Implementing a Walking Program for Sedentary Patients in a Weight Management Clinic: Methodology

Sedentary lifestyles and obesity are two major public health concerns that significantly impact individuals' well-being and increase the risk of various chronic diseases. Research indicates that a large proportion of the United States (US) adult population fails to meet recommended physical activity standards, and obesity rates continue to rise [1]. This sedentary behavior and excess body weight contribute to a range of comorbidities, including diabetes, hypertension, hyperlipidemia, and arthritis [1,2]. Obesity puts strain on the musculoskeletal system, leading to joint pain, limited mobility, and inflammation. National Institute of Health: Diabetes and Digestive and Kidney Diseases [NIDDK], 2022; World Health Organization [WHO], 2023).

Increasing physical activity, especially through walking programs, has emerged as a vital strategy for weight management and overall wellness) [3,4]. Walking serves as an accessible and low- impact form of exercise that can be adapted to different fitness levels and integrated into daily routines. Structured walking programs provide individuals with guidance, setting both short-term and long-term goals to gradually increase activity levels and adopt healthier habits [5].

The effect of obesity and sedentary lifestyles is profound. The link between sedentary behavior and obesity stems from prolonged periods of inactivity and can negatively impact energy balance, metabolic health, and overall body weight [6]. Risk for cancers, mental health disorders, cardiovascular disease, type II diabetes, sleep apnea, generalized pain, and overall morbidity are increased because of elevated body mass index (BMI) (Center for Disease Control (CDC), 2022;). Along with major organ disease like hypertension, diabetes, and cancer, obesity contributes to musculoskeletal damage. Obese individuals experience osteoarthritis and joint pain at a greater incidence than those with a normal BMI [7].

Obesity is a multifactorial, chronic condition that needs to be addressed by providers. Education on nutrition, sleep, hydration, and exercise all contribute to a healthy weight, and maintaining a healthy weight requires support, motivation, and determination [8]. Addressing sedentary behaviors allows for cost effective intervention, profound growth, and significant effects. This Doctor of Nursing Practice (DNP) Project focused on the exercise component of weight management.

For the purpose of the project focus, a PICOT question was established. The PICOT reads “In sedentary adult patients who do not require assistive devices (P), how does a walking program (I) in comparison to no walking program (C), affect steps taken over 20 minutes (O) in 6 weeks (T)?

Exercise, particularly walking, is crucial for weight management and reducing the risk of health conditions. Exercise helps burn calories, improve cardiorespiratory fitness, and lower BMI. Walking exercises have additional benefits such as improving depression symptoms, reducing cardiovascular disease risk factors, and lowering glucose levels and BMI.

Walking is particularly beneficial for sedentary individuals as it is low-impact, promotes joint health, and can be adapted to different fitness levels [9-11]. Walking requires no special equipment and can be done anywhere, making it a convenient exercise option. Walking has been shown to be a safe and effective intervention for addressing complications associated with sedentary lifestyles, such as obesity and decreased muscle tone, regardless of demographic factors. Moderate- intensity walking can decrease visceral fat thickness, improve cardiopulmonary capacity, and reduce BMI, making it an accessible and practical way for sedentary individuals to increase physical activity levels and improve joint mobility [12,13].

Engaging in group exercise programs offers additional benefits beyond physical improvements. These programs provide social support, positive encouragement, and accountability, which are crucial for sustaining motivation and adherence to regular exercise. Exercising in a group setting has been associated with better physical, mental, and emotional well-being, as well as reduced perceived stress levels. By emphasizing the link between physical activity, weight management, and improved health outcomes, healthcare professionals can empower individuals to break sedentary habits and prioritize an active lifestyle [14,15]. Encouraging the adoption of walking programs and promoting group exercise can significantly contribute to combating sedentary behavior, reducing obesity rates, and improving overall health in the population [16, 17].

Structured weight management programs aim to address patients’ physical, psychological, and nutritional well-being. Long-term weight management helps decrease the risk of comorbidities and poor outcomes. When starting a physical activity routine, it is important to start small. Walking programs have provided evidence that implementation can increase steps taken, change sedentary behavior, and improve exercise stamina among other benefits [18-20]. Walk with Ease (WWE) is an evidence-based walking program that has been shown to increase ambulatory function and lower extremity strength, while improving quality of life scores and cultivating physical activity confidence [21-23].

