Literature Review

American Journal of Health Promotion

1-13
Changing the Physical Activity Behavior ª The Author(s) 2019
Article reuse guidelines:
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of Adults With Fitness Trackers: DOI: 10.1177/0890117119895204
journals.sagepub.com/home/ahp
A Systematic Review and Meta-Analysis

Chris Lynch, MSc1,2 , Stephen Bird, PhD1, Noel Lythgo, PhD1, and
Isaac Selva-Raj, PhD1

Abstract
Objective: To examine whether a fitness tracker (FT) intervention changes physical activity (PA) behavior compared to a control
condition or compared to an alternative intervention.
Data Source: Searches between January 01, 2010, and January 01, 2019, were conducted in PubMed, CINAHL, Cochrane
CENTRAL, EMBASE, and PsycINFO.
Inclusion/Exclusion Criteria: Randomized clinical trials of adults using an FT to change PA behavior were included. Nonclinical
trials, studies that included the delivery of structured exercise, and/or studies that only used the FT to assess PA were excluded.
Data Extraction: Extracted features included characteristics of the study population, intervention components, PA outcomes,
and results.
Data Synthesis: Papers were pooled in a statistical meta-analysis using a fixed effects model. Where statistical pooling was not
possible, standardized mean difference (SMD) and 95% confidence intervals (CI) were calculated. Findings were presented in a
narrative form and tables.
Results: Of 2076 articles found, 21 were included in the review. A small yet significant positive effect (SMD ¼ 0.25, 95%
CI ¼ 0.17-0.32; P < .01; I2 ¼ 56.9%; P ¼ .03) was found in step count for interventions compared to control. A small yet significant
negative effect (SMD ¼ 0.11, 95% CI ¼ 0.20 to 0.02; P ¼ .02; I2 ¼ 58.2%; P ¼ 0.03) was found in moderate-to-vigorous PA
for interventions compared to an alternative intervention.
Conclusion: Trackers may enhance PA interventions, as a general positive effect is found in step count compared to a control.
However, there is no evidence of a positive effect when interventions are compared to an alternative intervention. It is unknown
whether results are due to other intervention components and/or clinical heterogeneity.

Keywords
fitness trackers, wearable electronic devices, exercise, telemedicine, mHealth

