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The objective of this study was to 1) determine the effects of a meditation app on depression and anxiety in adults with sleep disturbance, and 2) explore the potential mediating effects of fatigue, daytime sleepiness, and pre-sleep arousal on the relationship between use of the meditation app and changes in depression and anxiety. Participants were 239 adults with elevated insomnia symptoms (i.e., scores ≥ 10 on the Insomnia Severity Index) and limited or no previous experience with meditation. Depression, anxiety, fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, four weeks, and eight weeks. Repeated-measures ANCOVAs assessed intervention effects on depression and anxiety. Mediation models were estimated using the PROCESS macro. Participants in the meditation group had more improvement in depression and anxiety symptoms during the intervention period than did those in the control group. Changes in somatic and cognitive pre-sleep arousal at mid-intervention fully mediated effects on depression and partially mediated effects on anxiety. There were no significant indirect effects of fatigue and daytime-sleepiness on changes in mental health. A meditation app may improve depression and anxiety in adults with sleep disturbance, with effects being driven by improvements in pre-sleep arousal. Future studies should consider targeting pre-sleep arousal to improve mental health in this population. [ABSTRACT FROM AUTHOR]

Objectives: To describe the use of complementary approaches in pregnant women with a history of miscarriage and to investigate whether a miscarriage is associated with the use of complementary approaches during their pregnancy.Design: A cross-sectional survey was distributed to pregnant women residing in the United States (N=890).Results: Women who had a history of miscarriage, were Caucasian, were college educated, reported a high income, had low depression scores, and had low anxiety scores (all P<0.001) were more likely to use complementary approaches. In pregnant women with a history of miscarriage (N=193), the most frequently reported complementary approaches used were prayer (22.3%), yoga (15%), massage (14.5%), chiropractic (13%), and meditation (11.4%). Finally, after adjustment for age, race, education, and income, the odds of using a complementary approach in women with a history of miscarriage was 1.8 (95% CI: 1.3, 2.5, P<0.001) as compared with women without a history of miscarriage (model 1). Associations persisted after additional adjustment for depression, anxiety, and stress; the odds of using a complementary approach in women with a history of miscarriage was 1.7 (95% CI: 1.2, 2.4, P<0.001) (model 2), compared with women without a history of miscarriage.Conclusions: Findings from this study may help inform future studies for pregnant women with a history of miscarriage and may also provide information about appropriate strategies in which health care providers can refer their patients. [ABSTRACT FROM AUTHOR]

Objective To identify the psychosocial factors (i.e., stress, anxiety, depression, social support) that are associated with gestational weight gain (GWG) and the relationship of mindfulness with GWG during each trimester of pregnancy. Design In this cross-sectional study, an online survey that assessed physical and mental health and wellness practices was administered to pregnant women. Participants Pregnant women ≥8 weeks gestation, ≥18 years old, and could read and write in English. Measurement and findings Women who responded to the survey (N=1,073) were on average 28.7±4.6 years old. Findings from a regression analysis suggest that increased levels of depression may be predictive of increased GWG in the second trimester and decreased levels of mindfulness may be predictive of increased GWG in the first trimester. Anxiety, stress, and overall social support were not associated with GWG in any trimester. Key conclusions Mindfulness-based strategies (e.g., yoga) may have the potential to manage both depression and excessive GWG and may beneficial for and preferred by pregnant women. More research is warranted to determine clear relationships between psychosocial health, mindfulness, and GWG. Implications for practice Health care providers are encouraged to screen for depression in early pregnancy (i.e., first or second trimester) and provide resources to manage symptoms of depression and GWG to promote optimal birth outcomes. Health care providers may want to counsel patients on how to manage depression and/or GWG by suggesting mindfulness-based approaches. [ABSTRACT FROM AUTHOR]