Few studies have examined the effects of different evidence-based walking programs, the duration of walking time, or the setting of the program, such as a weight management clinic. Gender differences were only considered in a small number of studies, and there was limited reporting on participation and dropout rates. No studies investigated the variability of the effects of walking programs across different racial and ethnic groups.

There was support for walking programs increasing steps walked and decreasing sedentary behavior with positive effect on weight; however, specific walking programs were not listed.

The evidence-based practice model used in this project was the Johns Hopkins Evidence-Based Practice (JHEBP) Model and Guidelines. Pender’s Health Promotion Model guides the project with a focus on desirable patient outcomes [24]. The model consists of three main factors: individual characteristics, behavior cognitions, and behavioral outcomes. The change theory selected was the Theory of Planned Behavior as it focuses on participant motivation and behavioral control to change routines [25].

The DNP Project took place in a weight management outpatient clinic in a small Midwest community. The weight management clinic has been functioning as a bariatric center for excellence since 2020. The staff consisted of three registered nurses, three nurse practitioners, and three medical doctors. Providers saw adult patients of any race and BMI. The staff meet patients where they are with their diet, activity, and weight goals. Providers offer weight loss through medication therapy, surgery, psychotherapy, and nutrition consultation.

Participants in the project were required to be adults over the age of 18 and participants in a weight management program. Patients had to be capable of standing without assistance for at least 10 minutes without increased pain and possess a desire for a structured physical activity regimen. Patients could speak English or Spanish. In addition, participants needed to have a desire to make walking a daily habit with a structured walking/fitness program. Patients must have received support from one of the weight management medical professional in order to participate in the project.

Patients who were non-ambulatory, required the use of an assistive ambulatory device, were unable to stand unassisted for at least 10 minutes, and were deemed unfit by a healthcare provider were excluded. For this DNP Project, the desired sample size was 12 adult participants who were committed to being active in 18 walking sessions.

The WWE program is a group-based curriculum that promotes accountability and helps participants increase their walking activity. The program, developed by the Thurston Arthritis Research Center and the Institute on Aging, aims to improve overall health, build self-confidence in physical activity goals, reduce arthritis-related pain, and increase muscle tone. In addition, the program offers three formats: self-guided, self-directed enhanced and in-person and includes 18 sessions total. Participants use a WWE workbook as a guide, which provides step-by-step instructions for each session, including goal setting, warm-up movements, tracking walking distance, timing pace, cool-down movements, and behaviors to adopt [4].

The WWE leader conducts three sessions per week. Each meeting consists of a pre-walk discussion and warmup followed by a 20-minute walk. Discussions at the beginning of each session consist of goals, personal barriers, and questions participants may have. The session concludes with a cool down, reflection of the hour, and confirmation of the next scheduled session [26]. Patients are encouraged to set their own goals. There are several patient goals that can be achieved through this program including distance walked, length of time walking, weight loss, and improved mental health scores.

Through the assistance of weight management clinic staff, the DNP Project Manager created a recruitment flyer which was handed out by providers if the patient met inclusion criteria (See Appendix C). Recruitment for the project spanned 40 days, resulting in 37 patients referred to the program, of whom 10 agreed to participate.

This DNP Project followed the in-person format. Walking sessions took place at the local city park with a shelter area for warm-up and deliberation. Flat sidewalks and level ground were important features. Prior to project implementation, the DNP Project Manager and weight management advanced practice provider (APP) were both trained by South Dakota State University (SDSU) Extension. Training was done remotely. Both individuals watched videos provided by the Arthritis Foundation. Leader books were provided. Step-by-step instructions for each session are outlined in the leader book along with optional posters to post at the session location or handout to patients. Permission to share the booklet and poster content (Appendix D) was received by The Arthritis Foundation.

Meeting sessions took place three times per week on Monday, Wednesday, and Friday mornings from 8AM to 9AM. For this project, one WWE leader was present at each session. One half of the sessions were led by a weight management APP with the other sessions being led by the DNP Project Manager. At the first session, participants were given a booklet to journal and guide their walking journey. A written consent (Appendix E) was obtained. The WWE contract provided the patient with documentation of the walking plan and a section for participants to identify and record a personal goal at the halfway and completion time points. Leaders identified a universal starting point and measured steps taken during each session by each participant with the use of pedometers purchased by the DNP Project Manager. Participants returned pedometers at the end of each session. Steps taken were recorded on an Excel spreadsheet. During the program, there were 18 sessions, each with a slightly different focus.

