Received: 14 August 2019 

|  Revised: 2 January 2020 

|  Accepted: 6 January 2020

DOI: 10.1002/tsm2.138

ORIGINAL ARTICLE

The effects of manipulation of Frequency, Intensity, Time, and

Type (FITT) on exercise adherence: A meta-analysis

Kathryn Burnet1   | Simon Higgins2  | Elizabeth Kelsch1  | Justin B. Moore3  |

Lee Stoner1

1
Department of Exercise and Sport Science,
The University of North Carolina, Chapel
Hill, NC, USA
2
Department of Exercise Science, Elon
University, Elon, NC, USA
3
Department of Family and Community
Medicine, Wake Forest School of Medicine,
Winston-Salem, NC, USA
Correspondence
Lee Stoner, Department of Exercise and
Sport Science, The University of North
Carolina, Chapel Hill, NC 27278, USA.
Email: stonerl@email.unc.edu
This meta-analysis quantified the effect of FITT (frequency, intensity, time, and
type) manipulation on exercise adherence. Databases were searched from inception
to 09-2018. Manipulation of intensity resulted in a moderate, significant decrease in
adherence (MD: −3.3, 95% CI: −6.1 to −0.5), and for the remaining FITT compo-
nents, there were trivial-small, non-significant effects. When stratified by chronic
disease status, for populations with chronic diseases increasing Intensity resulted in
a moderate but non-significant decrease in adherence (MD: −3.6, 95% CI: −7.4, 0.3)
and increasing time resulted in a small, significant decrease in exercise adherence
(MD: −4.9, 95% CI: −9.4 to −0.4). Additionally, omission of a behavioral model
resulted in a moderate but non-significant decrease in exercise adherence (MD: −4.0,
CI: −8.3 to 0.2). For healthy populations, FITT manipulation and omission of behav-
ioral model resulted in trivial-small, non-significant effects. In conclusion, manipula-
tion of FITT and use of behavioral models may be of greater importance to exercise
adherence in diseased population. In particular, increasing intensity and time and
omitting a behavioral model may decrease adherence. The current meta-analysis elu-
cidates gaps in the literature and can assist clinicians and clinical exercise physiolo-
gists in determining the importance of FITT manipulation to exercise adherence.

KEYWORDS
adherence, behavioral model, chronic disease, exercise prescription, physical activity

1  |   IN TRO D U C T ION considerations in interpreting the findings of Rhodes et al3:

The recent scientific report from the 2018 Physical Activity
Guidelines Advisory Committee asserts that physical activ-
ity is a “best buy” for public health.1 However, the initiation
of and adherence to physical activity, particularly exercise is
low, and the global physical inactivity prevalence continues
to rise.2 One means by which adherence to exercise may be
improved is the manipulation of the frequency, intensity, time,
and type (FITT) principle.3,4 In 2009, Rhodes et al3 com-
pleted a systematic review examining the importance of FITT
manipulation to exercise behavior adherence and reported a
lack of unified findings. However, there are several important
(a) Studies published up to November 2007 were included;
(b) studies were not sub-classified according to chronic dis-
ease status; (c) the importance of behavioral model inclusion
was not considered; and (d) the findings were not quantified
using meta-analyses.
The FITT characteristic most commonly manipulated is
“time”.5,6 In particular, high-intensity interval training (HIIT)
has become popular,7 not least because HIIT training tends to
be of shorter duration and the most commonly cited barrier to
exercise participation is a lack of time.8 However, HIIT also
manipulates time and removal of a barrier to exercise, either
perceived or real, may not translate to increased adherence.

