1. Meta-Analysis of Anthropometric Outcomes of Motivational Physical Activity Interventions Jo-Ana D. Chase MN APN-BC Todd Ruppar PhD RN GCNS-BC Lorraine J. Phillips PhD RN Vicki S. Conn PhD RN FAAN University of Missouri Sinclair School of Nursing Jo-Ana D. Chase MN APN-BC Todd Ruppar PhD RN GCNS-BC Lorraine J. Phillips PhD RN Vicki S. Conn PhD RN FAAN University of Missouri Sinclair School of Nursing

2. Acknowledgements Parent study and funding: Meta-analysis of interventions to increase exercise/physical activity (R01NR009656, Dr. Vicki Conn – Principal Investigator)

3. Background Prevalence of obesity increasing Obesity linked with multiple chronic illnesses (Guh, et al, 2009; Suzuki, Orsini, Safi, Key, & Wolk, 2009) Inadequate physical activity (PA) contributes to epidemic of obesity (Rossner, et al., 2008; Wareham, van Slujs, & Ekelund, 2005) Many interventions designed to motivate subjects to increase PA have also examined anthropometric outcomes Prevalence of obesity increasing Obesity linked with multiple chronic illnesses (Guh, et al, 2009; Suzuki, Orsini, Safi, Key, & Wolk, 2009) Inadequate physical activity (PA) contributes to epidemic of obesity (Rossner, et al., 2008; Wareham, van Slujs, & Ekelund, 2005) Many interventions designed to motivate subjects to increase PA have also examined anthropometric outcomes

4. Background Prior meta-analyses of PA anthropometric outcomes Limited with no moderator analysis No separation of outcomes for diet or PA interventions Most comprehensive meta-analysis of PA on anthropometric outcomes – Ballor and Keesey, 1991 Prior meta-analyses of PA anthropometric outcomes Limited with no moderator analysis No separation of outcomes for diet or PA interventions Most comprehensive meta-analysis of PA on anthropometric outcomes – Ballor and Keesey, 1991

5. Research Questions What is the overall effect of interventions designed to motivate subjects to increase PA on anthropometric outcomes? Do anthropometric effects of these interventions vary depending on intervention, sample, or design attributes? What is the overall effect of interventions designed to motivate subjects to increase PA on anthropometric outcomes? Do anthropometric effects of these interventions vary depending on intervention, sample, or design attributes?

6. Methods Comprehensive search  motivational PA intervention studies reporting anthropometric outcomes (e.g., BMI, percent body fat, central obesity) in healthy adult subjects “Motivational PA intervention” = any deliberate intervention intended to motivate subjects to increase PA behavior, excluding supervised exercise sessions Comprehensive search  motivational PA intervention studies reporting anthropometric outcomes (e.g., BMI, percent body fat, central obesity) in healthy adult subjects “Motivational PA intervention” = any deliberate intervention intended to motivate subjects to increase PA behavior, excluding supervised exercise sessions

7. Methods – Data Extraction Coding frame developed from prior, related research and pilot tested Study characteristics (e.g., published/unpublished, funding) Sample characteristics (e.g., age, gender) Intervention characteristics (e.g., dose, delivery) Effect size information Coding frame developed from prior, related research and pilot tested Study characteristics (e.g., published/unpublished, funding) Sample characteristics (e.g., age, gender) Intervention characteristics (e.g., dose, delivery) Effect size information

8. Methods – Data Extraction Studies coded by two independent and extensively trained coders Coders compared all variables to reach consensus All effect size data independently verified by doctorally prepared researcher Studies coded by two independent and extensively trained coders Coders compared all variables to reach consensus All effect size data independently verified by doctorally prepared researcher

9. Methods - Analysis Standardized mean difference effect sizes (ES, d) under random-effects model Studies weighted by inverse of the variance Heterogeneity examined: Q statistic and I 2 Exploratory moderator analyses – meta-analytic analogues of ANOVA (dichotomous moderators) and regression (continuous moderators) Standardized mean difference effect sizes (ES, d) under random-effects model Studies weighted by inverse of the variance Heterogeneity examined: Q statistic and I 2 Exploratory moderator analyses – meta-analytic analogues of ANOVA (dichotomous moderators) and regression (continuous moderators) Pooled standard deviation d = mean treatment - mean control

