Methodological Standards for Meta-Analyses and Qualitative Systematic Reviews of Cardiac Prevention and Treatment Studies: A Scientific Statement From the American Heart Association.

Meta-analyses are becoming increasingly popular, especially in the fields of cardiovascular disease prevention and treatment. They are often considered to be a reliable source of evidence for making healthcare decisions. Unfortunately, problems among meta-analyses such as the misapplication and misinterpretation of statistical methods and tests are long-standing and widespread. The purposes of this statement are to review key steps in the development of a meta-analysis and to provide recommendations that will be useful for carrying out meta-analyses and for readers and journal editors, who must interpret the findings and gauge methodological quality. To make the statement practical and accessible, detailed descriptions of statistical methods have been omitted. Based on a survey of cardiovascular meta-analyses, published literature on methodology, expert consultation, and consensus among the writing group, key recommendations are provided. Recommendations reinforce several current practices, including protocol registration; comprehensive search strategies; methods for data extraction and abstraction; methods for identifying, measuring, and dealing with heterogeneity; and statistical methods for pooling results. Other practices should be discontinued, including the use of levels of evidence and evidence hierarchies to gauge the value and impact of different study designs (including meta-analyses) and the use of structured tools to assess the quality of studies to be included in a meta-analysis. We also recommend choosing a pooling model for conventional meta-analyses (fixed effect or random effects) on the basis of clinical and methodological similarities among studies to be included, rather than the results of a test for statistical heterogeneity.

Development of Participant-Informed Text Messages to Promote Physical Activity Among African American Women Attending College: A Qualitative Mixed-Methods Inquiry.

The purpose of this study was to develop a participant-informed technology-based physical activity (PA) promotion tool for young overweight and obese African American (AA) women. A mixed-method 3-phase study protocol design was used to develop text messages to promote PA in AA women attending the University of Alabama at Birmingham during the Spring of 2013. Nominal focus groups and a 2-week pilot were used to generate and test participant-developed messages. Participants ( n = 14) had a mean age of 19.79 years ( SD = 1.4) and mean body mass index of 35.9 ( SD = 5.926). Focus group data identified key themes associated with the use of text messages to promote PA including message frequency, length, tone, and time of day. Participants preferred text messages that were brief, specific, and time sensitive. Results showed that text messaging was a feasible and acceptable strategy to promote PA in overweight and obese AA women in a university setting.

Association of Mediterranean diet and cardiorespiratory fitness with the development of pre-diabetes and diabetes: the Coronary Artery Risk Development in Young Adults (CARDIA) study.

OBJECTIVE: To better understand the association between a modified Mediterranean diet pattern in young adulthood, cardiorespiratory fitness in young adulthood, and the odds of developing pre-diabetes or diabetes by middle age. RESEARCH DESIGN AND METHODS: Participants from the Coronary Artery Risk Development in Young Adults (CARDIA) study who did not have pre-diabetes or diabetes at baseline (year 0 (Y0), ages 18-30) and who had data available at the Y0 and year 25 (Y25) visits were included in this analysis (n=3358). Polytomous logistic regression models were used to assess the association between baseline dietary intake and fitness data and odds of pre-diabetes or diabetes by middle age (Y25, ages 43-55). RESULTS: At the Y25 visit, 1319 participants (39%) had pre-diabetes and 393 (12%) had diabetes. Higher baseline fitness was associated with lower odds of pre-diabetes and of diabetes at Y25. After adjustment for covariates, each SD increment in treadmill duration (181 s) was associated with lower odds for pre-diabetes (OR 0.85, 95% CI 0.75 to 0.95, p=0.005) and for diabetes (OR 0.71, 95% CI 0.60 to 0.85, p=0.0002) when compared to normal glycemia. A modified Mediterranean diet pattern was not associated with either pre-diabetes or diabetes. No interaction between cardiorespiratory fitness and dietary intake was observed, but baseline fitness remained independently associated with incident pre-diabetes and diabetes following adjustment for diet. CONCLUSIONS: Higher cardiorespiratory fitness in young adulthood, but not a modified Mediterranean diet pattern, is associated with lower odds of pre-diabetes and of diabetes in middle age. TRIAL REGISTRATION NUMBER: NCT00005130.