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© 2020 John Wiley & Sons Ltd Transl Sports Med. 2020;3:222–234.
BURNET et al.
Additionally, as exercise prescription knowledge grows, it
is clear that exercise prescription is not a “one size fits all
solution”.9 For example, patients with chronic diseases likely
vary in their abilities and needs compared to their healthy
peers.10-12 Relative to non-diseased peers, chronic disease pa-
tients may gain greater benefit from the inclusion of a behav-
ioral model.13,14 The American College of Sports Medicine
(ACSM) recommends taking a social ecological approach
and the utilization of a number of behavioral models in-
cluding the social cognitive theory and the transtheoretical
model.4 While these models may be important to exercise
adherence, no known studies have systematically examined
the interaction between behavioral model inclusion and FITT
manipulation with respect to exercise behavior adherence.
1.1  | Objectives
The current review aimed to identify randomized controlled
trials (RCTs) and quantify the effect of FITT manipulation
on exercise adherence. Subgroup analysis examined the im-
portance of population type (chronic diseased vs healthy)
and inclusion of behavioral model to exercise adherence. The
findings are discussed in terms of their relevance to ACSM
exercise prescription guidelines.
2  |   M ET H O D S
The review utilized the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines.15
2.1  |  Data sources and searches
Two investigators (KB and EK) searched the electronic
databases (PubMed, SPORTDiscus, and Google Scholar)
using population, intervention, control, and outcome (PICO)
search terms: (exercise OR physical activity) AND (adher-
ence) AND (frequency OR intensity OR time OR type OR
mode OR duration). The reference lists of the identified trials
and reviews were also examined. The research was limited to
English-language articles published between database incep-
tion and September 2018.
2.2  |  Article selection
For the purpose of this meta-analysis, the term “article”
is used synonymously with “study,” and “trial” is the be-
tween-group comparison included in the meta-analysis.
Additionally, the term “exercise” is used synonymously with
“physical activity.” A given article may have resulted in more
  