Each session was divided into the following components: 

1. Greeting: The group was welcomed, and participants greeted one another.
2. Group sharing: Participants received feedback. Leaders answered questions from the participants.
3. Lecturette: A different topic was discussed at each session (see Appendix F).
4. 5-Step Basic Walking Pattern Activity: Each session consisted of a warm-up, gentle stretch, walking with increasing intensity, cool down, and gentle stretch.
5. Closing: Participant questions were answered. Leaders encouraged participants to read the associated chapters with the next session and urged them to walk on their own.

Each session lasted 1 hour. Step-by-step instructions guided the flow of the hour. 

Each participant was given a 6-chapter WWE booklet with recommended chapter readings to coincide with the respective week.

There is always a concern for injury with activity. A plan was developed prior to implementation should a participant suffer an injury. Fortunately, there were no accidents or injuries during the DNP Project.

Considering the public location of sessions, confidentiality could have been a factor. This was addressed with participants prior to meetings to ensure awareness and comfort with this format. All participants shared information about involvement in the weight management program. Their first name, short-term and long-term goals, and other physical activity discussion topics took place during sessions.

Data was stored on an Excel spreadsheet that was password protected and only available to the DNP Project Manager. Each participant was given a number at the first session and retained the same number until program completion. No personal patient information was stored on the spreadsheet. Approval from the healthcare facility Institutional Review Board and SDSU Institutional Review Board along with the healthcare Nursing Research Council was obtained prior to implementation.

Demographics 

A total of 10 patients participated in this project. Participants were not removed from the project if they were absent from walking sessions. Of these 10 participants, 6 (60%) were female, and 4 (40%) were male. The population was exclusively white. Ages ranged from 31 years old to 83 years old with the average age of 52.4 and the median age of 54.5 (Appendix H). 

Statistical Results 

Ten participants completed the 6-week walking program. The goal of the analysis was to determine if there was statistically significant evidence to conclude that the  walking program increases the steps a patient can take. This was done through methods including a Friedman test, ANOVA, and linear regression.

A Friedman test for repeated measures was used to analyze the data results from pedometers. The total number of steps during each of the 18 walking sessions was tracked on a spreadsheet (See Appendix H). The number of steps taken increased each week for all patients with an average increase of 833.1 steps. From the Friedman test for all participants, a p-value of 3.86e-05 was calculated indicating that steps were increased significantly for the cohort. The range of increased steps across all 10 walkers was 273 to 1,382 steps while the average increase in steps was 833.1 over 6 weeks.

For the parametric ANOVA test, in which we assume normality within weeks, a p-value of 5.99e-07 was calculated indicating that the mean of at least 1 week was different from the means of the other weeks. This test did not reveal which weeks were different from the others nor how much change there was from week to week. To explore this further, linear regression was performed on the dataset. The main value of interest from this regression was to find the relationship between the week and the steps taken.

Specifically, a rate of how many steps gained or lost over each week was evaluated. Since each patient had a different base rate of steps that they took, the test allows for each patient’s individual steps. A corresponding p-value of < 2e-16 for all 10 patients was calculated indicating that one week leads to, on average, 68 more steps were walked with each consecutive week.

There was not a single participant who attended all 18 sessions. The range of sessions missed was 1-6. The average number of missed sessions per walker was 3.6 sessions. Given that patients had missed sessions throughout the project, it was of interest to explore whether missed sessions had an effect on steps taken. To do this, an indicator was added to the linear regression model which had a value of 1 if at least one session was missed. This test revealed a p-value of 0.179 which would indicate missing days did not influence steps taken. It is important to note this does not conclude that missing days does? not effect steps walked, but rather there is not enough evidence to conclude that it does have an effect. 

Clinical Results 

Throughout the 6-week program, patient feedback from session deliberation was very positive. Participants felt the scheduled sessions helped hold them accountable for being at a location at a certain time. Positive comments were shared regarding the lecturette content including correct walking posture, stretches, and body-weight movements. As part of the WWE program, patients received all content discussed during sessions in book form to utilize as a resource going forward. Participants also reported the 3 times per week frequency was often inconvenient in combination with busy schedules.

Walking programs can be effective in increasing activity and improving physical health. Evidence-based literature have shown that walking programs can lead to increased physical activity levels, weight loss, improved blood pressure and cholesterol levels, and reduced risk of heart disease, stroke, and type 2 diabetes. Improving walking ability and physical activity can have a positive impact on patient wellness.