Objective To accrue any health benefit, sufficient PA must be under-

There is extensive evidence that undertaking sufficient physical
activity (PA) has a significant benefit to health.1 Conversely,
insufficient PA is a significant factor in chronic disease risk and
all-cause mortality.2,3 If adults worldwide were sufficiently phy-
sically active, it is estimated that the incidence of the major
noncommunicable diseases of coronary heart disease, type 2
diabetes, colon cancer, and breast cancer would reduce by 6%
to 10%.2 However, few adults are sufficiently physically active.
Hallal et al4 reported that 31% of the global adult population is
insufficient for PA, and in the Americas, 43% of the adult pop-
ulation is insufficient for PA. Therefore, increasing PA partici-
pation in those who are currently insufficient would substantially
improve health and reduce the burden of chronic disease.
taken regularly over an extended period. However, changing
PA behavior to attain a health benefit is a formidable challenge.
Participation in PA intervention tends to decline the longer the
intervention duration.5 This decline may be due to a loss of
interest, motivation, enjoyment, time, and/or perceived
1
Exercise Science, School of Health and Biomedical Sciences, RMIT University,
Bundoora, Victoria, Australia
2
The Northern Health, Melbourne, Victoria, Australia
Corresponding Author:
Chris Lynch, RMIT University, GPO Box 2476, Melbourne, Victoria 3001,
Australia.
Email: chris.lynch@nh.org.au
2 American Journal of Health Promotion XX(X)
benefit.6 Among healthy adults, PA intervention shows only
moderate effectiveness,7 and few interventions that report
long-term results (1 year) show a positive effect on PA lev-
els.5 Analyses of interventions suggest that the characteristics
of the most effective are behavioral-based instead of cognitive-
based interventions, face-to-face delivery instead of mediated
interventions (eg, via telephone or mail), and the targeting of
individuals instead of communities.7 The targeting of individ-
uals is important as it enables specific content to be matched to
individual participant attributes, such as identified personal
barriers to PA. However, interventions with characteristics
such as these are likely to be resource intensive and have a
limited reach.
Emergent technologies now offer the potential to deliver
personalized, behavioral-based PA interventions to large popu-
lations over extended periods, for a relatively low cost. An
increase in smartphone ownership,8 a proliferation of fitness
applications (apps),9 and the development of popular low-cost
wearable fitness trackers (FTs) designed to monitor PA can all
be used to help individuals become more physically active.10-12
The potential of technology to increase levels of activity among
healthy and chronically diseased adults has been extensively
discussed,13-19 and the focus of this review is on one specific
technology, the FT, and how effective it is at increasing levels
of PA among adults.
Fitness trackers record movement and present it back as a
step count, distance traveled, or an estimation of energy expen-
diture. Trackers have gained widespread popularity and new
models are continually released. There is an expectation that
the market for FTs will continue to grow, with sales reaching
162.9 million units by the end of 2020.20 The criterion validity
of these devices to assess PA has been examined, and they
show strong validity for the assessment of step count but less
for the assessment of distance or energy expenditure.21 When
worn under free-living conditions and compared against
research-grade accelerometers, FTs show strong validity for
the assessment of step count.22
Fitness trackers normally have an associated app to which
PA data are downloaded and stored. Both the tracker and the
app contain behavior change techniques, such as self-
monitoring, social support and comparison, prompts, cues, and
rewards.23-25 Self-monitoring is considered a particularly
important technique in changing PA behavior. Michie et al26
reported that the self-monitoring of PA behavior is signifi-
cantly associated with positive PA outcomes, and Lewis
et al27 have found preliminary evidence that the use of an FT
produced positive findings in changing PA behavior. However,
subsequent analyses of the effectiveness of FTs to change PA
behavior have produced equivocal findings.27-31
The inclusion of an FT in an intervention is a relatively new
field of study within PA research. Trackers provide objective,
self-monitoring of PA, and the behavioral change techniques
present in them may help those less motivated increase levels
of PA. Coughlin and Stewart32 reported that trackers are fea-
sible tools to change PA behavior, but previous reviews of their
effectiveness have been limited by heterogeneity and the small
number of studies.27-31 As evidence emerges, there is a contin-
ued need for its evaluation and synthesis to guide and inform
future research. Therefore, the aim of this review is to synthe-
size current evidence in examining how effective FTs are in
changing PA behavior among adults. This review has 2 objec-
tives. First, to examine whether the inclusion of an FT in an
intervention is effective at increasing PA outcomes among
adults when compared to a control condition. Second, to exam-
ine whether the inclusion of an FT in an intervention changes
any incremental increase in PA compared to an alternative
intervention.
Methods
This systematic review was conducted in accordance with the
Preferred Reporting Items for Systematic Reviews and Meta-
analysis (PRISMA) guidelines.33
Data Sources
From an initial limited search of PubMed using the MeSH term
“Fitness Tracker” and under the guidance of a trained reference
librarian, a full search strategy was developed from the analysis
of words contained in the title, abstract, and index terms of
retrieved articles. The full, final search strategy included the
search terms: adult, fitness tracker, wearable electronic device,
activity monitor, PA, and the brand names of popular FTs (eg,
Fitbit). The search strategy for PubMed is detailed in Supple-
mentary Material 1. Search strategies were adapted for each
database as necessary. In January 2019, searches on titles and
abstracts were conducted in 5 online databases (PubMed,
CINAHL, Cochrane CENTRAL, EMBASE, and PsycINFO
online). Searches were limited to articles published between
January 01, 2010, and January 01, 2019. This range of dates
was selected, as the first release of an early and popular FT, the
Fitbit, was in September 2009. Citations were collated and
downloaded into Endnote X8 citation management software,
and duplicate citations were removed. Reference lists of rele-