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than one eligible “trial” if the article included more than one
intervention group. Initially, article titles and abstracts were
screened for relevance. The full texts of potentially eligible
articles were obtained to review eligibility for inclusion. The
following criteria were used to select studies for inclusion in
review: (a) The study was a randomized controlled trial; (b)
frequency, intensity, time, or type was manipulated for one
or more groups; (c) adherence was reported. In studies with
multiple treatment arms and a single control group, the sam-
ple size of the control group was divided by the number of
treatment groups to avoid over-inflation of the sample size.16
Repeated publications for the same trial were only included
once.17,18 Two researchers (KB, EK) completed the study se-
lection independently.
2.3  |  Data extraction and quality assessment
Data extracted for each eligible study included bibliographic
information (author, publication year), baseline participant
characteristics, details of intervention(s), and results of reported
outcomes. Data extraction was completed by three researchers
(KB, SH, EK). Study quality was assessed using the modified
Jadad's score (range 0-5), which includes items related to ran-
domization, blinding, and description of dropout/withdrawals.
Because it is difficult (if not impossible) to blind participants to
an exercise intervention, we considered the blinding of the op-
erator to the outcome assessment as a quality criterion. Quality
assessment was completed by two researchers (KB, EK).
2.4  |  Data synthesis
The pre- and post-intervention values (standard deviation,
SD) were entered into a spreadsheet. When the interven-
tion values were not published, a request of the missing
values was made to the corresponding author, and follow-
ing non-response, the values were estimated based on meth-
ods from the Cochrane Handbook for Systematic Reviews
of Interventions.16 For articles reporting multiple time
points, only the final time point was used in the analyses.
Aggregation and calculation of final results were conducted
by two authors (KB, SH).
2.5  |  Data analysis
All extracted data were entered into software designed
specifically for meta-analyses (Open Meta-Analyst, http://
www.cebm.brown.edu/open_meta). Meta-analysis and
meta-regression were run as random-effects models, with
the DerSimonian-Laird method, to account for both within-
and between-study variability.19 Publication bias, that is,
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224       BURNET et al.
smaller studies showing larger effects, was evaluated by
visual inspection of the Begg's funnel plot when (a) at least
10 trials were included in the meta-analysis, and (b) there
was substantial variation in sample size for the included
trials.16 Sensitivity analyses were carried out by exclud-
ing one trial at a time to test the robustness of the pooled
results. For meta-analysis, effect sizes are presented as the
mean difference as well as the standardized mean difference
(SMD). The SMD was used to determine the magnitude of
the effect, where <0.2 was defined as trivial, 0.2-0.3 as
small, 0.4-0.8 as moderate, and >0.8 as large.19,20 The sta-
tistical heterogeneity across different trials in meta-analy-
sis was assessed by the I2 statistic,21 where <25% indicates
low risk of heterogeneity, 25%-75% indicates moderate
risk of heterogeneity, and >75% indicates considerable risk
of heterogeneity.21 Univariate meta-regression was used
to determine the association between exercise duration
(months) and adherence (%). Three authors (LS, JR, SH)
conducted the data analysis. Additionally, ancillary analy-
ses were performed to permit less conservative estimates of
the effects of FITT manipulation.
3  |   R ES U LTS
3.1  |  Literature search and trial selection
The previous review included 27 articles.3 In the current review,
10 of these articles were excluded because there was no ma-
nipulation of the FITT principle (n = 1) and adherence (defined
as percentage of attendance to prescribed sessions) was not re-
ported (n = 9). An additional 821 potentially eligible articles
were identified from electronic database searches (Figure 1).
Following screening of abstracts and titles, 771 were excluded
because they did not meet selection criteria. Of the remaining
articles, five were identified for inclusion, totaling 20 articles
(31 trials) included in the current meta-analysis.
3.2  |  Description of the included trials
3.2.1  |  Trial setting and participants
The trials were conducted in Australia (n  =  2),22,23 Canada
(n  =  3),24-26 England (n  =  1),27 Norway (n  =  1),28 and the
United States (n = 13).18,29-40 The intervention settings included
community settings (n  =  9),18,22,23,26,29,31-34 hospital or clinic
(n = 2),24,30 laboratory (n = 12),28,34,36-40 and home (n = 2).18,35
The number of participants included in each trial ranged from
17 to 379, with the number of women in each trial ranging from
0 to 239. The ages of participants ranged from 18 to 89 years.
3.2.2  | Interventions
A brief description of the exercise interventions is
given in Table 1. For frequency, interventions included
5-7  days/wk and 3-4  days/wk.34 For intensity, interven-
tions included high intensity (80% VO2peak, 90%-95%
Max HR),18,22,24,26,30,34,36-38,41 moderate intensity (55%-
59% HRR, 65% HRpeak, 70%-75% Max HR, 40%-55%
VO2peak, 40%-55% HRR),22,24,34,36,38 low intensity (50%
VO2peak),18,38,41 ventilatory threshold (99.8  ±  2.4% Max
HR),24 high-intensity interval training (75%-90% HRR,
90% HRpeak),24,26,37 and vigorous intensity (65%-80%
VO2peak, 65%-80% HRR).36 For time, interventions in-
cluded choice,29 1 × 30-minute session,29,31,33 3 × 10-min-
ute sessions,29,31,33 long bout (30  minutes),27 and short
bout (10  minutes).27 For type, interventions included
swimming,23 walking,23,39 resistance training,38,39,42 aero-
bic,38 and walking/jogging.42 Fourteen of the trials were
supervised.18,22-28,30,34,36,38,39,42
3.3  |  Methodological quality assessment
The methodological assessment of included trials is summa-
rized in Table 1. The quality of the included studies ranged
from 2-5, with a median quality score of 3.6. All of the stud-
ies were randomized, but only five of the articles reported
the method used for randomization.18,22,23,28,34 In all articles,
the population was adequately categorized. Finally, drop-
outs were listed and described in the majority of articles
(n = 16).17,22-27,29,31-33,35-37,39,42
3.4  |  Publication bias and sensitivity analysis
Visual inspection of the funnel plot (Figure 2) indicated no
evidence of publication bias, and sensitivity analysis (Figure
3) indicated that none of the trials unduly influenced the out-
come. Funnel plot and sensitivity analysis were also performed
independently on each FITT category including 10 or more tri-
als: intensity and time. Visual inspection of the funnel plots did
not reveal substantial asymmetry, and none of the trials unduly
influenced the outcome when intensity or time was analyzed
independently.
3.5  |  Synthesis of the results
Frequency, Intensity, Time, and Type manipulation resulted
in a small, non-significant decrease (MD: −1.6, 95% CI:
−4.0 to 0.7) in exercise adherence (Table 2 and Figure 4).
The heterogeneity was high (I2 = 93%), which may partially
be explained by the inclusion of both diseased and healthy
BURNET et al.
F I G U R E 1   Flow diagram of the search and review process
populations, as well as studies with and without inclusion of
a behavioral model.
For all participants, manipulation of intensity resulted in a
moderate, significant decrease in adherence (MD: −3.3, 95%
CI: −6.1 to −0.5). Manipulation of time and type resulted
in a trivial, non-significant decrease and improvement in ex-
ercise adherence, respectively (MD: −0.6, 95% CI: −2.7 to
1.5 and MD: 0.4, 95% CI: −2.5 to 3.4). Finally, manipulation
of frequency resulted in a trivial, non-significant increase in
exercise adherence, though there was only one trial (MD: 2.0,
95% CI: −5.1 to 9.1).
  