There were minimal barriers to completing this project. The most prominent barrier was recruiting participants for the program. Although the program was free, it required time commitment and physical input from participants. Another potential barrier was patient dropout. Asking participants to attend 18 sessions over 6 weeks was a commitment. Attending all sessions was not mandatory, this provided participants with flexibility to participate when they could. None of the participants were able to attend all 18 sessions, which posed some limitations to the data analysis. Having weight management provider support was a concern at the beginning of the project, but ultimately provider buy-in was not a barrier. Provider recommendations encouraged patients to utilize all the resources the weight management program could offer to achieve their goals.

Although this project had a small sample of 10 participants, the results revealed the walking program increases a patient's steps over 6 weeks. Information on the number of steps taken over the 18 sessions was provided to participants at the end of the program. Participants were very pleased with their results and many reported they plan to continue the routine. Just like other evidence-based walking programs showed, the WWE program helped walkers start with a realistic goal, stay motivated, track progress and implement walking exercises beyond program completion.

The DNP Project was carried out through the outpatient weight management program at the local clinic attached to a critical access hospital. The cost of the program startup was approximately $440 dollars, which includes the cost of pedometers, instructor training and books for up to 15 participants. Currently, SDSU Extension will cover costs of the program implementation.

Implementing this program into weight management addressed a key component for weight loss. However, at this time the facility stakeholder does not plan to put the program into policy. Although the program did show an increase in steps over 20 minutes for 6 weeks indicating an improvement in sedentary behaviors in weight management patients, it is not sustainable for the rural clinic at this time. Yet, the importance of physical activity is discussed at length in the throughout the program. These discussions could include more specific guidelines along with the mental health and nutrition components as well. Identifying policies to guide care in this setting going forward has the potential to improve the overall health of weight management patients and reduce complications throughout the program. Including a walking program like WWE or the like provides another optional resource for patients to make improvements in their health.

The dependence on volunteers makes WWE vulnerable to sustainability challenges. Walk with Ease is a great initiative that helps sedentary adults become active. However, it is not a sustainable program for the weight management clinic due to its reliance on volunteers. Finding other volunteers aside from the project leader and facility stakeholder was a challenge. The program requires a significant time commitment. Due to being unable to recruit and retain other volunteers, it is unrealistic for the clinic to continue the program in this way. Continued interest in the program by participants was another factor. Although 10 patients participated in the initial program, patients reported difficulty attending all in person sessions. There was discussion between the stakeholders. 

to trial a similar form of the program that is considered a hybrid. This consists of one in- person session per week with the other 2 sessions each week being individual and, on the participant’s own time and choice of location. This is the current plan in place in order to proceed with a sustainable exercise program.

The main limitation to the project was the small sample size, and thus limited generalizability.

Future projects could consider a focus on more patient perspective values such as quality of life scores. Other considerations for future projects include anyone interested in a walking program versus only those who are deemed to be living sedentary lifestyles by weight management providers.

Implementation of the Walk with Ease program in a weight management clinic aimed to improve the exercise capabilities of sedentary patients. Implementing an evidenced-based walking program as part of the weight management clinic repertoire provided more resources for patients. Overall, the proposed practice change was a smooth implementation process. Cost and buy-in are two factors that often hinder change in the workplace, this intervention was held back very little by these determinants. Moving forward with a consistent walking program is an important part of a weight management program because it is a safe and effective way to increase physical activity, improve cardiovascular health, and build muscle. Walking is also a low-impact activity that is accessible to people of all fitness levels. If people know about a leader-guided program and are interested in joining, it is more likely that the program will lead to changes in practice.