vant reviews were checked for eligible studies, and citation
searches were performed on earlier articles. Studies were then
imported into the Joanna Briggs Institute (JBI) System for the
Unified Management, Assessment and Review of the Informa-
tion (JBI SUMARI; JBI, Adelaide, Australia).
Inclusion and Exclusion Criteria
Titles and abstracts were screened against inclusion and exclu-
sion criteria by 1 reviewer (C.L.). The full text of the remaining
studies was retrieved and screened against inclusion and exclu-
sion criteria by 2 reviewers (C.L. and I.S.-R.).
Inclusion in the review required a study to be a randomized
clinical or controlled trial of only adult participants and used an
FT in the intervention. Nonclinical trials and cross-sectional
studies were excluded. The term adult was defined as an indi-
vidual aged 18 years or older and included aged participants.
Studies were excluded if participants were hospital inpatients,
Lynch et al.
terminally ill, and/or receiving hospice care. Studies were
excluded if the FT was a pedometer or research-grade activity
monitor or if the FT was only used to assess PA outcomes. For
inclusion, a primary or secondary aim of the study had to be a
change in PA behavior. Change in PA behavior may be
assessed through outcomes that include bouts, minutes/day or
week of light (LPA), moderate (MPA), vigorous (VPA),
moderate-to-vigorous PA, step count, accelerometer count,
and/or estimations of energy expenditure. Physical activity
included any form of PA (eg, promotion of PA during leisure
time, occupationally, within the household, and/or while com-
muting). However, if the intervention included the delivery of
structured exercise, the study was excluded. Any disagreement
between reviewers was resolved through discussion or by a
third reviewer (S.B.). Detail of inclusion and exclusion criteria
is provided in Supplementary Material 2.
Risk of Bias and Assessment of Methodological Quality
Risk of bias and the methodological quality of each study were
assessed by 2 independent reviewers (C.L. and I.S.-R.) using
the JBI Critical Appraisal Instrument for Randomised Con-
trolled Trials.34 The appraisal instrument assesses the random
sequence generation, allocation concealment, blinding of par-
ticipants, personnel, and blinding of outcome assessment,
thereby assessing the extent to which a study has addressed the
possibility of bias in its study design, conduct, and analysis.
Responses were also used to judge the methodological quality
of a study. Responses to questions were yes, no, unclear, or not
applicable. When a response was “unclear,” attempts to contact
the author(s) of the study were made for clarification. To
ensure a minimum standard of methodological quality in the
synthesized evidence, at least 7 “yes” responses to questions
were needed for a study to be included in the final review. As
the design of studies included in this review generally mean the
blinding of participants is not feasible, responses to this ques-
tion were not counted when assessing methodological quality;
however, it was still assessed as part of the risk of bias assess-
ment. The small number of studies included in each meta-
analysis excluded the use of tests to assess selective reporting
bias. Any disagreement of the risk of bias or methodological
assessment was resolved by consensus or consultation with a
third reviewer (S.B.).
Data Extraction
Two independent reviewers (C.L. and I.S.-R.) extracted data
from each study into a standardized data abstraction form.
Documented features included study design, characteristics of
the study population, components of the intervention, outcomes
of PA, and description of the main results. Discrepancies were
resolved by consensus or consultation with a third reviewer
(S.B.). Where missing or additional data were required, sup-
plementary material, the website of the study, and/or attempts
to contact the author(s) of the study were made. If effect esti-
mate variability was not adequately reported and any request to
3
the authors not responded to, the required statistic was calcu-
lated per section 7.3.3 of the Cochrane Handbook for Systema-
tic Reviews of Interventions.35
Data Synthesis
Papers, where possible, were pooled in a statistical meta-
analysis using Jamovi software.36 A fixed effects model using
inverse variance, as guided by Tufanaru et al,37 was used.
Effect sizes were expressed as standardized mean difference
(SMD) and 95% confidence intervals (CIs). For each analysis,
the I2 statistic was calculated to estimate the proportion of
observed variance in effect, across studies. As per Higgins
et al,38 values of 25%, 50%, and 75% were used as boundary
limits for low, moderate, or high heterogeneity, respectively.
Where statistical pooling was not possible, SMD and 95% CI
were calculated for outcomes and findings presented in a nar-
rative form and tables. Thresholds for interpretation of effect
were as advocated by Cohen.39
Results
A flowchart of the systematic review describing the number
of studies and reasons for exclusion is provided in the
PRISMA flow diagram (Figure 1). The search strategy iden-
tified 2539 records, and of 2076 unique articles screened on
title and abstract, 1284 (63%) were excluded as nonexperi-
mental design (ie, not a randomized clinical or controlled
trial). The full texts of 78 records were retrieved and
assessed against inclusion criteria. Twenty-five full-text
articles were assessed for risk of bias and methodological
quality. Four studies40-43 did not meet the minimum level of
methodological quality and were excluded from the final
analysis. Twenty-one studies were included in the narrative
synthesis.44-64
Risk of Bias
A summary of the risk of bias is provided in Figure 2. Selection
bias was unclear; 4 studies45,47-49 reported procedures used to
prevent those allocating participants from knowing whether
treatment or control was next in the allocation process, and all
other studies were unclear. Procedures used to randomly allo-
cate participants to study groups were adequately reported, and
2 studies51,55 were unclear on the procedure used.
Two studies47,56 reported that those assessing outcomes
were unaware of participants’ allocation, and all other stud-
ies were unclear. Three studies45,46,64 reported that those
delivering treatments were not blind to treatment assign-
ment, and Hartman et al14 reported that all other studies
were unclear.
All studies analyzed participants in the groups to which they
were randomized. Ten studies 45,47,49,51,53,54,56,58-60 used
intention-to-treat analysis. Two studies44,54 reported 100%
retention. The outcomes of critical appraisal for each study is
provided in Supplementary Material 3.
4 American Journal of Health Promotion XX(X)