|
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For healthy participants, manipulation of intensity re-
sulted in a small, but non-significant decrease in adherence
(MD: −2.0, 95% CI: −9.1 to 5.0), whereas manipulation of
time (MD: 0.5, 95% CI: −1.6 to 2.6) and type (MD: 2.3, 95%
CI: −8.2 to 12.8) resulted in a trivial but non-significant
improvements in exercise adherence. For participants with
chronic diseases, increasing time resulted in a small, signif-
icant decrease in exercise adherence (MD: −4.9, 95% CI:
−9.4 to −0.4). Similar results were seen for increasing in-
tensity, which resulted in a moderate, non-significant (MD:
−3.6, 95% CI: −7.4 to 0.3) decrease in exercise adherence.
T A B L E 1   Characteristics of the included trials, grouped by FITT (frequency, intensity, time, and type) manipulation
|

Ages, years
226      

Sample Female (SD or Duration Behavioral

First Author Refs Quality Country (Setting) Size (n) (n) range) Disease Exp.Grp Con. Grp (m) Model Retention
Frequency Exp. (%) Con. (%)
34
Perri (2002)a 3.5 USA (Laboratory) 379 239 49.8 (8.3) No 5-7d/wk 3-4 d/wk 6 Yes NR NR
Intensity
22
Cox (2003) 5 Australia (Community) 126 126 48.2 (5.6) Yes High Moderate 18 Yes 62 81
41
Gossard (1986) 3 USA (Home) 64 0 49 (6.0) No High Low 3 No 100 95
26
Jung (2015) 3.5 Canada (Community) 32 27 51 (10.0) Yes High Moderate 1 Yes 66 100
18
King (1995)a 5 USA (Community) 269 120 57 (50-65) No High Low 24 No NR NR
18
King (1995)b 5 USA (Community) 269 120 57 (50-65) No High Low 24 No NR NR
30
Lee (1996) 3 USA (Clinic) 197 0 53.8 (0.6) Yes High Low 12 No NR NR
34
Perri (2002)b 3.5 USA (Community) 379 239 49.8 (8.3) No High Low 6 Yes NR NR
24
Rizk (2015)a 4 Canada (Hospital) 35 21 69 (9.0) Yes High VT 3 Yes NR NR
24
Rizk (2015)b 4 Canada (Hospital) 35 21 69 (9.0) Yes Interval High 3 Yes NR NR
24
Rizk (2015)c 4 Canada (Hospital) 35 21 69 (9.0) Yes Interval VT 3 Yes NR NR
36
Slentz (2004)a 3.5 USA (Laboratory) 120 55 52.8 (6.4) Yes Vigorous Moderate 8 No 61 66
36
Slentz (2004)b 3.5 USA (Laboratory) 120 55 52.8 (6.4) Yes Vigorous Moderate 8 No 46 66
37
Vella (2017) 3 USA (Laboratory) 17 10 26.2 (7.8) Yes High Moderate 1.25 No 80 90
38
Visek (2011)a 3 USA (Laboratory) 30 30 73 (1.3) No High Moderate 9 Yes NR NR
28
Wisloff (2007)a 4 Norway (Laboratory) 27 7 75.5 (11.1) Yes Interval Moderate 3 No 100 89
Time
29
Coleman (1999)a 3 USA (Community) 32 18 38.1 (7.6) No 1x30 Choice 4 Yes 83 92
29
Coleman (1999) 3 USA (Community) 32 18 38.1 (7.6) No 3x10 Choice 4 Yes 92 92
b
29
Coleman (1999)c 3 USA (Community) 32 18 38.1 (7.6) No 1x30 3x10 4 Yes 83 92
31
DeBusk (1990) 3 USA (Community) 36 0 51.5 (6.0) No LB SB 2 No 90 90
32
Jakicic (1995) 2 (USA (Community) 56 56 49.1 (6.1) Yes LB SB 5 No 96 89
33
Jakicic (1999) 3 USA (Community) 148 148 36.7 (5.6) Yes LB SB 18 No 76 71
33
Jakicic (1999) 3 (USA (Community) 148 148 36.7 (5.6) Yes LB SB 18 No 76 88
27
Murphy (2000) 3.5 England 47 47 44.4 (6.2) No LB SB 2.5 No 75 75
36
Slentz (2004)c 3.5 USA (Laboratory) 120 55 52.8 (6.4) Yes High Low 8 No 61 46
BURNET et al.

