 4,963 ≅ 6,200 ≅ N/A
2007 dwelling; 147 participants 12-week quasi- 200 (Yamax Corporation, 1,237
USA experimental Tokyo, Japan)
Sarkisian ≥ 65 years; community- 7-week intervention; 7- Digiwalker (Yamax DW- 3,536 ± 2,280* 4,387 ± 2,770* 851 0.34
[92] dwelling; 46 participants week quasi- 500, New Lifestyles, Inc.,
2007 experimental Kansas City, MO)
USA
Wellman Mean 74.6 years; 12-week intervention; NR 3,110 ± 2,448 4,183 ± 3,257 1,073 0.38
[93] community-dwelling; 320 12-week quasi-
2007 participants experimental
USA
Rosenberg 74-92 years; living in 2 week intervention; 3- Accusplit AH120M9, 3,020 ± 1,858 4,246 ± 2,331 1,226 0.59
[24] continuing care retirement week quasi- Pleasanton, CA
2008 community; 12 participants experimental
USA
Culos-Reed 46-83 years; community- 8-week intervention; 8- NR 5,055 ± 1,374 5,969 ± 1,543 914 0.63
[94] dwelling; 39 participants week quasi-
2008 experimental
Canada
Fitzpatrick Mean 75 years; 4-month intervention; Accusplit, San Jose, CA 2,895 ± 2,170 3,743 ± 2,311 848 0.38
[95] attending senior centers; 4-month quasi-
2008 418 participants experimental
USA
Opdenacker ≥ 60 years; community- 11-month intervention; Yamax Digiwalker SW- 7,390 ± 7,465 ± 3,344** 75 0.02
[27] dwelling; 46 intervention 23-month randomized 200, Yamax Corporation, 2,693**
2008 participants controlled trial Tokyo, Japan
Belgium
Sugden [96] 70-86 years; community- 12-week intervention; Omron HJ-005 2,895 NR N/A N/A
2008 dwelling; 12-week randomized
U.K. 54 participants controlled trial
Koizumi [97] 60-78 years; community- 12-week intervention; Kenz Lifecorder, 7,811 ± 3,268 9,046 ± 2,620 1,235 0.42
2009 dwelling; 34 intervention 12-week randomized Suzuken Company,
Japan participants controlled trial Nagoya, Japan
Steps/day presented as mean ± SD unless otherwise noted; *reported as steps/week in original article; divided by 7 days here; **SD calculated from reported SE
Controlled studies that community-dwelling older adults (mean age 69

Controlled studies conducted on treadmills or desig- years) who were regular exercisers (confirmed by regular
nated walking courses can provide direct information attendance at exercise classes that they were recruited
about the number of steps in continuous timed walks. from) took approximately 3,400 steps in a 30-minute
The only study identified that focused on older adults timed group exercise walk (translating to a cadence or
was conducted by Tudor-Locke et al. [37] who reported stepping rate of approximately 113 steps/minute)
Table 3 Pedometer - based physical activity intervention studies with special populations
Reference Sample Intervention duration; Instrument Intervention Intervention Delta Cohen’s D
study duration and Group Group Steps/day
design Baseline Steps/ Immediately
day Post-
Intervention
Steps/day
Cancer
Wilson [98] Adult breast cancer 8-week intervention; NR 4,791 8,297 3,506 N/A
2005 survivors; 22 intervention 8-week quasi-
USA participants experimental
Pinto [32,33] Adult breast cancer 12-week intervention; 9- Intervention: 4,471.7 ± 5,196.1 14,571.5 ± 10,100 1.38
2005, 2009 survivors; 43 intervention month randomized pedometer 9,489.5
USA participants controlled trial (Yamax
Digiwalker)
Assessment:
accelerometer
(Caltrac, Muscle
Dynamics,
Torrance, CA)
Vallance [99] Adult breast cancer 3-month intervention; 6- Digi-Walker SW- 8,476 ± 3,248 8,420 ± 5,226 -210 -0.06
2007 survivors; 94 print month randomized 200 PED (New (Pedometer (Pedometer
Canada materials, 94 pedometer controlled trial Lifestyles Inc., only) only)
only, 93 pedometer with Lee’s Summit, 7,993 ± 3,559 7,783 ± 3,048
print materials, 96 MO) (Pedometer with (Pedometer
standard print materials) with print
recommendation materials)
Irwin [100] Adults with early stage 6-month intervention; 6- NR 5,083 ± 2,313 6,738 ± 2,958 1,655 0.63
2008 breast cancer; 37 month randomized (based on n = (based on n
USA intervention participants controlled trial 37) = 34)
Pinto [34] Breast cancer survivors; 12-week intervention; 24- Intervention: No pre- 1,695.4 ± 1,180 1.39
2008 25 intervention week quasi-experimental pedometer intervention 1,221.3
USA participants (Yamax steps data
Digiwalker) reported but
Assessment: week one mean
accelerometer steps/day =
(Biotrainer-Pro, 515.8 ± 470.8
Individual
Monitoring
Systems,
Baltimore, MD)
Matthews Breast cancer survivors; 12-week intervention; 12- Intervention: 7,409.4 ± 2,791.1 8,561.8 ± 1,152 0.41
[35] 13 intervention week randomized pedometer 2887.3
2007 participants comparative trial (Brand NR)
USA Assessment:
Manufacturing
Technology
Actigraph (MTI,
Fort Walton
Beach, FL, USA)
Blaauwbroek Adult survivors of 10-week intervention; 36- Yamax digiwalker 7,653 ± 3,272 11,803 ± 4,150 1.23
[101] childhood cancer; 38 week quasi-experimental SW-200 3,483
2009 intervention participants
The
Netherlands
Mustian [28] Mixed cancer type 4-week intervention; 3- NR 7,222 ± 2,691 11,200 ± 3,978 0.93
2009 patients receiving month randomized 5,851
USA radiation; 19 intervention controlled trial
participants
Swenson [30] Breast cancer patients 12- month intervention; Walk 4 Life No pre- 9,429 ± 3,488 1,976 0.66
2010 receiving chemotherapy; 12-month quasi- LS2500 (Walk 4 intervention
USA 36 intervention experimental study Life, Inc.) steps data
participants (subsample conducted within a larger reported but
of larger randomized randomized trial week one mean
trial) steps/day =
7,453 ± 2,519
Table 3 Pedometer - based physical activity intervention studies with special populations (Continued)
Unweighted 2,743 0.73
mean
Weighted 2,139 0.51
mean
Chronic obstructive pulmonary disease (COPD)
De Blok [102] Adults with COPD; 8 9-week intervention; 9 Yamax Digi- 2,140 3,927 1,787 N/A
2006 intervention participants week randomized Walker SW-200
The controlled trial (Tokyo, Japan)