Objectives: women who have experienced miscarriage may be at increased risk for elevated depressive and anxiety symptoms in subsequent pregnancies. Exercise may be a useful strategy for coping with these symptoms. Little is known about how miscarriage influences prenatal exercise behavior. The study purpose was to examine the influences of miscarriage history and prepregnancy weight status on pregnant women's psychological health, exercise motivation, and behavior using the Theory of Planned Behavior. Participants/Setting: Pregnant women (N=203; 41 with prior miscarriage; 72 overweight/obese; BMI > 25.0) in the northeast United States. Design: Women prospectively reported their depressive/anxiety symptoms and exercise motivation/behavior in the 1st, 2nd, and 3rd trimesters via mailed surveys. Group differences in depressive/anxiety symptoms, exercise behavior, and its motivational determinants were examined using Chi Square analyses and Univariate and Multivariate Analyses of Covariance. Measurements and findings: Women with a history of miscarriage had higher 1st and 2nd trimester depressive/anxiety symptoms and lower 1st trimester attitudes about exercise and 1st and 2nd trimester perceived behavior control than women without a history of miscarriage. Overweight/obese women had higher 1st and 2nd trimester pregnancy depressive/anxiety symptoms, engaged in less prepregnancy exercise, and had lower levels of exercise intention, attitude, and perceived behavior control throughout pregnancy than normal weight women. Key Conclusions: Women with a history of miscarriage and overweight/obese women have poorer psychological health and lower motivation to exercise during pregnancy than women without a history of miscarriage and normal weight women. Implications for practitioners: Interventions and healthcare provider communications aimed at promoting perinatal exercise behavior and psychological health should take into account pre-pregnancy weight status and pregnancy history to identify strategies to help women, particularly overweight/obese women with a history of miscarriage, to overcome exercise barriers. [ABSTRACT FROM AUTHOR]

Introduction Breast cancer survivors (BCSs) often report fatigue that persists for years following treatment. Despite a growing body of evidence for meditative movement practices to improve symptoms among BCSs, few studies have explored using Qigong/Tai Chi to reduce fatigue. Additionally, few have examined the biological mechanisms through which fatigue may be reduced using Qigong/Tai Chi. Methods/study design We will recruit 250 fatigued, post-menopausal women diagnosed with breast cancer (stage 0-III), between 6 months and 5 years past primary treatment and randomize to a standardized Qigong/Tai Chi Easy (QG/TCE) intervention, a “sham” Qigong group (movements without a focus on the breath and meditative state) (SQG), or an educational support (ES) group. The primary outcome (fatigue), secondary outcomes (anxiety, depression, sleep quality, cognitive function, physical activity), and a biomarker of HPA axis dysregulation (diurnal cortisol) will be assessed at baseline, post-intervention and 6 months postintervention, and biomarkers of inflammation (IL1ra, IL6, TNFα and INFᵧ) at pre/post-intervention. We hypothesize that QG/TCE will reduce fatigue (and improve other symptoms associated with fatigue) in BCSs experiencing persistent cancer-related fatigue more than SQG and ES. Biomarkers will be examined for relationships to changes in fatigue. Conclusions Findings from this study may reveal the effects of the unique mind-body aspects of QG/TCE on fatigue in BCSs with a complex design that separates the effects of low-intensity physical activity (SQG) and social support/attention (ES) from the primary intervention. Further, results will likely contribute greater understanding of the biological mechanisms of these practices related to improved symptoms among BCSs. [ABSTRACT FROM AUTHOR]