1. Ajzen I (1991) The Theory of Planned Organizational Behavior and Human Decision Processes 50: 179-211.
2. Arthritis Foundation (2021) Walk with Your guide to walking for better health, improved fitness, and less pain. The Arthritis Foundation.
3. Blain H, Jaussent A, Picot MC, Maimoun L, Coste O, et al. (2017) Effect of a 6-month brisk walking program on walking endurance in sedentary and physically deconditioned women aged 60 or older: A randomized trial. The Journal of Nutrition, Health & Aging 21: 1183-1189.
4. Cavero-Redondo I, Martinez-Vizcaino V, Fernandez-Rodriguez R, Saz-Lara A, Pascual-Morena C, et al. (2020) Effect of behavioral weight management interventions using lifestyle mHealth self-monitoring on weight loss: A systematic review and meta-analysis. Nutrients 12:
5. https://www.cdc.gov/healthyweight/physical_activity/index.html
6. Cooper L, Ryan CG, Ells LJ, Hamilton S, Atkinson G, et al. (2018) Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: a mixed methods systematic review. Obesity Reviews 19: 989-1007.
7. Fanning J, Rejeski WJ, Leng I, Barnett C, Lovato JF, et al. (2022) Intervening on exercise and daylong movement for weight loss maintenance in older adults: A randomized, clinical Obesity (Silver Spring) 30: 85-95.
8. Göçer E, Ard?ç F, Akkaya N, Herek D (2017) Efficacy of moderate-intensity walking provided feedback by ECE PEDO on abdominal fat in overweight and obese women: A randomized, exercise Turkey Journal Physical Medicine Rehabilitation 63: 340-347.
9. Hensman-Kettrey H, Schaffer KA, King SB (2021) Evaluating physical activity and quality of life for older adults through walk with ease. Archives of Rheumatology and Arthritis Research
10. Hossain MA, Amin A, Paul A, Qaisar H, Akula M, et al. (2018) Recognizing obesity in adult hospitalized patients: A retrospective cohort study assessing rates of documentation and prevalence of Journal of Clinical Medicine 7: 203.
11. Hsu CY, Wu HH, Liao HE, Liao TH, Su SC, et al. (2021) Self-monitored versus supervised walking programs for older Medicine 100: e25561.
12. https://www.hopkinsmedicine.org/gim/faculty resources/core_resources/Patient%20Handouts/Handouts_May_2012/The%20Ski nny%20on%20Visceral%20Fat.pdf
13. https://uptodate.com/contents/epidemiology-andriskfactorsforosteoarthritis?sectionName=Obesity&search=obesity%20&topicRef=5370&anchor=H4111593320&source=see_link#H4111593320
14. Mierzwicki, JT, Good TA, Reed DC, Greer CD (2018) The impact of the Walk with Ease program on lower extremity strength and ambulation in individuals with osteoarthritis. Physical Therapy and Rehabilitation 5: 12.
15. https://www.niddk.nih.gov/health- information/weight-management.
16. Patel AV, Hildebrand JS, Leach CR, Campbell PT, Doyle C, et al.  (2018) Walking in relation to mortality in a large prospective cohort of older U.S. adults. American Journal of Preventive Medicine 54: 10-19.
17. https://deepblue.lib.umich.edu/bitstream/handle/2027.42/85350/HEALTH_PROMOTION_MANUAL_Rev_5-2011.pdf.
18. Pereira D, Afonso A, Medeiros, Fátima (2015) Overview of Friedman’s test and post-hoc Communications in Statistics - Simulation and Computation 44: 2636-2653.
19. Perreault L, Laferrere B (2022) Overweight and obesity in adults: Health UpToDate.
    
20. Powell-Wiley TM, Poirier P, Burke LE, Després JP, Gordon-Larsen P, et al. (2021) Obesity and cardiovascular disease: A scientific statement from the American Heart Association. Circulation (New York, N.Y.) 143: e984- e1010.
21. Sheikh SZ, Kaufman K, Gordon BB, Hicks S, Love A, et al. (2019) Evaluation of the self-directed format of Walk with Ease in patients with system lupus erythematosus: The walk-SLE pilot study. Lupus 28: 764-770.
22. Ward ZJ, Bleich SN, Long MW, Gortmaker SL (2021) Association of body mass index with healthcare expenditures in the United States by age and sex. PLOS ONE 16: e0247307.
23. https://www.who.int/health-topics/obesity#tab=tab_1.
24. https://assessment-module.yale.edu/human-subjects-protection/protocol-design-inclusion-and-exclusion-
25. Yorks DM, Frothingham CA, Schuenke MD (2017) Effects of group fitness classes on stress and quality of life of medical students. The Journal of the American Osteopathic Association 117: e17-e25.
26. Yuenyongchaiwat K, Pipatsitipong D, Sangprasert P (2017) Increasing walking steps daily can reduce blood pressure and diabetes in overweight participants. Diabetology International 9: 75-79. 

Facility

University

WWE Recruitment Flyer

Permission to Reprint Arthritis Foundation Materials

Waiver and Consent

Lecturette Content 

Demographic Data 

Appendix H

Data Collection Tables