Netherlands
Hopses [103] Adults with COPD; 18 12-week intervention; 12- Digiwalker SW- 7,087 ± 4,058 7,872 ± 3,962 785 0.20
2009 intervention participants week randomized 2000 (Yamax,
The controlled trial Tokyo, Japan)
Netherlands
Nguyen [36] Adults with COPD; 8 self- 6-month intervention; 6- Intervention: SM: SM: SM: SM: 0.02
2009 monitored (SM), 9 month randomized Omron HJ-112 5,229 ± 3,021* 5,838 ± 609 C:
USA coached (C) comparative trial of cell- (Omron C: 3,100* C: -0.34
phone supported Healthcare, 6,692 ± 3,021* C: -1,017
pedometer programs Bannockburn, IL, 5,675 ±
USA) 3,021*
Assessment:
Stepwatch 3
Activity Monitor
(SAM; OrthoCare
Innovations,
Washington, DC,
USA)
Unweighted 541 0.02
mean
Weighted 562 0.06
mean
Coronary heart disease and related disorders
VanWormer Adults with coronary 17-week intervention; 17- NR 6,520.10 ± 8,210.24 ± 1,690 0.62
[104] artery disease; 22 week quasi-experimental 2,926.99 2,534.91
2004 intervention participants
USA
Izawa Adult myocardial 6-month intervention; 12- Kenz Lifecorder, 6,564.9 ± 1,114.6 10,458.7 ± 3,894 1.76
[105] 2005 infarction patients month randomized (Suzuken, Nagoya, 3,310.1
Japan completing 6 months of controlled trial Japan)
cardiac rehabilitation;
24 intervention
participants
mean
Weighted 2,840 1.21
mean
Diabetes and related disorders
Tudor-Locke Adults with type 2 4-week intervention; 4- Yamax Digiwalker 6,342 ± 2,244 10,115 ± 3,773 1.34
[29] diabetes; 9 intervention week quasi-experimental SW-200 3,407
2001 participants
Canada
Tudor-Locke Adults with type 2 16-week intervention; 24- Yamax SW-200, 5,754 ± 2,457 9,123 ± 4,539 3,369 0.96
[106] diabetes; 24 intervention week randomized (Yamax
2004 participants controlled trial Corporation,
Canada Tokyo, Japan)
Araiza [107] Adults with type 2 6-week intervention; 6- Yamax Digiwalker 7,220 ± 2792 10,410 ± 3,190 0.92
2006 diabetes; 15 intervention week; randomized SW-701 (New 4,162
USA participants controlled trial Lifestyles, Kansas
City, MI)
Engel [108] Adults with type 2 6-month intervention; 6- Yamax Digi- NR averaged N/A N/A
2006 diabetes; 30 coaching month randomized Walker-700 7,296 ± 2,066
Australia intervention, 24 comparative trial during
pedometer intervention intervention
Richardson Adults with type 2 6-week intervention; Omron HJ-720IT Lifestyles goals: Lifestyles Lifestyles Lifestyles
[109] diabetes; 17 lifestyle 6-week comparative trial (beta test version) 4,157 ± 1,737 goals: goals: goals:
2007 goals, 13 structured goals of two types of Structured goals: 5,171 ± 1,769 1,014 0.58
USA pedometer goal-setting 6,279 ± 3,306 Structured Structured Structured
strategies goals: goals: goals:
6,868 ± 3,751 589 0.17
Bjorgaas Adults with type 2 6-month intervention; Yamax Dig-Walker 7,628 ± 3,715 8,022 ± 3,368 394 0.11
[110] diabetes; 19 intervention 6-month randomized ML AW-320,
2008 participants controlled trial Yamax Corp,
Norway Tokyo, Japan
LeMaster [31] Adults with diabetic 12-month intervention; Intervention: 3,335 ± 1,575* 3,183 ± -152 -0.10
2008 peripheral neuropathy; 12-month randomized Accusplit Eagle 1,537*
USA 41 intervention controlled trial 170 (Pleasanton,
participants CA)
Assessment:
Stepwatch 3
(Orthocare
Innovations,
Washington, DC)
Cheong Adults with type 2 16-week intervention; 16- NR P: P: P: P:
[111] diabetes; 19 pedometer- week randomized 5,721 ± 2,232* 8,527 ± 2,806 1.00
2009 only intervention (P); 19 comparative trial PGI: 3,374* PGI: PGI:
Canada pedometer and low 5,251 ± 1,944* PGI: 4,130 1.16
glycemic index food 9,381 ±
intake intervention (PGI) 5,187*
Johnson Adults with type 2 12-week randomized Digi-Walker SW- All participants: All 1,685 0.44
[112] diabetes; 21 Enhanced comparative evaluation of 200, (Yamax, 8,948 ± 3,288 participants:
2009 program, 17 Basic two types of pedometer Kyoto, Japan) 10,485 ±
Canada program programs 4,264**
Kirk [113] Adults with type 2 6-month intervention; 12- ActiGraph GT1M IP: IP: IP: IP:
2009 diabetes; 42 in-person month randomized (ActiGraph LLC, 6,600 ± 2,700 6,500 ± 2,300 -100 -0.04
U.K. intervention (IP), controlled trial Pensacola, FL, WF: WF: WF: WF:
40 written form USA) 5,500 ± 2,300 5,300 ± 2,300 -200 -0.09
intervention (WF)
Newton Adolescents with type 1 12-week intervention; 12- NR Median 11,242 Median N/A N/A
[114] diabetes; 34 intervention week randomized 10,159
2009 participants controlled trial
New Zealand
Tudor-Locke Adults with type 2 16-week intervention; 16- Yamax SW-200, PRO: 3,980 ± PRO: PRO: PRO:
[115] diabetes; 157 week quasi-experimental (Yamax 2,189 7,976 ± 4,118 3,996 1.27
2009 professional-led (PRO), 63 comparison of program Corporation, PEER: PEER: PEER: PEER:
Canada peer-led (PEER) delivery Tokyo, Japan) 4,396 ± 2,045 8,612 ± 3,202 4,216 1.61
participants
Vincent [116] Adults with type 2 8-week intervention; 8- NR 4,175 7,238 3,063 N/A
2009 diabetes; 9 intervention week randomized
USA participants controlled trial
De Greef [72] Adults with type 2 12-week intervention, 12- Yamax DigiWalker 7,099 ± 4,208 8,024 ± 5,331 925 0.19
2010 diabetes; 20 intervention week randomized SW200
Belgium participants controlled trial
Diedrich Adults with type 2 3-month intervention; 3- Yamax Digiwalker 4,145 ± 2,929*** 6,486 ± 2,341 0.82
[117] diabetes; 11 intervention month quasi-experiment SW-200 2,766***
2010 participants
USA
mean
Weighted 2,405 0.78
mean
Joint or muscle disorders
Talbot [118] Adults with knee 12-week intervention; 12- New Lifestyles 3,519 ± 2,603 4,337 ± 2,903 818 0.30
2003 osteoarthritis; 17 walking week randomized Digi-walker SW-
USA plus education program comparative trial of a self- 200 (Yamax,
management education Tokyo, Japan)
program with and
without walking program
Kilmer [119] Adults with 6-month intervention; 6- NR ≅ 4,600 (from ≅ 5,900 (from N/A N/A
2005 neuromuscular disease; month quasi-experimental figure) figure)