Figure 1. PRISMA flow diagram.

Figure 2. Summary of risk of bias.

Lynch et al. 5

Table 1. Included Studies and Intervention Characteristics.

Population; Mean Physical Activity

Study Age, years N Setting Intervention/Control or Comparator Outcomes

Barwais Sedentary; 27.8 33 Home i. FT þ app/c. Normal daily activities Sedentary time,
et al44 LPA, MPA, VPA
Brakenridge Office workers; 38.9 153 Workplace i1. FT þ app þ organizational wellness program/i2. Sedentary time,
et al45 Organizational wellness program step count
Cadmus- Overweight post- 51 Home i1. FT þ app þ individualized goals þ 1  follow-up call/i2. LPA; MVPA,
Bertram menopausal; 60.9 Pedometer þ printed materials þ brief goal setting MVPA bouts,
et al46 guidance step count
Finkelstein Employees; 35.5 800 Workplace i1. FT þ app þ printed materials/i2. i1 þ charity donation MVPA bouts, step
et al47 incentive/i3. i1 þ cash incentive/c. Printed materials count
Hartman Overweight, elevated 54 Home i. FT þ MyFitnessPal app þ 12  coaching calls/c. US Dietary MVPA, MVPA
et al48 breast cancer risk; 59.5 Guidelines for Americans þ 2  follow-up calls bouts
Jakicic et al49 Overweight; 30.9 471 Home i1. FT þ app þ dietary intervention þ weekly texts þ Sedentary time,
monthly calls/i2. Self-report of daily MVPA via a study LPA, MVPA,
website MVPA bouts
Jauho et al50 Young males; 17.9 276 Home i. FT/c. Blinded FT Sedentary time
Kim et al51 College students; 20.6 187 Home i. FT þ app/c. Normal, daily activities Sedentary time,
LPA, MVPA,
MVPA bouts
Kooiman Type 2 diabetics; 56.4 72 Home i. FT þ eHealth program/c. Normal daily activities MVPA bouts, step
et al52 count
Lewis et al53 Overweight, older; 63.7 40 Home i1. FT þ app/i2. Pedometer þ activity log MVPA, step count
Li et al54 Older with knee 34 Home i. FT þ app þ education session þ 4  follow up calls/c. MVPA bouts
osteoarthritis; 55.5 Normal, daily activities
Lystrup First year medical 107 Medical i. FT þ app/c. Normal, daily activities Step count
et al55 students; 25.4 school
McDermott Older with lower 200 Home i. FT þ 4  weekly supported sessions þ diminishing follow- Accelerometer
et al56 extremity peripheral up phone calls/c. Normal, daily activities count
artery disease; 70.3
Melton Female, African American 69 Home i1. FT þ app þ weekly e-mails/i2. Diet app þ weekly e-mails Step count,
et al57 students; 19.7 accelerometer
count
Pellegrini Overweight adults; 44.2 51 Home i1. FT þ app þ e-mailed goals þ supported telephone calls/i2. Energy
et al58 FT þ Standard behavioral weight loss/i3. Standard expenditure
behavioral weight loss
Shuger Overweight adults; 46.9 197 Home i1. FT þ app/i2. Group-based behavioral weight loss program Energy
et al59 only 14 sessions þ 6  telephone/i3. i1 þ i2/c. Printed expenditure
materials
Thomas Overweight; 55.0 271 Home i1. FT þ app þ Weight Watchers Online program/i2. Weight MVPA
et al60 Watchers Online program only/c. Printed materials
Thompson Overweight, older; 79.5 49 Home i. FT þ printed materials þ bimonthly counseling/c. Blinded Accelerometer
et al61 FT count
Thorndike Physicians; 29.0 104 Hospital i. FT þ app/c. Blinded FT Step count
et al62
Uhm et al63 Posttreatment breast 356 Home i1. FT þ app þ prescribed activity goal/i2. Prescribed activity Energy
cancer survivors; 50.3 goal þ printed materials expenditure
Vidoni Cognitively impaired, 30 Home i. FT þ app þ prescribed activity goal þ printed materials/c. Step count
et al64 older; 71.5 Blinded FT
Abbreviations: c, control; FT, fitness tracker; I, intervention; i#, alternative intervention; LPA, light physical activity; MPA, moderate physical activity;
MVPA, moderate-to-vigorous physical activity; VPA, vigorous physical activity.

remaining studies were conducted in Australia,44,45 Canada,54

Study and Intervention Characteristics
Intervention characteristics of included studies are described in
Table 1. Further detail of study and intervention characteristics
are provided in Supplementary Material 4. Fourteen (67%) stud-
ies were conducted in the United States.46,48,49,51,53,55-62,64 The
Finland,50 the Netherlands,52 Korea,63 and Singapore.47
Two studies58,60 were 3-arm trials, 2 studies47,59 were 4-arm
trials, and the remaining 17 studies were 2-arm clinical or
controlled trials. In total, 14 studies44,47,48,50-52,54-56,59-62,64
compared an FT intervention against a control condition. Nine
6 American Journal of Health Promotion XX(X)

Table 2. Effect of Fitness Tracker Interventions on PA: Comparison to Control: SMD (95% CI).