10. Study Characteristics Reviewed 54,642 potentially eligible reports ES calculated from data for 94,711 subjects Two group comparisons: 76 comparisons 94,711 subjects Single group, treatment pre-post comparisons 436 comparisons 56,258 subjects Reviewed 54,642 potentially eligible reports ES calculated from data for 94,711 subjects Two group comparisons: 76 comparisons 94,711 subjects Single group, treatment pre-post comparisons 436 comparisons 56,258 subjects

11. Sample Characteristics Sample sizes Two group: median 56 subjects Single group: median 52 subjects Percent female: median 81% Percent minority: median 15% Baseline BMI: median 27-30 kg/m 2

12. Intervention Characteristics Number of intervention strategies: median 3 Total number of intervention minutes: median 720 minutes Recommended minutes of PA per session: median 30 minutes Recommended minutes of PA per week: median 140 minutes Number of intervention strategies: median 3 Total number of intervention minutes: median 720 minutes Recommended minutes of PA per session: median 30 minutes Recommended minutes of PA per week: median 140 minutes

13. Results – Anthropometric Outcomes k=number of comparisons ES=effect size p=test of statistical significance for effect size I 2 =index of heterogeneity beyond within-study sampling error

14. Effect Size Meanings Converted ES to original metrics – weight (kg) and BMI Mean difference of 1.3 kg between treatment and control subjects at outcome BMI difference of 0.4 between treatment and control subjects at outcome (ex. 27 vs. 27.4)

15. Results – Moderator Analyses Larger ESs for interventions using transtheoretical model (TTM) (d=0.21) vs. social cognitive theory (SCT) (d=0.07) Studies with mean ages in 30s and early 60s demonstrated higher ESs than studies with other age groups Studies recommending walking were not more effective in improving anthropometric outcomes than studies recommending other forms of exercise Larger ESs for interventions using transtheoretical model (TTM) (d=0.21) vs. social cognitive theory (SCT) (d=0.07) Studies with mean ages in 30s and early 60s demonstrated higher ESs than studies with other age groups Studies recommending walking were not more effective in improving anthropometric outcomes than studies recommending other forms of exercise

16. Limitations Study specific Anthropometric measurement error Low reporting of ethnic diversity among samples Long-term results not often examined Study quality and treatment fidelity Meta-analysis specific Exclusion of studies based on insufficient information Findings observational Moderator analyses – hypothesis generating

17. Discussion Findings support significant improvements in anthropometric outcomes associated with motivational PA interventions Future research to directly compare TTM- based to SCT-based interventions Future research to test interventions recommending varied forms of PA (not just walking) Findings support significant improvements in anthropometric outcomes associated with motivational PA interventions Future research to directly compare TTM- based to SCT-based interventions Future research to test interventions recommending varied forms of PA (not just walking)

18. References Ballor, D. L., & Keesey, R. E. (1991). A meta-analysis of the factors affecting exercise-induced changes in body mass, fat mass and fat-free mass in males and females. International Journal of Obesity, 15(11), 717-726. Guh, D. P., Zhang, W., Bansback, N., Amarsi, Z., Birmingham, C. L., & Anis, A. H. (2009). The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health, 9, 88. Rossner, S., Hammarstrand, M., Hemmingsson, E., Neovius, M., & Johansson, K. (2008). Long-term weight loss and weight-loss maintenance strategies. Obesity Reviews, 9(6), 624-630. Suzuki, R., Orsini, N., Saji, S., Key, T. J., & Wolk, A. (2009). Body weight and incidence of breast cancer defined by estrogen and progesterone receptor status--a meta-analysis. International Journal of Cancer, 124(3), 698-712. Wareham, N. J., van Sluijs, E. M. F., & Ekelund, U. (2005). Physical activity and obesity prevention: a review of the current evidence.[erratum appears in Proc Nutr Soc. 2005 Nov;64(4):581-4]. Proceedings of the Nutrition Society, 64(2), 229-247.