USA 20 intervention home-based activity and
participants dietary intervention
Fontaine Adults with fibromyalgia 12-week intervention; 12- Accusplit Eagle 2,337 ± 1,598* 3,970 ± 1,633 0.85
[120] syndrome; 14 week randomized Activity 2,238*
2007 intervention particpants comparative trial Pedometer (San
USA Jose, CA)
mean
Weighted 1,186 0.55
mean
Note: Values are means ± SD unless otherwise stated, personal communication with Fontaine [120] clarified that what was reported in the published manuscript
was actually SE; COPD = Chronic obstructive pulmonary disease; *SD calculated from reported SE; * post-test data obtained directly from corresponding author;
***reported as steps/week in original article, divided by 7 days here.
around a gymnasium. Intensity was not directly mea- In a clinically-based study, 64 older subjects with per-
sured and it is plausible that the group nature of the ipheral artery disease (PAD) and claudication took 575
walk influenced individual paces. However, the finding ± 105 steps to ambulate 355 ± 74 meters during a 6-
does fit within estimates for the number of steps taken minute walk test, equating to an average speed of 2.2
in 30 minutes of moderate intensity walking in adults mph and an average cadence of 96 steps/min [47].
[38,39] and within published normal cadence ranges Given that these research participants were instructed to
representing “free-speed walking” for men (81-125 cover as much distance as possible, this average cadence
steps/minute) and women (96-136 steps/minute) aged represents a relatively high exercise intensity (i.e., possi-
65-80 years [40]. Studies conducted with younger adult bly exceeding moderate intensity, at least in terms of
samples [41-45] that have directly measured the number relative intensity) in this population. This is confirmed
of steps and verified activity intensity in absolute terms by the results of a separate study that demonstrated that
of metabolic equivalents or METs (1 MET = 3.5 ml O2/ for these patients, walking at a slightly slower speed of
kg/min or 1 kcal/kg/hour) have concluded that, despite 2.0 mph equates to an energy expenditure of approxi-
individual variation, a cadence of 100 steps/minute mately 70% of their peak oxygen uptake [48].
represents a reasonable heuristic value for moderate Walking at a cadence of 96 steps/min during a clinical
intensity walking. This suggests that 1,000 steps taken in test represents a much higher ambulatory challenge
10 minutes of walking, or 3,000 steps taken in 30 min- than that measured during free-living daily activities of
utes, could be used to indicate a floor value for abso- PAD patients monitored for one week with a step activ-
lutely-defined moderate intensity walking. However, it is ity monitor [49]. The maximum cadence for one minute
important to note that this cadence may be unattainable of free-living ambulation (i.e., the minute with the single
for some individuals living with disability or chronic dis- highest cadence value each day) averaged 90.8 steps/
ease (including frail older adults), reflecting known dif- min, which was significantly lower than the average
ferences between absolute and relative intensity with age value of 99 steps/min in age-matched control subjects
and illness [46]. Unfortunately, there are no data to spe- from the same study. The maximum cadence for 30
cifically inform absolute or relative intensity of different continuous minutes of ambulation each day was only 28
cadences in healthy older adults. With that being said, it steps/min in PAD patients versus 35.4 steps/min in the
is possible that any increase in daily step count relative age-matched control subjects. Thus, the cadence
to individualized baseline values could confer health observed under testing conditions may not be represen-
benefits. This is congruent with the now accepted con- tative of that performed during everyday life.
cept that some activity is better than none, and that No other controlled study of cadence or steps taken in
some relatively important health benefits may be rea- timed walks related to intensity was identified for any
lized even with improvements over the lowest levels [5]. other special population group. However, the data in
older adults with PAD indicate that the relative intensity translation of this recommendation produces an esti-
of walking speeds (captured as cadence) is higher for mate of approximately 8,000 on days that include a tar-
some groups of older adults, particularly special popula- get of achieving 30 minutes of MVPA, but
tions living with disability or chronic illness, than for approximately 7,100 steps/day if averaged over a week
younger and healthy adults [50,51]. Therefore, future (i.e., 7 days at 5,000 plus 15,000 steps of at least moder-
research is needed to extend values for measured ate intensity). In reality, this background level of daily
cadences, associated walking speeds, absolute intensity activity is likely to vary, and it is possible that steps/day
(MET values), and ratings of perceived exertion and/or values indicative of functional activities of daily living in
heart rate (to assess relative intensity) in healthy older some older adults (especially special populations living
adults across a range of abilities, as well as in disease- with disability or chronic illness) are much lower than
specific populations. Although there appears to be gen- 5,000 steps/day. Recognizing this potential, and as
eral agreement with regards to the cadence (i.e., 100 described above, the adult graduated step index has
steps/min) associated with an absolute measure of mod- been extended to include ‘basal activity’ (< 2,500 steps/
erate intensity in younger adult samples [41-45], it is day) and ‘limited activity’ (2,500-4,999 steps/day) [17].