Study LPA MPA VPA MVPA (Bouts) Step Count Counts

Barwais 2.07 (1.22-2.91)a 1.13 (0.39-1.86)a 0.82a (0.10-1.53)

et al44
Finkelstein 6 months
et al47 (i1) 0.24 (0.04-0.44)
(i2) 0.31 (0.11-0.51)
(i3) 0.43 (0.23-0.63)
12 months
(i1) 0.52 (0.32-0.72)b
(i2) 0.44 (0.24-0.64)
(i3) 0.21 (0.01-0.40)
Hartman 0.43 (0.14 to 1.00)
et al48
Kim et al51 Mid-semester Mid-semester
0.09 (0.38 0.10 (0.19 to 0.39)
to 0.20)
End semester End semester 0.10
0.23 (0.51 (0.19 to 0.39)
to 0.06)
Li et al54 0.12 (0.55 to 0.80)
McDermott 0.01 (0.29 to 0.26)
et al56
Thompson 0.36 (0.20 to 0.93)
et al61
Vidoni 0.84 (1.59 to 0.09)
et al64
Abbreviations: CI, confidence interval; LPA, light physical activity; MPA, moderate physical activity; PA, physical activity; MVPA, moderate-to-vigorous physical
activity; SMD, standardized mean difference; VPA, vigorous physical activity.
a
P < .01.
b
P < .05.

studies45,46,49,53,57-60,63 compared an FT intervention against an
alternative intervention.
Weight loss was the primary aim of 5 studies,48,49,58-60 reduc-
ing sedentary behavior was the primary aim of 3 studies,44,45,50
and the primary aim for Uhm et al63 was to improve physical
function and quality of life. Ten studies46,48,50,51,53,55,57,58,63,64
did not report if the sample size was sufficiently powered for the
primary aim.
Population Characteristics
A total of 3605 participants are included in this review. All
participants were adults, but mean age was dependent on the
targeted population and included populations of young adults50
and older adults.61 Four studies46,48,57,63 recruited only female
participants, with 3 of those studies specifying being postme-
nopausal,46 having an elevated breast cancer risk,48 or who
were a posttreatment breast cancer survivor.63 The remaining
female-only study57 was of healthy young adults. One study50
recruited male participants exclusively.
Intervention Characteristics
The duration of interventions ranged from 4 weeks 44 to
18 months.49 Six studies45,50-53,63 were of 3-month duration
and 3 studies47,48,61 were of 6-month duration. The most
common brand of FT was Fitbit, and it was used in 10
studies.46-48,52,54-56,61,62,64 Other brand/models of tracker were
the Jawbone UP,53,57 Polar Active,50 Misfit Flash,51 Gruve
Solution,44 LUMOback,45 BodyMedia Fit,58 SenseWear,59
ActiveLink,60 and InBodyBand.60
All FTs had an associated app. It was unclear in 2 stud-
ies50,61 if the app linked to the tracker was described to parti-
cipants. Two studies52,56 required participants to download
tracker data into a specific study website. All other studies
described the app to the participants, but it was unclear whether
the intervention required the use of the app. One study48 pro-
moted the use of an additional app that promotes PA (eg,
MyFitnessPal).
A variety of intervention components to promote PA were
included in interventions. Providing an FT was the only interven-
tion component of 7 studies.44,50-53,55,62 Components of other
studies included provision of incentives,47 individualized goal
setting,46,64 prescribed PA,63 and regular text, e-mail, or telephone
contact.45,48,49,54,56-61 Studies that had a primary aim of weight
loss also included intervention components for that aim.45,49,58-60
The reporting of a theoretical basis for the intervention was
limited to elements based upon social cognitive theory48,56,59
and material based upon the transtheoretical model.59 One
study46 used the CALO-RE framework, which identifies self-
Lynch et al. 7

Table 3. Effect of Fitness Tracker Interventions on Physical Activity: Comparison to an Alternative Intervention: SMD (95% CI).