25-year weight gain in a racially balanced sample of U.S. adults: The CARDIA study.

OBJECTIVE: To examine 25-year trends in weight gain, partitioned by time-related and aging-related changes, during early and middle adulthood. METHODS: Coronary Artery Risk Development in Young Adults (CARDIA), a prospective, non-nationally representative cohort study conducted at four urban field centers that began in 1985 to 1986 with 5,109 Black (B) and White (W) men (M) and women (W) aged 18 to 30 years, has followed participants for 25 years (aged 43-55 years in 2010-2011). Time-related and aging-related components of weight change were estimated to construct longitudinal models of linear and nonlinear trends. RESULTS: There were nonlinear trends in time-related weight gain in W, with larger weight gains early that attenuated at subsequent exams. Time-related trends were linear in M. There were nonlinear trends in aging-related weight gain in BM, BW, and WM, with the greatest weight gains at younger ages. Aging-related trends were linear in WW. Participants with overweight or obesity in early adulthood had greater attenuation of aging-related weight gain during middle adulthood. CONCLUSIONS: These findings partially support recent surveys indicating slower increases in obesity prevalence in recent years. Findings further suggest that aging-related weight gain is greatest in the 20s and may begin attenuating as early as the mid-30s among some groups.

Results of a Culturally Adapted Internet-Enhanced Physical Activity Pilot Intervention for Overweight and Obese Young Adult African American Women.

PURPOSE: This study evaluated a culturally relevant, social cognitive theory-based, Internet-enhanced physical activity (PA) pilot intervention developed for overweight/obese African American (AA) female college students. DESIGN: Using a 3-month, single group, pretest-posttest design, participants accessed a culturally relevant PA promotion website and engaged in four moderate-intensity PA sessions each week. RESULTS: Study completers (n = 25, mean age = 21.9 years) reported a decrease in sedentary screen time (p < .0001); however, no changes in moderate-to-vigorous PA were reported (p = .150). A significant increase in self-regulation for PA (p < .0001) and marginally significant increases in social support (p = .052) and outcome expectations (p = .057) for PA were observed. No changes in body mass index (p = .162), PA enjoyment (p = .151), or exercise self-efficacy (p = .086) were reported. CONCLUSIONS: Findings of this exploratory study show some preliminary support for Internet-enhanced approaches to promote PA among overweight/obese AA women. IMPLICATIONS FOR PRACTICE: Future studies with larger samples are needed to further explore culturally relevant Internet-enhanced PA programs in this underserved population.

Feasibility, acceptability, and characteristics associated with adherence and completion of a culturally relevant internet-enhanced physical activity pilot intervention for overweight and obese young adult African American women enrolled in college.

BACKGROUND: African American women are one of the least active demographic groups in the US, with only 36% meeting the national physical activity recommendations in comparison to 46% of White women. Physical activity begins to decline in African American women in adolescence and continues to decline into young adulthood. Yet, few interventions have been developed to promote physical activity in African American women during this critical period of life. The purpose of this article was to evaluate the acceptability and feasibility of a culturally-relevant Internet-enhanced physical activity pilot intervention for overweight/obese African American college females and to examine psychosocial and behavioral characteristics associated with intervention adherence and completion. METHODS: A 6-month single group pre-posttest design was used. Participants (n = 27) accessed a culturally-relevant Social Cognitive Theory-based physical activity promotion website while engaging in a minimum of four moderate-intensity physical activity sessions each week. Acceptability and feasibility of the intervention was assessed by participant retention and a consumer satisfaction survey completed by participants. RESULTS: Fifty-six percent of participants (n = 15) completed the intervention. Study completers were more physically active at baseline (P = 0.05) and had greater social support for exercise from family members (P = 0.04). Sixty percent of study completers (n = 9) reported the website as "enjoyable" or "very enjoyable" to use and 60% (n = 9) reported increased motivation from participation in the physical activity program. Moreover, 87% (n = 13) reported they would recommend the website to a friend. CONCLUSIONS: Results provide some preliminary support for the acceptability and feasibility of an Internet-enhanced physical activity program for overweight/obese African American women, while highlighting important limitations of the approach. Successful promotion of physical activity in college aged African American women as they emerge into adulthood may result in the development of life-long healthy physical activity patterns which may ultimately reduce physical activity-related health disparities in this high risk underserved population. Future studies with larger samples are needed to further explore the use of Internet-based programs to promote physical activity in this population.