likely that cadence associated with relative intensity will Therefore, if we consider 2,500 steps/day as a general
differ between individuals in much the same manner as indicator of basal activity in older adults and/or indivi-
heart rate. duals living with disability or chronic illness, the mini-
mal estimate is 5,500 daily steps or 4,600 steps/day if
Computed step count translations for physical activity averaged over a week of free-living behaviour. Admit-
guidelines tedly, these estimates are based on assumed baseline
Physical activity guidelines from around the world do levels, but also an increment that is tied to a cadence
not generally recommend that older adults do less aero- that has only been established as an indicator of abso-
bic activity than younger adults [5,52]. If anything, there lutely-defined moderate-intensity walking in younger
seems to be even more emphasis on the importance of adults.
obtaining adequate amounts of MVPA over and above The results of the first computational strategy produce
activities of daily living [3]. It therefore makes sense to a range of 7,100- 8,000 steps/day that should be compa-
recommend a similar step-based translation of physical tible with all but the most sedentary older adults (nor-
activity guidelines for healthy older adults as for their mative data indicate 2,000- 9,000 steps/day) [13,14] and
younger counterparts. However, in special populations, includes criterion referenced values for healthy body
specifically individuals (young or old) living with disabil- mass index (BMI) status related to older women
ity and chronic illness, it is important to promote a phy- (reviewed below; 8,000 steps/day for 60-94 year old
sically active lifestyle to the fullest extent that it is women [54]). However, the limited interventions to date
possible, even if this may fall short of general public assembled in Table 2 suggest that it may be precisely
health recommendations. For these groups where an these most sedentary older adults who are recruited for
absolute intensity or cadence interpretation may not be such pedometer-based interventions. The second strat-
realistic, a shift to promoting relative intensity (and egy produces a range of approximately 4,600- 5,500
therefore relative cadence) may become increasingly steps/day, which seems reasonable for the most seden-
important to maintain physical function and indepen- tary older adults (i.e., those taking < 2,500 steps/day),
dence. In essence, for those living at the lowest levels of typically characterized as living with disability and
habitual physical activity, the clinical perspective chronic illness, but would under value the achievements
becomes paramount and overtakes the need for more of more active older adults or those with chronic illness
generic public health messaging. that does not limit their physical mobility or endurance
As noted above, there is no evidence to inform a mod- capacity. Communication using a graduated step index
erate intensity cadence specific to older adults at this would span these two concerns by providing additional
time. However, using the adult cadence of 100 steps/ “rungs on the ladder” that take into consideration indivi-
minute to denote the floor of absolutely-defined moder- dual variability while still promoting healthful increases
ate intensity walking, and multiplying this by 30 min- in physical activity. Barring health issues that might
utes, produces an estimate of 3,000 steps. To be a true compromise abilities, there appears to be no need to
translation of public health guidelines these steps should otherwise reduce physical activity guidelines for appar-
be taken over and above activities of daily living, be of ently healthy older adults (compared to those for young
at least moderate intensity accumulated in minimally 10 to middle-aged adults). Any lower accommodation is
minute bouts, and add up to at least 150 minutes spread only in recognition of anyone (including both younger
out over the week [3,5,53]. Considering a background of adults and older adults) living with disabilities or
daily activity of 5,000 steps/day [15,16], a computed chronic illness that challenge their physical abilities. It is
important to emphasize that both of the computational 6,470 steps/day and optimal amounts (i.e., 2,200 kcal/
strategies outlined above produce minimal (or thresh- week) corresponded with 8,496 steps/day.
old) estimates and it is expected that even more physical In summary, the evidence suggests that, in apparently
activity will be beneficial. healthy older adults, taking approximately 7,000-10,000
steps/day under free-living conditions is equivalent to
Direct studies of step equivalents of physical activity accumulating 30 minutes/day of MVPA (as detected by
guidelines accelerometer). The only direct evidence of a steps/day
Rowe et al. [55] studied older adults’ (60+ years of age) equivalent of recommended amounts of MVPA that is
pedometer-determined steps/day and used a Receiver specific to any special population (in this case, cardiac
Operating Curve (ROC) analysis to inform maximal rehabilitation patients) indicates that minimal and opti-
classification accuracy related to 30+ minutes of acceler- mal amounts of PAEE are accumulated with approxi-
ometer-determined MVPA. They reported that 6,200- mately 6,500-8,500 steps/day, respectively. The evidence
6,800 steps/day taken in the course of everyday life was to support a more specific translation of public health
congruent with the time-and intensity-based guidelines guidelines into steps/day for special populations is lack-
if discontinuous (i.e., interrupted) minutes of MVPA ing. In addition, as presented above, the wide variety
were accepted and 7,000-8,000 steps/day if 30 minutes and types of disabilities observed in special populations
of continuous (bouts ≥ 10 minutes) MVPA was may limit individual ability to perform exercise at any
required. rigidly defined absolute moderate intensity, thus requir-
Aoyagi and Shephard [56] reviewed results of a num- ing a shift toward clinical strategies focused on relative
ber of studies based on the Nakanajo Study of Older goal attainment and related improvements.