Study LPA MVPA (Bouts) Counts Energy Expenditure

Cadmus- 0.03 (0.52 to 0.58) 0.07 (0.48 to 0.61)a

Bertram
et al46
Jakicic et al49 12 months 0.17 (0.35 to 0.02) 12 months 0.27 (0.45 to 0.08)
18 months 0.14 (0.32 to 0.02) 18 months 0.17 (0.35 to 0.01)
24 months 0.05 (0.24 to 0.13) 24 months 0.11 (0.29 to 0.07)
Melton et al57 6 weeks 0.17 (0.65 to 0.31)
8 weeks 0.39 (0.88 to 0.09)
Pellegrini (i1) 0.41 (0.27
et al58 to 1.09)a
(i2) 0.62 (0.07
to 1.30)a
Uhm et al63 0.19 (0.02 to 0.40)
Abbreviations: LPA, light physical activity; MPA, moderate physical activity; VPA, vigorous physical activity; MVPA, moderate-to-vigorous physical activity.
a
P < .01.

Figure 3. Forest plot of standardized mean difference (SMD; 95% confidence interval [CI]) of objectively assessed moderate-to-vigorous
physical activity (MVPA; minutes/day): fitness tracker intervention versus control. Repeated assessments at (a) mid-semester; (b) end semester;
(c) 3 months; (d) 12 months.

monitoring combined with other self-regulatory skills, to iden-
tify behavior change techniques.
Physical Activity Outcomes
Three studies55,57,62 did not report baseline PA behavior, and 2
studies 55,59 did not report postintervention PA behavior.
Methods used to assess PA behavior were objective and/or
self-report. Objective methods included using accelerome-
try,46-48,51,56,57,61 combined inclinometry and accelerometry,45
and accelerometry combined with other sensors.49,53,54,59,60
Five studies50,52,55,62,64 used the FT as an intervention compo-
nent and to assess PA. Five studies44,50,52,58,63 included self-
report methods to assess PA behavior.
Metrics for assessed PA outcomes included reporting of
levels of activity as minutes/day or week of LPA, MPA, VPA,
and MVPA. 44,46-49,51,53,60 Six studies included bouts of
MVPA.46-49,51,54 Nine studies45-47,52,53,55,57,62,64 reported step
count. Three studies56,57,61 reported raw accelerometer counts,
and 3 studies 58,59,63 reported estimations of energy
expenditure.
Inclusion of an FT in an Intervention Compared
to a Control Condition
Of 14 studies that compared an intervention using an FT
against a control condition, SMD and 95% CI could not be
calculated in 4 studies50,52,55,59 due to incomplete data. Five
8 American Journal of Health Promotion XX(X)

Figure 4. Forest plot of standardized mean difference (SMD; 95% confidence interval [CI]) of step count: fitness tracker intervention versus
control.

Figure 5. Forest plot of standardized mean difference (SMD; 95% confidence interval [CI]) of objectively assessed moderate-to-vigorous
physical activity (MVPA; minutes/day): fitness tracker interventions versus an alternative intervention. Repeated assessments at (a) 12 months;
(b) 18 months; (c) 24 months; (d) 3 months; (e) 12 months.