Association of a 62 Variants Type 2 Diabetes Genetic Risk Score With Markers of Subclinical Atherosclerosis: A Transethnic, Multicenter Study.

BACKGROUND: Type 2 diabetes mellitus (T2D) and cardiovascular disease share risk factors and subclinical atherosclerosis (SCA) predicts events in those with and without diabetes mellitus. T2D genetic risk may predict both T2D and SCA. We hypothesized that greater T2D genetic risk is associated with higher extent of SCA. METHODS AND RESULTS: In a cross-sectional analysis, including ≤9210 European Americans, 3773 African Americans, 1446 Hispanic Americans, and 773 Chinese Americans without known cardiovascular disease and enrolled in the Framingham Heart Study, Coronary Artery Risk Development in Young Adults, Multi-Ethnic Study of Atherosclerosis, and Genetic Epidemiology Network of Arteriopathy studies, we tested a 62 T2D-loci genetic risk score for association with measures of SCA, including coronary artery or abdominal aortic calcium score, common and internal carotid artery intima-media thickness, and ankle-brachial index. We used ancestry-stratified linear regression models, with random effects accounting for family relatedness when appropriate, applying a genetic-only (adjusted for sex) and a full SCA risk factors-adjusted model (significance, P<0.01=0.05/5, number of traits analyzed). An inverse association with coronary artery calcium score in Multi-Ethnic Study of Atherosclerosis Europeans (fully-adjusted P=0.004) and with common carotid artery intima-media thickness in the Framingham Heart Study (P=0.009) was not confirmed in other study cohorts, either separately or in meta-analysis. Secondary analyses showed no consistent associations with ß-cell and insulin resistance genetic risk sub-scores in the Framingham Heart Study and in the Coronary Artery Risk Development in Young Adults. CONCLUSIONS: SCA does not have a major genetic component linked to a burden of 62 T2D loci identified by large genome-wide association studies. A shared T2D-SCA genetic basis, if any, might become apparent from better functional information about both T2D and cardiovascular disease risk loci.

Internet-Based Physical Activity Interventions.

This article provides a comprehensive review of Internet- and Website-based physical activity interventions targeting adult populations. Search procedures identified 72 unique Internet-based physical activity interventions published in peer-reviewed journals. Participants of the studies were predominately White, middle-aged (mean age = 43.3 years), and female (65.9%). Intervention durations ranged from 2 weeks to 13 months (median = 12 weeks). Forty-six of the studies were randomized controlled trials, 21 were randomized trials without a control condition, 2 were non-randomized controlled trials, and 3 used a single-group design. The majority of studies (n = 68) assessed outcomes immediately following the end of the intervention period, and 16 studies provided delayed postintervention assessments. Forty-four of the 72 studies (61.1%) reported significant increases in physical activity. Future directions for Internet-based physical activity interventions include increasing representation of minority and male populations in Internet-based efforts, conducting delayed postintervention follow-up assessments, and incorporating emerging technologies (ie, cellular and Smartphones) into Internet-based physical activity efforts.

Recommendations for a culturally relevant Internet-based tool to promote physical activity among overweight young African American women, Alabama, 2010-2011.

INTRODUCTION: Innovative approaches are needed to promote physical activity among young adult overweight and obese African American women. We sought to describe key elements that African American women desire in a culturally relevant Internet-based tool to promote physical activity among overweight and obese young adult African American women. METHODS: A mixed-method approach combining nominal group technique and traditional focus groups was used to elicit recommendations for the development of an Internet-based physical activity promotion tool. Participants, ages 19 to 30 years, were enrolled in a major university. Nominal group technique sessions were conducted to identify themes viewed as key features for inclusion in a culturally relevant Internet-based tool. Confirmatory focus groups were conducted to verify and elicit more in-depth information on the themes. RESULTS: Twenty-nine women participated in nominal group (n = 13) and traditional focus group sessions (n = 16). Features that emerged to be included in a culturally relevant Internet-based physical activity promotion tool were personalized website pages, diverse body images on websites and in videos, motivational stories about physical activity and women similar to themselves in size and body shape, tips on hair care maintenance during physical activity, and online social support through social media (eg, Facebook, Twitter). CONCLUSION: Incorporating existing social media tools and motivational stories from young adult African American women in Internet-based tools may increase the feasibility, acceptability, and success of Internet-based physical activity programs in this high-risk, understudied population.