Adults and shared data related to patterns of physical
activity collected using an accelerometer (modified Kenz Steps/day associated with various health outcomes
Lifecorder, Suzuken Co., Ltd., Nagoya, Aichi, Japan) that Eight cross-sectional studies have focused on older
detected both steps and time in MVPA defined as > 3 adults. Newton et al. [58] found that accumulating over
METs. They reported a strong (r 2 = .93) correlation 7,500 steps/day was related to reduced perceptions of
between the two outputs such that those who took < fatigue in older women (mean age 63 years) with a diag-
2,000 steps/day spent almost no time in MVPA. From nosis of primary biliary cirrhosis. This was the only
that point, each 1,000 step increment in daily free-living study of steps/day associated with any health outcome
activity up to 6,000 steps/day was associated with an identified in any special population.
additional 2.5 minutes of MVPA. From 6,000- 12,000 Yasunaga et al. [59] split total values of steps/day into
steps/day each 1,000 step increment added another 5 quartiles and reported concurrently accumulated time in
minutes of MVPA. Corresponding increases in MVPA MVPA (from the same instrument; Suzuken Lifecorder)
associated with an additional 1,000 steps from 12,000- and health-related quality of life (HRQoL) in older
18,000 steps/day and above 18,000 steps/day were 7.5 adults. They reported that HRQoL was better in the sec-
minutes and 10 minutes, respectively. These findings ond quartile of steps/day (men: 5,500 steps/day and 13
indicate that 30 minutes of MVPA is associated with minutes detected in moderate intensity; women: 4,500
10,000 steps/day in older adults (computing a running steps/day and 14 minutes moderate intensity) compared
total from the details reported above). To be clear, to the first quartile but that no additional benefit (smal-
although continuous walking performed under labora- ler and clinically insignificant improvements) was
tory conditions consistently demonstrates that 1,000 observed with higher quartiles. Although these were
steps taken continuously over 10 minutes meets the cri- cross-sectional data, the authors suggested that an
terion for absolutely-defined moderate intensity [41-45], increase of 2,000 steps over baseline might be recom-
step accumulation patterns under free-living conditions mended for enhanced HRQoL in older adults. Park et
include lighter intensity activities and ultimately suggest al. [60] conducted a similar analysis, this time focused
that substantially more total steps must be accrued in on presence vs. absence of metabolic syndrome in older
order to achieve recommended amounts of MVPA per- adults. They reported age-range specific results. They
formed in the course of daily living. observed a lower likelihood of metabolic syndrome in
Ayabe et al. [57] also used a Suzuken Lifecorder accel- 65 to 74 year olds who took 10,000 steps/day and/or 30
erometer to record both step and physical activity minutes at > 3 METs (also from the same instrument;
energy expenditure (PAEE) among cardiac rehabilitation Suzuken Lifecorder) and in those > 75 years of age who
patients. Steps/day correlated strongly with PAEE (r = took 8,000 steps/day and/or 20 minutes at > 3 METs.
.92) and with time spent in MVPA (r = .85). Achieve- Shimuzu et al. [61] studied the effects of habitual phy-
ment of minimal amounts of recommended PAEE (i.e., sical activity determined using a pedometer on an indi-
1,500 kcal/week) corresponded with a daily total of cator of immune functioning (salivary secretory
immunoglobulin A or sIgA) in older Japanese adults clinical and public health applications, it remains impor-
(aged 65-86 years). The steps/day data were split into tant to present these pedometer-determined data as
quartiles and the results showed that older adults who indicators of expected values in these free-living popula-
took more than approximately 7,000 steps/day also had tions (that include obese individuals).
the highest level of sIgA and this was significantly Swartz et al. [67] conducted a simple analysis, report-
higher compared to older adults who took < 4,600 ing blood pressure and fasting glucose results in older
steps/day. Mitsui et al. [62] also studied older (mean age adults split by median pedometer-determined steps/day.
62.8 years) Japanese adults and reported that women They reported that active older adults, defined by having
taking 7,500-9,999 steps/day had significantly lower BMI steps/day above the median value of 4,227 steps/day,
and percent body fat than women taking < 5,000 steps/ had lower blood pressure and fasting glucose. Since a
day. Although this study failed to observe any significant simple median split suggests only that “more is better,”
difference between those taking > 10,000 steps/day and this study cannot be used to inform the dose response
those taking < 5,000 steps/day, there were only 14/117 relationship, nor can it be used to identify threshold
women who took > 10,000 steps/day. Thus, this study values of steps/day relative to lower blood pressure or
was likely underpowered to identify small to modest dif- fasting glucose in older adults. Schmidt et al. [68] exam-
ferences in BMI that might exist. In addition, obesity in ined cardiometabolic risk, including measures of waist
these older Japanese women was low (the mean BMI for circumference, systolic blood pressure, fasting glucose,
the sample was 22.2 kg/m2). The only significant differ- triglyceride, and HDL cholesterol, across the graduated
ence in health parameters observed in men in this study step index in a sample that included older adults. They
across step-defined physical activity was in triglycerol reported that individuals achieving ≥ 5,000 steps/day
levels; only men who took > 10,000 steps/day showed had a substantially lower prevalence of adverse cardio-
significantly lower values. metabolic health indicators.
Foley et al. [63] examined the relationship between In summary, based on these cross-sectional studies, it
pedometer-determined steps/day and bone density at appears that 4,500-5,500 steps/day is associated with
the spine and hip in older adults between 50 and 80 higher HRQoL scores [59] compared to that associated
years of age. In men and women over age 65, the with better measures of immunity (> 7,000 steps/day
increasing difference in hip bone density ranged from [61]), metabolic syndrome (8,000-10,000 steps/day [60]),
3.1% to 9.4% across the increasing steps/day quartiles. or BMI-defined weight status (8,000-11,000 steps/day
The effect on the spine was only observed in women. [54,62]). Dose-response relationships may also be modi-
There was no threshold effect, that is, bone density con- fied by sex [62,63]. The dose-response relationship with
tinued to be higher with higher steps/day. In a second bone density of the hip and, at least in women, spine,
study of older Japanese women (age 61 to 87 years of appears to be linear and without threshold values [63].
age), Kitigawa et al. [64] observed a positive association The evidence indicating distinctly different dose-
(adjusted for age and weight) between ultrasound-mea- response curves related to step-defined physical activity
sured calcaneus bone density and steps/day up to a is consistent with what was presented at a dose-response
maximum of 12,000 steps/day; thereafter additional symposium [69] and may not be limited to older adults
steps/day were not associated with any further increase [70]. Of course, prospective and intervention studies are
in bone density. needed to confirm any relationship between steps/day
Tudor-Locke et al. [54] reported an age-specific analy- and health outcomes. There is a general lack of any evi-
sis of BMI-criterion referenced and amalgamated data dence relative to special populations at this time.