studies were not included in the meta-analysis44,54,56,61,64 for
being too clinically or methodologically diverse. Meta-analysis
was conducted on outcomes of MVPA (minutes/day)48,51,60
and step count.47,62 Standardized mean differences and 95%
CI for other outcomes of remaining studies are presented in
Table 2.
No significant effect was found for an FT intervention ver-
sus control in minutes of MVPA minutes/day (SMD 0.01,
95% CI ¼ 0.15 to 0.13). Statistical heterogeneity was low
and nonsignificant (I2 ¼ 20.4%).
A significant positive effect was found for an FT interven-
tion versus control in step count (SMD ¼ 0.25, 95% CI ¼
0.17-0.32; P < .01). Statistical heterogeneity was moderate and
significant (I2 ¼ 56.9%; P ¼ .03).
Inclusion of an FT in an Intervention Against
an Alternative Intervention
Of the 9 studies that enabled comparison of an intervention
with an FT against an alternative intervention, SMD and 95%
Lynch et al.
Figure 6. Forest plot of SMD (95% CI) of step count: fitness tracker interventions versus an alternative intervention. Repeated assessments at
(a) 3 months; (b) 12 months; (c) 6 weeks; (d) 8 weeks.
CI were unable to be calculated from one study59 due to
incomplete data. Two studies60,63 were excluded from the
meta-analysis for clinical or methodological heterogeneity.
Meta-analysis was conducted on outcomes of MVPA (min-
utes/day)46,49,53,60 and step count.45,46,53,57 Standardized mean
differences and 95% CI for other outcomes of remaining stud-
ies are presented in Table 3.
A significant negative effect was found for an intervention
that included an FT versus an alternative intervention in
minutes of MVPA (SMD ¼ 0.11, 95% CI ¼ 0.20 to
0.02; P ¼ .02). Statistical heterogeneity was moderate and
significant (I2 ¼ 58.2%; P ¼ .03).
No significant effect was found for an intervention that
included an FT versus a comparative intervention in step count
(SMD ¼ 0.05, 95% CI ¼ 0.22 to 0.13). Statistical hetero-
geneity was moderate and significant (I2 ¼ 67.0%; P ¼ .01).
Conclusion
Fitness trackers may enhance behavioral PA interventions.
This systematic review and meta-analysis found a small posi-
tive effect for step count when an FT intervention is compared
to a control condition (Figure 4). The effect is equivalent to
approximately 500 steps/day. Current evidence supports
6000 to 7000 steps/day as indicative of usual daily activity65
and as public health guidelines recommend at least 30 accu-
mulated minutes of MVPA on most days (equivalent to 3000-
4000 steps/day), an effect of 500 steps/day is unlikely to be
enough of a change to ensure an individual meets public health
guidelines. No significant effect was found for MVPA minutes/
day (Figure 3).
When compared to an alternative intervention, an FT inter-
vention has no effect for step count and a significant negative
effect for MVPA minutes/day (Figures 5 and 6). Statistical
9
heterogeneity in all these analyses was moderate and signifi-
cant, except for when an FT intervention is compared to a
control condition on MVPA minutes/day. Subgroup analysis
to reduce statistical heterogeneity was not possible due to the
small number of studies and the clinical heterogeneity of the
populations and interventions.
Inclusion of an FT in an Intervention Compared
to a Control Condition
The primary objective of this review was to examine whether
the inclusion of an FT in an intervention is effective at increas-
ing PA outcomes when compared to a control condition. The
significant positive effect found in step count is consistent with
other meta-analyses of healthy and chronically diseased adults
where the self-monitoring of PA behavior is an intervention
component.66,67 However, the finding of no significant effect
for MVPA minutes/day differs to the findings of Brickwood
et al30 in which a significant effect (SMD ¼ 0.27; 95% CI 0.15-
0.39; P < .0001) was reported. While it is possible to accrue the
effect of step count (500 steps/day) through increases in LPA
minutes/day and perhaps VPA minutes/day, because no single
study included in the meta-analyses of this review assessed
both step count and MVPA minutes/day, it is unknown whether
there are actual differences for step count and/or MVPA min-
utes/day.
Standardized mean differences of PA outcomes (Table 2)
indicate that inclusion of an FT does have a small positive
effect compared to a control condition. The studies of Li
et al54 and Thompson et al61 show small positive effects. How-
ever, McDermott et al56 shows no effect. While small positive
effects are found in individual studies, the SMD has relatively
wide CI, which indicates that the accuracy of the estimated
effects is low.
10
Two studies are anomalous, Barwais et al44 and Vidoni
et al64; Barwais et al44 has a large positive effect. This study
had the shortest intervention duration (4 weeks) of all stud-
ies and used self-report to assess PA. It is unclear whether
the use of an FT for a short duration is more effective at
increasing PA. However, self-report is known to overesti-
mate PA,68 and it is likely that this is a contributory factor
to the large effect. Vidoni et al64 shows a large negative
effect. The duration of this study was relatively short
(8 weeks) and had a small sample size with a high with-
drawal rate, which may have contributed to the large nega-
tive effect. This study was also a unique cohort (cognitively
impaired older adults; mean age: 71.5 years) and should be
considered too clinically diverse to include in future analy-
ses of this type.
Inclusion of an FT in an Intervention Against
an Alternative Intervention
A second objective of this review was to examine whether
the inclusion of an FT in an intervention is effective at
increasing PA outcomes when compared to an alternative
intervention. Meta-analysis found no effect for step count
and a significant negative effect for MVPA. These are find-
ings which contrast to that of de Vries et al.28 However,
SMD of PA outcomes (Table 3) support no or a negative
effect when an intervention is compared to an alternative
intervention. Two studies, Pellegrini et al58 and Uhm et al,63
differ from this.
Pellegrini et al58 shows a small–moderate positive effect of