(Continues)
 BURNET et al.   
|
   227

NR
NR
83
92
81
61
Retention

NR
NR
69
65
87
79
Behavioral
Model

Yes

Yes
Yes
No
No
No

F I G U R E 2   Funnel plot (standardized mean difference vs

standard error) for studies meeting inclusion criteria
Duration

6.5

Abbreviations: Con., control; Exp., experimental; LB, long bout; NR, not reported; RT, resistance training; SB, short bout; SD, standard deviation; VT, ventilatory threshold.
6
3

3
9
9
(m)

3.5.1  |  Subgroup analysis: inclusion of

behavioral mode by chronic disease status
Con. Grp

Walk/Jog
Aerobic

Aerobic
Aerobic
Walk

Walk

For all participants, subgroup analysis revealed that omis-

sion of a behavioral model resulted in a moderate, non-
Exp.Grp

significant decrease in exercise adherence (MD: −1.6, CI:

Swim

−4.0 to 0.7), whereas the inclusion of a behavioral model

RT
RT
RT
RT
RT

had no effect on adherence (Table 3). For healthy partici-

pants, omission of a behavioral model resulted in a trivial
Disease

but non-significant decrease in adherence (MD: −0.5, CI:

Yes
No
No
No

No
No

−3.1 to 2.0, Table 3). For participants with chronic dis-

eases, omission of a behavioral model resulted in a mod-
Ages, years

60 (50-70)

74 (70-79)

erate but non-significant decrease in exercise adherence

78.6 (6.8)

73 (1.3)
73 (1.3)
(SD or
range)

(MD: −4.0, CI: −8.3 to 0.2).

25-49

3.6  | Meta-regression
Female

116
24
32
37
30
30
(n)

Overall, there was no association (P = .323) between exer-

Size (n)
Sample

cise intervention duration (months) and exercise adherence

116
33
57
37
30
30

(%; Table 4 and Figure 5). For both healthy and diseased par-
ticipants, there were non-significant (P = .191 and P = .951,
Australia (Community)

respectively, Table 4) associations between intervention du-

Canada (University)
Country (Setting)

ration and exercise adherence. Furthermore, there was no

USA (Laboratory)
USA (Laboratory)

USA (Laboratory)
USA (Laboratory)

association between intervention duration and adherence

in trials that either included or omitted a behavioral model
(P = .552 and P = .515, respectively, Table 4).

3.6.1  |  Ancillary analysis

Quality

5
5
4
4
3
3

A given trial may have been included in more than one

T A B L E 1   (Continued)

Refs

model due to apparent manipulation of several FITT char-

23

39

40

25

38

38

acteristics simultaneously. Such manipulations led to am-

Mangione (2005)

biguity when assigning the primary FITT characteristic for

Pollock (1991)

Visek (2011)b
Visek (2011)c
First Author

comparison in our main analysis. For example, one inter-

Sale (1996)
Cox (2008)