collected from around the world. For women aged 60-
94 years of age the best cut point was 8,000 steps/day in Discussion
terms of discriminating between BMI-defined normal Monitoring steps taken is only one of many ways to
weight and overweight/obesity. In men aged 51-88 years track physical activity and individuals may prefer to
the value was 11,000 steps/day. The authors acknowl- count minutes in activity rather than wear any type of
edged that they had better confidence in the women’s step counting device. Step counting by definition is
data since the men’s value was based on a sparse sample most relevant to ambulatory activity; however, this is
size collected over a relatively wider age range. It is not the only activity that can be performed at health-
important to note that spring-levered pedometers are related intensities. Other examples include cycling and
known to undercount steps related to obesity [65], so swimming. In addition, public health guidelines categori-
these BMI-referenced values can be questioned. How- cally recognize the importance of other types of non-
ever, even accelerometer-determined steps/day differ in ambulatory activity, including resistance training [3,5].
a similar pattern across BMI-defined obesity categories Therefore, the estimates contained herein are limited to
[66]. Since pedometers are more likely to be used in translations of physical activity guidelines only in terms
of ambulatory activity. For those who swim and cycle (e. Regardless, the interest in detecting even very low
g., stationary or recumbent cycling), it may be possible force accelerations is evident from research studies
to consider adding ‘bonus steps’ to daily totals to focused on physical activity behaviours of older adults
account for these extra non-ambulatory activities [71]. [13,79] and especially of individuals living with disability
For example, Miller et al. [71] suggest adding 200 steps and chronic illness [14] that have been adopting the
for every minute of non-ambulatory activities like StepWatch Activity Monitor (SAM, CYMA Corporation,
cycling or swimming. De Greef et al. [72] have Mountlake Terrace, WA). The SAM is an ankle worn-
instructed participants in pedometer-based interventions accelerometer that detects a “stride” or “gait cycle.” To
to add 150 steps to their daily total for every minute be interpreted relative to more traditional waist-
engaged in cycling and/or swimming. mounted instruments (both accelerometers and ped-
On face value, a step is the fundamental component of ometers), its output needs to be doubled and expressed
walking; it represents the initiation of body weight as steps. However, this instrument is designed to be
transfer and a basic expression of human mobility. exceptionally sensitive to slow gaits [80] (and is also
Cadence, or steps/minute, is a reasonable indicator of more likely to detect “fidgeting” activities [80]) and
speed [73] and is also related to the intensity of ambula- therefore its output would appear higher than that of
tion [41-45], and can theoretically capture the “purpose- more traditional pedometers [17]. For example, a sample
fulness” of ambulatory activity. As steps are of older adults (mean age 83 years) who wore the SAM
accumulated more rapidly and continuously, an indivi- for 6 consecutive days averaged approximately 10,000
dual can be said to be walking purposefully, that is, to steps/day [81], or ‘active’ if directly (and inappropriately)
get somewhere and/or for exercise. Of course, running interpreted against the graduated step index based on
is represented at the highest cadences, but this is not pedometer output [15,16]. The SAM remains an impor-
likely applicable to many older adults or individuals liv- tant research tool, however, it is less practical for public
ing with disability or chronic illness. As mentioned health applications. No conversion factor exists at this
above, 100 steps/minutes is a cadence that is growing in time to assist in translation of SAM-detected steps to
acceptance as a heuristic value indicative of walking at that of pedometers that have been more traditionally
an absolutely-defined intensity of 3 MET intensity, at used in research and practice.
least in younger adults [41-45]. This cadence may be Another instrument, the ActiGraph accelerometer, is
unrealistic for many older adults (especially for those also known to be more sensitive to lower force accelera-
who are more frail) or for those living with disability or tions ([82-84]) and its output from earlier models
chronic illness. It may be useful to embrace a “some- needed to be manipulated in order to interpret it against
thing is better than nothing” approach [5], or even a existing pedometer-based scales [15,16]. More recently,
“better than usual” approach, in terms of setting relative the manufacturers of this instrument have offered a ‘low
goals for such special populations. extension’ option that can be selected, or deselected,
The correlation between age and preferred walking depending on sensitivity requirements. Since pedometers
speed in a population study of older adults 60-86 years are more likely to be adopted by a range of users includ-
of age was -.34 (women) and -.41 (men) [74]. Those living researchers, practitioners, and the general public,
ing with disability or chronic illness may walk at even and since public health guidelines specifically emphasize
slower speeds [75]. Overall, aging, disabled, and ill older MVPA (and not lighter intensity activities), the step-
adults may gradually lose their ability to walk at higher based translations presented in this article are intention-
cadences and what remains is the “pottering” (i.e., ran- ally more reflective of what would be expected from the
dom, unplanned movements) associated with activities use of good quality pedometers. Although the need to
of daily living that all ages appear to engage in to some detect less forceful steps, especially in some clinical
extent [76]. Slow walking speed in older adults is populations can be justified, it remains a concern that
strongly associated with increased risk of cardiovascular comparisons between datasets collected with different
mortality [77]. Since public health guidelines for older devices are hampered unless acceptable conversion fac-
adults continue to emphasize the importance of engage- tors to facilitate such interpretation can be determined.
ment in aerobic activities that are of at least moderate Regardless of the choice of instrumentation, normative
intensity, it follows that any step count translation also step values for older adults and special populations span
reflects this emphasis. Although pedometers have been a very wide range. Although the graduated step index
widely criticized for not being sensitive to detecting described above offers a definite improvement over eva-
slow walking, their ability to “censor” low force accelera- luation using any single step value (e.g., 10,000 steps/
tions might actually be seen as a feature that permits a day), even smaller increments would provide additional
concerted focus on only those steps that are more likely “rungs on the ladder” and represent a more continuous
to be beneficial to health [78]. and fully expanded steps/day scale. Specifically, 1,000
step increments [41-45] are congruent with the concept daily 30-minute minimally moderate intensity physical
of 10-minute bouts taken at 100 steps/min or minimally activity recommendation. Figure 1 presents the fully
moderate intensity [3,5], and three 10-minutes bouts (i. expanded steps/day scale. The scale begins at zero and
e., 3 × 1,000 steps = 3,000 steps) are congruent with a continues to 18,000+ steps/day, representing the single
18000
At least 15,000
At least 6,000 daily steps in steps/week in
17000 moderate-to-vigorous moderate-to-
physical activity vigorous physical
16000 activity, e.g., 3,000
daily steps in
moderate-to-
15000 vigorous physical
activity most days
of the week
14000
13000
Boys
12000 6Ͳ11
years
11000
Girls
10000 6Ͳ11
years
9000
Steps/day
Adolescents
PreͲ 12Ͳ19years
8000 school
children
7000 4Ͳ6 Adults
years 20Ͳ65years
6000 Healthy
older
5000 adults
65+years
4000 Arrows Individuals
indicate living
3000 that with
disability
2000 higher is and/or
even chronic
1000 better illness
0
Additional benefits can come from adding in vigorous intensity activity
Figure 1 Steps/day scale schematic linked to time spent in MVPA.