To review the evidence of the potential mechanisms (behavioral, psychological/emotional, and physical factors) of prenatal yoga for preventing excessive gestational weight gain (GWG) in pregnant women to guide future research. Prenatal yoga is a common form of physical activity during pregnancy and includes a combination of physical postures, breath control and meditation. This review theorizes how combining physical activity (i.e., prenatal yoga postures) with the add-ons brought by prenatal yoga (e.g., breath control, meditation), might provide a more comprehensive and effective strategy to prevent excessive GWG than physical activity alone. This article a) summarizes the literature on potential mechanisms of prenatal yoga to prevent excessive GWG specifically focusing on behavioral (diet, physical activity, and sleep), psychological/emotional (self-awareness, emotion regulation, stress, mood, mindfulness) and physical factors (pregnancy discomforts), b) highlights limitations of current studies, and c) provides suggestions for future research. The findings demonstrate there is insufficient evidence that prenatal yoga improves behavioral, psychological/emotional and physical factors in pregnant women and more research is needed. Though these factors have been more strongly linked to improved weight outcomes in non-pregnant populations, further testing in pregnant women is necessary to draw definitive conclusions for the efficacy of prenatal yoga to prevent excessive GWG. Effective strategies are needed to prevent excessive GWG to encourage optimal maternal and child health outcomes. More research is warranted to evaluate the impact of prenatal yoga on weight outcomes during pregnancy and design studies to test the proposed mechanisms discussed in this review. • Effective strategies to prevent EGWG are needed to promote maternal health outcomes. • There is insufficient evidence for prenatal yoga to prevent EGWG. • More research is needed to examine effects of prenatal yoga and EGWG. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: The objective of this study is to report on the development of an instrument to assess non-physical aspects of physical activity (PA)-related self-worth (SW). Methods: Three hundred thirty five women (mean age=36.69±15.94 yrs, BMI=24.87±4.56) completed the Women''s Physical Activity Self-Worth Inventory (WPASWI), General SW Scale, and a PA Questionnaire. Rasch analysis was used to evaluate the WPASWI. Results: Three PA-related SW subscales were identified: PA Knowledge (16 items), PA Emotional (13 items), and PA Social (8 items). Rasch analysis supported construct validity, and items demonstrated acceptable internal consistency (Cronbach''s alpha=0.90, 0.87 and 0.72) and test-re-test reliability (r =0.79, 0.70, 0.81). Women who reported regular PA participation had higher PA Knowledge, PA Emotional, PA Social, and General SW than those who reported some or no PA (p <0.01) and correlations between Knowledge, Emotional, and Social SW subscales and General SW were 0.207, 0.130, and 0.220, respectively. PA Knowledge and PA Emotional SW had stronger correlations with PA (r =0.344, 0.273, respectively) than did General SW (r =0.133). Conclusions: The WPASWI demonstrated good internal consistency, reliability, construct validity and a stronger relationship with PA than a General SW instrument. [ABSTRACT FROM AUTHOR]

Background: Afterschool programs (3pm–6pm; ASPs) are positioned to play a vital role in the improvement of children''s daily physical activity. Recent guidelines specify that children should accumulate 4600 steps per day while attending an ASP. The extent to which ASPs currently meet this goal and how many steps per day children naturally accumulate within the ASP setting is unknown. Purpose: The purpose of this study was to describe the pedometer-determined physical activity of a large sample of children attending a diverse range of ASPs and evaluate the extent to which ASPs are meeting current physical activity guidelines. Methods: Children (N=934, 51% girls, average 8.2 years; range 4–14 years) enrolled across 25 ASPs wore Walk4Life MVPa pedometers (number of steps accumulated, time spent active [hours:minutes:seconds]) up to 4 days. Data were collected in fall/spring 2010–2011 and analyzed in summer 2011. Results: On average, children attended ASPs for 125 minutes per day, accumulated 2944 steps per day, and spent approximately 26.6 minutes per day in physical activity. Only 16.5% of the 1819 daily observations met the 4600 steps per day guideline. No differences in steps per day, minutes per day in physical activity, or demographics were observed among children measured a single day versus 2, 3, or 4 days. Based on current practice, children would need to spend approximately 3.4 hours per day at an ASP to reach 4600 steps per day. Conclusions: Activity levels in ASPs are well below recommendations. Substantial effort is needed to identify strategies ASPs can employ to ensure children are sufficiently active. [Copyright &y& Elsevier]

To describe pregnant women's experiences and perceived facilitators/barriers of a prenatal yoga intervention to prevent excessive gestational weight gain (EGWG). Pregnant women (N = 13) were interviewed after participation in a 12-week prenatal yoga intervention to prevent EGWG. Interviews were summarized using thematic analysis. Twelve themes were identified and organized into four categories: 1) experiences of prenatal yoga (positive experience/enjoyment, pain relief, connecting to body), 2) prenatal yoga and weight (increased mindfulness/self-awareness, increased physical activity, weight management), 3) barriers to prenatal yoga (physical body, commute/traffic, schedule), and 4) facilitators of prenatal yoga (healthy pregnancy, support from other pregnant women, the feeling from prenatal yoga). Prenatal yoga may relieve pain and help women be more connected to their bodies. Prenatal yoga may also help women become more aware of their health behaviors and increases their physical activity which may have important implications for reducing EGWG. • Prenatal yoga may help women be more connected to their bodies. • Prenatal yoga may help women become more self-aware/mindful of health behaviors. • Women report prenatal yoga provides an opportunity to increase physical activity. [ABSTRACT FROM AUTHOR]