vention28 classified by the author as an intensity manipula-

tion was coded as an intensity comparison within our main
Type

analysis. However, within this intervention, exercise time

 |
228       BURNET et al.
F I G U R E 3   Leave one out analysis
also differed between groups (38 vs 47 minutes) due to the
nature of energy expenditure matching. Thus, to permit
less conservative estimates of the effects of FITT manipu-
lation, separate models were run for frequency, intensity,
time, and type with subgroups examining the effect of inclu-
sion of a behavioral model and chronic disease status (see
Suppl. Table 1-5). Findings from the ancillary analysis
were in accordance with the findings of our main analysis.
Additionally, we assessed the effect of differing exercise en-
vironment, the use of interval training versus continuous ex-
ercise, and defining frequency as number of exercise bouts
rather than exercise days. None of these comparisons re-
sulted in significant effects, likely due to the small numbers
of included trials; however, the environmental comparison
indicated a potential moderate effect in favor of indoor and/
or clinic-based exercise on adherence.
4  |  DISCUSSION
The purpose of this meta-analysis was to review the effects
of FITT manipulation on exercise behavior adherence.
Findings from this meta-analysis suggest that manipula-
tion of FITT results in a small, non-significant decrease in
exercise adherence, that is, FITT manipulation was harm-
ful rather than beneficial. Increasing exercise intensity was
most harmful to adherence. Importantly, we found that
the chronic disease status of the population needs to be
BURNET et al.   
|
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T A B L E 2   Adherence meta-analysis: effects of FITT (frequency, intensity, time, and type) manipulation with subgroup analysis by chronic
disease status

Pooled Effect Heterogeneity

Trials Sample
Subgroup   (n) (n) MD (95% CI) P SMD I2 P
All (vs Con.) 31 2076 −1.6 (−4.0 to 0.7) .171 −0.21 93% <.001
  Frequency 1 328 2.0 (−5.1 to 9.1) N/A 0.06 N/A N/A
  Intensity 15 1184 −3.3 (−6.1 to −0.5) .020 −0.45 81% <.001
  Time 9 379 −0.6 (−2.7 to 1.5) .605 −0.11 59% .012
  Type 6 185 0.4 (−2.5 to 3.4) .785 0.15 67% .010
Healthy   16 1326 −0.5 (−3.1 to 2.0) .677 −0.05 86% <.001
  Frequency 1 328 2.0 (−5.1 to 9.1) N/A 0.06 N/A N/A
  Intensity 6 752 −2.0 (−9.1 to 5.0) .575 −0.30 81% <.001
  Time 5 124 0.5 (−1.6 to 2.6) .663 0.16 66% .018
  Type 4 122 2.3 (−8.2 to 12.8) .663 0.16 72% .014
Diseased   15 750 −3.4 (−7.4 to 0.7) .105 −0.40 93% <.001
  Frequency 0 0 N/A N/A to N/A N/A N/A N/A N/A
  Intensity 9 432 −3.6 (−7.4 to 0.3) .070 −0.54 77% <.001
  Time 4 255 −4.9 (−9.4 to −0.4) .032 −0.28 0% .666
  Type 2 63 −0.9 (−7.5 to 5.8) .799 0.12 68% .079
Abbreviations: CI, confidence interval; FITT, frequency, intensity, time, type; MD, mean difference; SMD, standardized mean difference.

considered. While FITT manipulation had a non-significant
effect for healthy populations, in populations with chronic
diseases, increasing intensity or time had a small-moderate
negative effect on exercise adherence. Additionally, in-
clusion of a behavioral model had a non-significant effect
for healthy populations, but for populations with chronic
disease, the absence of a behavioral model resulted in a
moderate negative effect, albeit the confidence interval did
cross zero.
4.1  |  Comparison with other studies
Our primary meta-analysis findings lead to a different in-
terpretation to that provided by Rhodes et al following their
systematic review.3 Contrary to Rhodes et al, who reported
that FITT manipulation did not affect exercise behavior ad-
herence, we found a moderate negative effect for increas-
ing exercise intensity. These differences may be due to the
addition of five studies23,24,26,37,38 published in the preced-
ing 11 years and the exclusion of 10 articles42-52 that were
included in the Rhodes et al study. The 10 articles were
excluded because we were unable to determine study effect
sizes, in particular, the articles did not report adherence
(%)43-48,50-53 and did not manipulate a component of the
FITT principle.54
The finding that increasing exercise intensity has a nega-
tive effect on adherence is in accordance with an earlier re-
view by Dishman et al,55 who concluded that high-intensity
activities may negatively influence behavior. However, these
findings are contrary to the popular idea that HIIT may be
a more viable, time-efficient option to increase adherence
to exercise.7,56,57 In interpreting these findings, it should be
considered that while our primary meta-analysis attempted
to isolate the independent effect of intensity and time ma-
nipulation, HIIT training typically simultaneously increases
intensity while decreasing time. Findings from our primary
analysis (Table 2) indicate that manipulation of time has a
non-significant effect on adherence, while the effect of in-
tensity is significant. We did also conduct a less conservative
ancillary analysis, in which a given trial may have been clas-
sified as manipulating both time and intensity, and where we
compared interval to continuous training. Findings from the
less conservative ancillary analyses are in accordance with
the primary analysis, and interval training did not improve
exercise adherence when compared to continuous training.
Nonetheless, time is considered the primary barrier to ex-
ercise participation, and given the popularity of HITT pre-
scription, further study is warranted which directly compares
HITT to time- and intensity-matched continuous training.
4.2  |  Chronic diseased vs healthy
populations
Findings from our subgroup analysis indicate that while
FITT manipulation had a non-significant effect for healthy
populations, in populations with chronic diseases increasing
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230       BURNET et al.