highest average value reported for a sample at this time with undertaking recommended amounts and bouts of
in Amish men [85]. Although all age groups are repre- MVPA [86,87].
sented, the one-way arrows identify step-based transla-
tions of population-specific public health guidelines Conclusions
contained herein (and separately reviewed in companion The very broad ranges of habitual activity evident from
papers) but also suggest that more is better. For exam- normative data reflect the natural diversity of physical
ple, the range for healthy older adults is 7,000-10,000 capacity common to older adults and special popula-
steps/day, at least 3,000 of which should be accumulated tions. There is no evidence to inform an absolutely-
at a brisk pace. For individuals living with disability or defined moderate intensity cadence specific to older
chronic illness the range is 6,500-8,500 steps/day adults at this time. However, using the adult cadence of
(although this is based on limited evidence at this time). 100 steps/minute to denote the floor of absolutely-
The difference between thresholds for adults 20-65 defined moderate intensity walking, and multiplying this
years of age and healthy older adults 65+ years of age is by 30 minutes produces a reasonable heuristic value of
nominal (i.e., approximately 300 steps), but it is based 3,000 steps. To be a true translation of public health
on the empirical evidence assembled, and suggests that guidelines these steps should be taken over and above
apparently healthy older adults are capable of achieving activities of everyday living, be of at least moderate
minimum steps/day for improving health. However, intensity accumulated in minimally 10 minute bouts (i.
quite clearly there is a larger gap at the upper end, e., at least 1,000 steps taken at a cadence of 100 steps/
which reflects decreasing capacity with age (and disease min), and add up to at least 150 minutes spread out
and disability) to achieve upper-end targets. Again, it is over the week. Computed translations of this recom-
important to emphasize, that the oldest-old, especially mendation approximate 8,000 daily steps and 7,100
those compromised by frailty, are more likely to be steps/day if averaged over a week. Directly measured
described as a special population where a clinical estimates of free-living activity that include recom-
approach to increasing physical activity will more appro- mended amounts of MVPA are not too different: 7,000
priately supersede a public health approach. Regardless, -10,000 steps/day. Recognizing that the most sedentary
adoption of this fully expanded steps/day scale applied older adults and individuals living with disability and
across the lifespan would facilitate communication, eva- chronic illness may be more limited in their everyday
luation, and research. As evidence accumulates, it may activities, but could still benefit from a physically active
be possible to locate population-specific likelihoods of lifestyle, a similarly computed translation approximates
achieving valued health-related outcomes along the 5,500 daily steps or 4,600 steps/day if averaged over a
scale. week of free-living behaviour. Direct evidence (measured
An important limitation must be emphasized. It is objectively by accelerometer) suggests a somewhat
well known that the measurement mechanism of accel- higher range (6,500- 8,500 steps/day), however, it is
erometers is more sensitive to lower force accelerations important to remember that this is based on a single
(e.g., slow walking) and therefore this type of instrumen- study of patients in a cardiac rehabilitation program.
tation will detect more steps than simple pedometers. Direct evidence is urgently needed for other special
However, there are no data at this time to inform us populations. Individuals living with more physically lim-
about the health value of steps taken at very low inten- iting conditions may demonstrate lower normative
sity steps independent of higher intensity steps. Indeed, values and thus may benefit from more individualized
perhaps one contributory factor to age-related decline is daily step targets relative to their unique baseline values.
the decrease in intensity of daily movement and the pro- Health outcome-referenced values of steps/day appear
gressive loss of higher intensity movements. This is to differ in older adults depending upon which health-
speculative. Regardless, the difference in instrument sen- related outcome is desired. All estimates herein express
sitivity makes it so that the output of accelerometers translations of minimal recommendations, and more is
should generally not be directly interpreted against the likely better.
scaling presented herein. A direct conversion factor
between instruments is not known at this time, but
Acknowledgements and Funding
would certainly be useful. The continued use of BMI as Production of this literature review has been made possible through a
a useful, albeit imperfect, indicator of body fatness is an financial contribution from the Public Health Agency of Canada (PHAC). The
appropriate analogy to the use of a pedometer as an funding body had no role in study design, in the collection, analysis, and
interpretation of the data, in the writing of the manuscript, or in the
indicator of healthful levels of physical activity. Regard- decision to submit the manuscript for publication. The views expressed
less, any step-based translation of current physical activ- herein solely represent the views of the authors. We would like to thank Dr.
ity guidelines should clearly convey the importance of David R. Bassett, Jr. (Department of Kinesiology, Recreation, and Sport
Studies, The University of Tennessee, Knoxville, TN, USA) and Dr. Ann M.
making an appropriate portion of daily steps congruent
Swartz (Department of Human Movement Sciences, University of Wisconsin- 3. Paterson DH, Warburton DE: Physical activity and functional limitations in
Milwaukee, WI, USA) for their thorough reviews of this manuscript prior to older adults: a systematic review related to Canada’s Physical Activity
submission. Guidelines. Int J Behav Nutr Phys Act 2010, 7:38.
4. Global strategy on diet, physical activity and health: Physical activity
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Baton Rouge, LA, USA. 2Canadian Fitness and Lifestyle Research Institute, 5. U.S. Department of Health and Human Services: 2008 Physical Activity
201-185 Somerset Street West Ottawa, ON, K2P 0J2, Canada. 3School of Guidelines for Americans: Be Active, Healthy, and Happy! Washington, D.
Public Health, Edward Ford Building (A27), University of Sydney, Sydney, C 2008.
NSW 2006, Australia. 4Exercise Sciences Research Group, Tokyo Metropolitan 6. Brownson RC, Boehmer TK, Luke DA: Declining rates of physical activity in
Institute of Gerontology, 35-2 Sakaecho, Tokyo Itabashi, Tokyo 173, Japan. the United States: what are the contributors? Annu Rev Public Health
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Department of Exercise, Health, and Sport Sciences, University of Southern Time Use Survey 2003-2005. J Phys Act Health 2008, 5:633-647.