Lessons Learned from the Development and Implementation of Two Internet-enhanced Culturally Relevant Physical Activity Interventions for Young Overweight African-American Women.

This research team has designed and implemented 2 culturally relevant, Internet-enhanced physical activity (PA) interventions for overweight/obese African-American female college students. Presumably, these are the only prospectively designed, culturally relevant interventions using the Internet to promote PA among African-American women. Due to the limited research on this topic, the experiences associated the design and implementation of these studies were syntesized and 5 key lessons learned from this research were formulated. Findings provide insight for researchers to consider when developing Internet-based PA promotion interventions for African-American women. Lessons learned included: 1) Elicit and incorporate feedback from the target population throughout development of an Internet-based PA promotion tool; 2) Incorporate new and emerging technologies into Internet-enhanced PA programs; 3) Maintain frequent participant contact and provide frequent incentives to promote participant engagement; 4) Supplement Internet-based efforts with face-to-face interactions; 5) Include diverse images of African-American women and culturally relevant PA-related information in Internet-based PA promotion materials.

Physical Activity and Social Cognitive Theory Outcomes of an Internet-Enhanced Physical Activity Intervention for African American Female College Students.

BACKGROUND: African American women report low levels of physical activity (PA) and are disproportionately burdened by related chronic diseases. This pilot study tested a 6-month theory-based (Social Cognitive Theory, SCT) culturally-relevant website intervention to promote PA among African American female college students. MATERIALS AND METHODS: A single group pre-post test design (n=34) was used. PA and associated SCT constructs (outcome expectations, enjoyment, self-regulation, social support) were assessed at baseline, 3 months and 6 months. RESULTS: The sample was comprised of mostly obese (M BMI= 35.4, SD=6.82) young adults (M age= 21.21 years, SD=2.31). Fifty percent of the sample completed all assessments. Intent-to-treat analyses showed that participants reported a significant median improvement in moderate-to-vigorous physical activity from 82.5 minutes/week (M=81.76, SD=76.23) at baseline to 115.0 minutes/week (M=122.44, SD=97.93) at 3 months (Wilcoxon z=2.39, p=.02). However these gains appear to have attenuated by 6 months (Median= 82.5 minutes/week, M=96.73, SD=84.20; Wilcoxon z=1.02, p=.31). Significant increases from baseline to 6 months were found in self-regulation for PA (p=.02) and social support for PA from friends (p=.02). Changes in the SCT variables were not significantly associated with changes in PA; however, this may have been due to small sample size. CONCLUSIONS: Future studies with larger samples and more aggressive retention strategies (e.g., more frequent incentives, prompts for website use) are needed to further explore the applicability of web-based approaches to promote PA in this at-risk population.

Attitudes and beliefs associated with leisure-time physical activity among African American adults.

OBJECTIVE: More than 60% of African American adults do not meet recommendations for moderate physical activity. We sought to discover the extent to which health attitudes and beliefs are associated with leisure-time physical activity in this population. DESIGN: Cross-sectional study. SETTING: African American adults were asked about their health attitudes and beliefs during a national survey. PARTICIPANTS: Participants were 807 African American men and women aged 18 years and older. Random-digit dialing was employed, sampling telephone numbers by geographical region, area code, and population size. MAIN OUTCOME MEASURES: Participants were asked six health belief questions on the importance of exercise and body weight in health. Logistic regression was used to determine which of these factors were associated with physical activity participation. RESULTS: The percent of respondents participating in some form of physical activity during the past month was 87.1% in men and 82.9% in women. Factors associated with previous month physical activity in men were perceived personal importance of exercise (P < .001) and necessity of exercise for health (P = .018). In women, perceived personal importance of exercise (P < .001), necessity of exercise for health (P = .006), and having enough activity space (P = .017) were associated with physical activity participation. CONCLUSION: Though the direction of causation is unknown, having the attitude that it is important to exercise or be physically active for health predicts physical activity participation in both African American men and women. Creating a sense of importance of physical activity to relieve stress and foster good health may stimulate physical activity participation in African American adults.