including an FT. However, the primary aim of this study was
weight loss, and the PA outcome was energy expenditure. It is
unclear whether the significant contributing factor to the pos-
itive effect found is intervention components for promotion of
weight loss or inclusion of an FT. Uhm et al63 also has energy
expenditure as the PA outcome, but the primary aim of the
intervention was to change PA behavior. When an alternative
intervention is examined, it is a prescribed activity goal and
printed materials, and it is that the alternative intervention is
like a control and consequently mirrors the earlier findings.
However, as with earlier findings of the initial objective, SMD
of all studies have relatively wide CI, indicating that the accu-
racy of the estimated effects is low.
Statistical Heterogeneity
The ambiguity of findings in this review is likely due to the
highly diverse nature of the studies. There is a diversity of
study populations, interventions, comparators, and outcomes,
and with statistical heterogeneity closely linked to the degree of
clinical and methodological heterogeneity, it is highly likely
that this contributes to the significant statistical heterogeneity
found in 3 of the 4 analyses. The significant statistical hetero-
geneity makes it difficult to attribute the cause of a positive (or
negative) effect to the inclusion of an FT in an intervention.
American Journal of Health Promotion XX(X)
Limitations
This review has several limitations. First, the findings of
meta-analyses are limited to only the included studies and
are not generalizable. A fixed-effects model for meta-
analysis was used as the number of included studies for
each analysis was small, and therefore, there is not enough
evidence to support generalization beyond those studies.
Furthermore, many studies reported multiple PA outcomes;
however, if the outcome were not significant, it may not
have been reported subjecting this review to reporting bias
limiting its comprehensiveness. Because of the large variety
in activity monitor types, intervention duration, and inter-
vention design, a sensitivity analysis was not feasible.
Therefore, it is not possible to demonstrate differences
between different FTs, intervention durations, and interven-
tion designs.
Second, the diversity of study and intervention character-
istics may have influenced intervention effects. Intervention
durations (4 weeks to 18 months), components of interven-
tions (incentives, individualized goal setting, prescribed PA,
degree of text, e-mail or telephone contact), FTs (Fitbit,
Jawbone, and so on), and participant characteristics (age
and gender) all differed among studies. For example, the
mean age of different study populations ranged from 18 to
79 years. Inclusion of study populations that comprise of
older adults can impact meta-analyses of behavioral PA
interventions, as older adults show a lower compliance with
behavior change techniques, such as setting behavioral goals
or prompting self-monitoring of behavior.69 Furthermore,
few studies explicitly referred to any theory base for the
intervention. The heterogeneity meant that a sensitivity
analysis was not feasible, and differences between different
FTs, intervention durations, and intervention designs could
not be identified.
Third, differing primary aims of studies may have further
influenced intervention effects. The primary aim of 5 studies
was weight loss, and the primary aim of 3 studies was to
reduce sedentary behavior. While PA should be facilitated
in intervention programs primarily for weight loss, weight
loss may be achieved through dietary intervention alone,
without any change in PA behavior. Targeting change in
sedentary behavior can also be achieved without any signifi-
cant change in PA behavior. Sedentary behavior is a concept
distinct from PA, and while there is some, though limited
evidence, that the displacement of sedentary behavior can
increase LPA minutes/day, where the primary outcome of a
study is MVPA minutes/day, the change in activity profile
may be overlooked. This is particularly relevant in studies
that are based within the workplace. Additionally, some stud-
ies reported targeting sedentary behavior but were assessing
physical (in)activity.
Finally, 21 studies were selected for this review, but not all
studies could be included in the meta-analysis because studies
used different PA outcomes or different methods to assess PA.
Additionally, some of the authors did not reply to the request
Lynch et al.
SO WHAT?
What is already known on this topic?
Fitness trackers are becoming ubiquitous among the
population and provide an opportunity for individuals
to self-monitor PA, a behavior change technique which
is associated with positive PA outcomes.
What does this article add?
Findings suggest that that FTs alone or combined with
other intervention components are unlikely to generate
meaningful changes in PA behavior. Furthermore, the
wide CI found in effects suggest that individual identifi-
cation of adjunct behavior change tools is needed to
support those who need them.
What are the implications for health promotion
practice or research?
Fitness trackers may enhance individual behavioral PA
interventions, but it is unknown whether there is an
actual effect of an FT on outcomes or if observed effects
are the product of diverse study populations and inter-
vention components. Further work is needed that exam-
ines which features of FTs are most effective in
combination with other intervention components and
determine which populations are most receptive to FTs.
for additional data or were not able to provide the requested
data and so the observed effect of the meta-analyses may be
biased by this exclusion.
Acknowledgments
The manuscript has been read and approved by all the authors. The
requirements for authorship as stated in the ICMJE guidelines have
been met and that each author believes that the manuscript represents
honest work.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Chris Lynch https://orcid.org/0000-0001-9503-6994
Supplemental Material
Supplemental material for this article is available online.
11
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