Maine, 37 College Ave, Gorham, USA. 7Department of Movement and Sport 8. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M: Physical
Sciences, Sint-Pietersnieuwstraat 25, Ghent University, B - 9000 Ghent, activity in the United States measured by accelerometer. Med Sci Sports
Belgium. 8Centre for Clinical Epidemiology and Biostatistics, University of Exerc 2008, 40:181-188.
Newcastle, Callaghan, NSW 2308, Australia. 9CMRI Diabetes and Metabolic 9. Cyarto EV, Myers AM, Tudor-Locke C: Pedometer accuracy in nursing
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OK, USA. 10Tokyo Gakugei University, 4-1-1 Nukuikitamachi, Koganeisi, Tokyo 10. Tudor-Locke C, Craig CL, Beets MW, Belton S, Cardon GM, Duncan S,
184-8501, Japan. 11Department of Psychology, East Carolina University, Hatano Y, Lubans DR, Olds TS, Raustorp A, Rowe DA, Spence JC, Tanaka S,
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of Medicine, Springfield IL. 14Department of Physical Education and Hatano Y, Inoue S, Matsudo SM, Mutrie N, Oppert J-M, Rowe DA,
Recreation, Rio Piedras Campus, University of Puerto Rico, San Juan, Puerto Schmidt MD, Schofield GM, Spence JC, Teixeira PJ, Tully MA, Blair SN: How
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Medicine, Springfield, IL, USA. 16School of Psychological Sciences and Health, 12. Tudor-Locke C, Myers AM: Methodological considerations for researchers
University of Strathclyde, Glasgow, Scotland, UK. 17Department of and practitioners using pedometers to measure physical (ambulatory)
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18
Menzies Research Institute, Medical Science 1, 17 Liverpool Street, 13. Tudor-Locke C, Hart TL, Washington TL: Expected values for pedometer-
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Public Health (NI), Royal Victoria Hospital, Grosvenor Road, Queen’s Act 2009.
University, Belfast, Ireland. 20Departments of Exercise Science and 14. Tudor-Locke C, Washington TL, Hart TL: Expected values for steps/day in
Epidemiology/Biostatistics, Arnold School of Public Health, University of special populations. Prev Med 2009, 49:3-11.
South Carolina, Columbia, USA. 15. Tudor-Locke C, Bassett DR Jr: How many steps/day are enough?
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CT-L and CLC conceived and designed the project. CT-L acquired the data steps are enough?”. Med Sci Sports Exerc 2008, 40:S537-543.
and prepared analysis for initial interpretation. DAR conducted additional 17. Tudor-Locke C, Johnson WD, Katzmarzyk PT: Accelerometer-determined
analyses. All authors contributed to subsequent interpretation of data. CT-L steps per day in US adults. Med Sci Sports Exerc 2009, 41:1384-1391.
prepared a draft of the manuscript. All authors contributed to critically 18. Ramirez-Marrero FA, Rivera-Brown AM, Nazario CM, Rodriguez-Orengo JF,
revising the manuscript for important intellectual content. KAC, DAR, MDS, Smit E, Smith BA: Self-reported physical activity in Hispanic adults living
and MAT verified data presented in the tables. All authors gave final with HIV: comparison with accelerometer and pedometer. J Assoc Nurses
approval of the version to be published and take public responsibility for its AIDS Care 2008, 19:283-294.
content. 19. Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R,
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Competing interests and improve health: a systematic review. JAMA 2007, 298:2296-2304.
The following authors declare they have no competing interests: CT-L, YA, 20. Richardson CR, Newton TL, Abraham JJ, Sen A, Jimbo M, Swartz AM: A
RCB, KAC, IDB, BE, AWG, YH, LDL, SMM, FAR-M, LQR, DAR, MDS, and MAT. meta-analysis of pedometer-based walking interventions and weight
CLC is associated with the Canadian Fitness and Lifestyle Research Institute loss. Ann Fam Med 2008, 6:69-77.
which is funded in part by the Public Health Agency of Canada (PHAC). SNB 21. Kang M, Marshall SJ, Barreira TV, Lee JO: Effect of pedometer-based
receives book royalties (< $5,000/year) from Human Kinetics; honoraria for physical activity interventions: a meta-analysis. Res Q Exerc Sport 2009,
service on the Scientific/Medical Advisory Boards for Alere, Technogym, 80:648-655.
Santech, and Jenny Craig; and honoraria for lectures and consultations from 22. De Cocker KA, De Bourdeaudhuij IM, Brown WJ, Cardon GM: Effects of
scientific, educational, and lay groups. During the past 5-year period SNB has “10,000 steps Ghent": a whole-community intervention. Am J Prev Med
received research grants from the National Institutes of Health, Department 2007, 33:455-463.
of Defence, Body Media, and Coca Cola. 23. Eakin EG, Mummery K, Reeves MM, Lawler SP, Schofield G, Marshall AJ,
Brown WJ: Correlates of pedometer use: results from a community-
Received: 15 November 2010 Accepted: 28 July 2011 based physical activity intervention trial (10,000 Steps Rockhampton). Int
Published: 28 July 2011 J Behav Nutr Phys Act 2007, 4:31.
24. Rosenberg D, Kerr J, Sallis JF, Patrick K, Moore DJ, King A: Feasibility and
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doi:10.1186/1479-5868-8-80
Cite this article as: Tudor-Locke et al.: How many steps/day are enough?
For older adults and special populations. International Journal of
Behavioral Nutrition and Physical Activity 2011 8:80.
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Tudor-Locke et al.

International Journal of Behavioral Nutrition and Physical Activity 2011, 8:80

REVIEW Open Access

How many steps/day are enough? For older

Introduction concluded that, in addition to the well known cardiovas-

Evidence-based guidelines for older adults communi- Methods

Controlled studies that community-dwelling older adults (mean age 69

116. Vincent D: Culturally tailored education to promote lifestyle change in

Submit your next manuscript to BioMed Central

• Convenient online submission

Submit your manuscript at

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