F I G U R E 4   Meta-analysis: of FITT (frequency, intensity, time, and type) manipulation on exercise adherence. The dashed vertical line
indicates the mean difference (effect size). CI, confidence interval; IV, inverse-variance method; SD, standard deviation

intensity or time had a small-moderate negative effect on ex-
ercise adherence. It should be emphasized that the heteroge-
neity for both populations was high, which may be ascribed
to varying manipulation of FITT, varying quality of included
trials (Jadad range: 2-5), variety in sample populations (age,
gender, diseased status), low number of trials, and the vary-
ing duration of studies, which ranged from 1 to 18 months.
However, meta-regression findings do indicate a lack of sig-
nificant effect of study duration on exercise adherence for
both populations. Further study is warranted to examine the
effects of FITT manipulation, particularly intensity and time,
on exercise behavior adherence in populations with chronic
disease.
4.3  |  Inclusion of behavioral model
The absence of a behavioral model resulted in a moderate
decrease in exercise behavior adherence in all participants,
albeit the confidence interval did cross zero. Subgroup analy-
sis revealed that this effect is likely driven by chronic disease
status. While inclusion of a behavioral model had a non-sig-
nificant effect for healthy populations, for populations with
chronic diseases the absence of a behavioral model resulted
in a moderate negative effect; however, the confidence in-
terval did cross zero. The lack of effect for healthy popu-
lations is surprising when considering that the inclusion of
behavioral models within exercise prescription is supported
BURNET et al.   
|
   231

T A B L E 3   Adherence meta-analysis: effects of behavioral model inclusion with subgroup analysis by chronic disease status

Pooled Effect Heterogeneity

Trials Sample
Subgroup Behavior (n) (n) MD (95% CI) P SMD I2 P
All (vs Con.) 31 2076 −1.6 (−4.0 to 0.7) .171 −0.21 93% <.001
  Yes 15 1039 −0.1 (−3.9 to 3.7) .952 −0.02 59% .002
  No 16 1037 −2.5 (−5.5 to 0.4) .092 −0.42 96% <.001
Healthy   16 1326 −0.5 (−3.1 to 2.0) .677 −0.05 86% <.001
  Yes 10 928 −0.4 (−4.6 to 3.9) .856 −0.02 67% .001
  No 6 398 −0.5 (−4.1 to 3.1) .780 −0.14 94% <.001
Diseased   15 750 −3.4 (−7.3 to 0.4) .082 −0.40 93% <.001
  Yes 5 111 −0.3 (−8.0 to 7.5) .945 −0.04 8% .359
  No 10 639 −4.0 (−8.3 to 0.2) .062 −0.58 95% <.001
Abbreviations: CI, confidence interval; FITT, frequency, intensity, time, type; MD, mean difference; SMD, standardized mean difference.

T A B L E 4   Adherence meta-regression:
Pooled Effect
effects of FITT (frequency, intensity, Trials Sample
time, and type) manipulation and exercise Subgroup   (n) (n) ß (95% CI) P
intervention duration (months) with
Disease All (vs Con.) 31 2076 −0.2 (−0.5 to 0.2) .323
subgroup analysis by chronic disease status
  Healthy 16 1326 −0.3 (−0.9 to 0.2) .191
and by behavioral model inclusion
  Diseased 15 750 0.0 (−0.5 to 0.5) .951
Behavior All (vs Con.) 31 2076 −0.2 (−0.5 to 0.2) .323
  Yes 15 1039 −0.3 (−1.2 to 0.6) .552
  No 16 1037 −0.1 (−0.5 to 0.3) .515
Abbreviations: Β, beta coefficient; CI, confidence interval.