Patient provider communication about the health effects of obesity.

OBJECTIVE: We assessed the influence of race/ethnicity and provider communication on overweight and obese patients' perceptions of the damage weight causes to their health. METHODS: The study included 1071 overweight and obese patients who completed the 2002 Community Health Center (CHC) User survey. We used logistic regression analyses to examine determinants of patients' perceptions of the impact of their weight on their health. Models were adjusted for covariates and weighting was used to account for the sampling design. RESULTS: Forty-one percent of respondents were overweight and 59% were obese. Non-Hispanic Blacks and Hispanics were half as likely as non-Hispanic Whites to believe weight was damaging to their health while controlling for covariates. Overweight/obese CHC patients who were told they were overweight by healthcare providers were almost nine times more likely to perceive that weight was damaging to their health compared to those not told. CONCLUSIONS: We observed large racial/ethnic disparities in the perception that overweight is unhealthy but provider communication may be a powerful tool for helping patients understand that overweight is damaging to health. PRACTICE IMPLICATIONS: Given obesity is a national epidemic, further attention to the role of patient provider communication in illness is essential with important implications for both health professional training and health care provision.

Where are youth active? Roles of proximity, active transport, and built environment.

PURPOSE: This study examined factors related to two sources of physical activity for youth: active use of recreation sites and active transport to recreation sites. METHODS: Parents of children (n = 87) and matched pairs of parents and adolescents (n = 124 pairs) in three US cities reported on youths' active use of, proximity to, and walking/biking to 12 recreation sites and on neighborhood walkability and safety. Multivariate regression models evaluated factors associated with youths' frequent site use and active transport to sites. RESULTS: Proximity to the site was associated with frequent use of large parks and public open space. Walking/biking to the site was associated with frequent use of most sites (indoor recreation sites, small and large parks, basketball courts, walking/running tracks, school recreation sites, playgrounds, and public open space). After controlling for proximity and demographic factors, active transport to sites remained significantly associated (P < 0.05) with frequent use of four sites for children (indoor recreation, walking/running tracks, school recreation facilities, and public open space) and all but three sites for adolescents (indoor recreation, playfields/courts, and beach/lake/rivers). Adolescents' active transport to more sites was most positively related to higher perceived traffic safety and to better pedestrian infrastructure and was negatively related to crime threat. Adolescents with driver's licenses walked/biked to recreation sites less often. CONCLUSIONS: Active transport was strongly associated with the use of multiple recreation sites by children and adolescents, even when accounting for proximity and demographic factors. Adolescents living in neighborhoods with better traffic safety walked/biked to more recreation sites for physical activity. Findings support the need for built environments and transportation policies that facilitate safe, active transport to recreation sites for youth physical activity.

Reliability and validity of destination-specific barriers to walking and cycling for youth.

OBJECTIVE: To investigate the psychometric properties of a new measure of barriers youth encounter while walking to specific destinations and to validate the measure with self-reported walking to these destinations. METHODS: In 2005 in Boston, Cincinnati and San Diego, parents of youth (n=289, aged 5-18) and adolescents (n=189, aged 12-18) completed surveys in a two-week test-retest study design. Seventeen items assessed participant agreement with the influence of different barriers to walking or cycling to three types of destinations: 1) parks, 2) shops and restaurants and 3) school. Participants also reported whether or not they walked or cycled to the destinations at least once a week. RESULTS: Principal components analysis identified three barrier subscales labeled 'environmental', 'psychosocial/planning', and 'safety', which were consistent across the three destinations and two respondent groups. Internal consistency for the subscales was good (alphas> .70) and two-week test-retest reliability was moderately high (ICCs .56-.81) for both parents and adolescents for all destinations. Psychosocial and environmental barriers were higher in adolescents who did not walk (p< .003). Parents of younger children reported high environmental barriers. CONCLUSION: The three barrier subscales to active commuting to multiple destinations demonstrated good reliability and some initial evidence of validity.