F I G U R E 5   Univariate random-effects
meta-regression scatter plots: exercise
duration (months) and exercise adherence
(%)

in a variety of populations.58-61 However, it should be em-
phasized that the effects were heterogeneous. Although the
quality of the trials was relatively high (JADAD: 3.5-4.0),
there was substantial variation between studies in terms of
the populations included. More importantly, a wide variety
of behavioral models were prescribed, including the stages of
change model,22 social cognitive theory,26 and measurement
of affective response.24
Given the low number of included trails, the current
meta-analysis was unable to determine the importance of
specific behavioral models. That being said, it should also
be considered that the absence of a behavioral model was
most important. As such, it may be postulated that elements
common to most behavioral models, such as social interac-
tion, accountability, and building self-efficacy may be more
important than the exact behavioral model. Further study is
required to decipher the interaction between specific behav-
ioral models, specific components of behavioral models, and
FITT manipulation, especially for populations with chronic
diseases.
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232       BURNET et al.
4.4  |  Limitations and strengths
There are several limitations when considering these find-
ings. First, the sample size of included trials was gener-
ally small. Second, the majority of trials were mixed sex,
and it remains unclear whether sex moderates the relation-
ship between FITT manipulation and adherence. Third, the
quality of the included trials was generally suboptimal,
and lacked detail of exercise interventions used. Lastly,
the interpretation of findings is confounded by the high
proportion of studies that manipulate more than one FITT
component. We did attempt to address this, within the
bounds of the data, by running ancillary analyses that ex-
amined all potential classifications of FITT. Strengths of
this meta-analysis included the ancillary analysis, which
was in accordance with our primary findings, and sub-
group analysis by chronic disease status and inclusion of
behavioral models. Additionally, the current findings pro-
vide a timely update the previous systematic review on the
topic 3 and make an important contribution to exercise pre-
scription guidelines.
5  |   P E R S P E C T IV E
Prior to this meta-analysis, a systematic review con-
cluded that FITT manipulation has no consistent, discern-
able effect on exercise behavior adherence. However,
the previous review was limited to studies published up
until November 2007. The present meta-analysis also in-
cludes literature published between November 2007 and
September 2018. Additionally, the current meta-analysis
conducted subgroup analysis by chronic disease status and
behavioral model inclusion. The meta-analysis findings
suggest that manipulation of FITT results in a small, non-
significant decrease in exercise adherence. However, the
findings differed by chronic disease status. While FITT
manipulation had a non-significant effect for healthy pop-
ulations, in populations with chronic diseases, increasing
intensity or time had a small-moderate negative effect
on exercise adherence. Additionally, inclusion of a be-
havioral model had a non-significant effect for healthy
populations, but for populations with chronic disease,
the absence of a behavioral model resulted in a moderate
negative effect; albeit the confidence interval did cross
zero. Practically, these findings help clinicians and clini-
cal exercise physiologists in determining the importance
of FITT manipulation to exercise behavior adherence, in
both healthy and chronic diseased populations. Moving
forward, future research should explore how the inclusion
of specific behavioral models interact with one or more
FITT component(s) to influence exercise behavior adher-
ence, in populations with and without chronic diseases.
CONFLICTS OF INTEREST
Kathryn Burnet, Simon Higgins, Elizabeth Kelsch, Justin
B. Moore, and Lee Stoner declare that they have no con-
flicts of interest relevant to the content of this review.
ORCID
Kathryn Burnet  https://orcid.org/0000-0001-5008-5389
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SUPPORTING INFORMATION
Additional supporting information may be found online in
the Supporting Information section. 
How to cite this article: Burnet K, Higgins S, Kelsch
E, Moore JB, Stoner L. The effects of manipulation of
Frequency, Intensity, Time, and Type (FITT) on
exercise adherence: A meta-analysis. Transl Sports
Med. 2020;3:222–234. https​://doi.org/10.1002/tsm2.138