Background: Activate Omaha (AO), a community-wide health initiative, was awarded a grant by Active Living by Design in 2003. Purpose: To establish credibility of the partners in AO and increase awareness of active living in the community by emphasizing promotions (branding, logo recognition). Methods: Media, including billboards, TV and radio ads, high-profile spokespersons, grassroots efforts, and worksite “toolkits” featuring tips and creative messaging on physical activity were combined to incentivize people to be physically active. Campaign surveys were conducted by the Market Survey Research Group each year from 2005 to 2008. Results: Survey data based on the first campaign indicated that 86% of Omahans wanted to be part of an active community and to be active with younger generations. The second campaign focused on getting families physically active together, and this survey data showed that citizens wanted to be a part of an active community. A third campaign added practical examples of citizens being active within the community and efforts expanded to worksites with consistent messaging for employees. The final survey indicated that 78% of respondents found Omaha to be an active community compared to 63% who had that response 3 years earlier. Conclusions: Activate Omaha was successful in gaining credibility and leveraging additional funding to implement complementary programming and physical projects, and as a result, changing community perceptions and influencing policy decisions. [ABSTRACT FROM AUTHOR]

Background: Omaha, an urban Nebraska community, represents 26% of the state''s population. Activate Omaha, formed in 2003, addressed the obesity epidemic caused by physical inactivity and poor infrastructure to support active living in the community. Intervention: Activate Omaha''s efforts focused on a strategic social-marketing campaign, using baseline and annual data for guidance. Complementary programming was implemented parallel to the marketing campaigns. Safe Routes to School infrastructure projects were federally funded, and 20 miles of on-street bicycle facilities were funded privately. The mayor''s Bicycle Pedestrian Advisory Committee was formed, including directors from city planning and public works. Results: The initiative became recognized by the community as the lead resource promoting physical activity. This enabled the initiative to be instrumental in infrastructure changes and programming targeting the underserved. The initiative leveraged an additional $1,475,000 over 5 years. These funds created opportunities to invest in shared community resources such as providing bicycles for underserved youth, building infrastructure through Safe Routes to School initiatives, and successful worksite programming. Lessons learned: Partners should be utilized in a strategic manner, where they are engaged purposefully and serve a role in assuring successful outcomes. Community readiness should determine the focus on policy, physical projects, and promotional and programmatic strategies, as well as the integration of these strategies. Conclusions: Activate Omaha grew into a credible organization moving public policy and leveraging new public–private relationships through multilevel strategies. This approach ultimately led to sustainable changes in the community infrastructure and the behavior of its citizens. [Copyright &y& Elsevier]

Background: Policies call on afterschool programs to improve the physical activity and nutrition habits of youth attending. No tool exists to assess the extent to which the afterschool program environment meets physical activity and nutrition policies. Purpose: To describe the development of the Healthy Afterschool Activity and Nutrition Documentation (HAAND) instrument, which consists of two subscales: Healthy Afterschool Program Index for Physical Activity (HAPI-PA) and the HAPI-Nutrition (HAPI-N). Methods: Thirty-nine afterschool programs took part in the HAAND evaluation during fall/spring 2010–2011. Inter-rater reliability data were collected at 20 afterschool programs during a single site visit via direct observation, personal interview, and written document review. Validity of the HAPI-PA was established by comparing HAPI-PA scores to pedometer steps collected in a subsample of 934 children attending 25 of the afterschool programs. Validity of the HAPI-N scores was compared against the mean number of times/week that fruits and vegetables (FV) and whole grains were served in the program. Results: Data were analyzed in June/July 2011. Inter-rater percent agreement was 85%–100% across all items. Increased pedometer steps were associated with the presence of a written policy related to physical activity, amount/quality of staff training, use of a physical activity curriculum, and offering activities that appeal to both genders. Higher servings of FV and whole grains per week were associated with the presence of a written policy regarding the nutritional quality of snacks. Conclusions: The HAAND instrument is a reliable and valid measurement tool that can be used to assess the physical activity and nutritional environment of afterschool programs. [ABSTRACT FROM AUTHOR]

Introduction: Across the U.S., afterschool programs (ASPs, 3:00pm-6:00pm) are trying to achieve nationally endorsed nutrition standards (Healthy Eating Standards) calling for fruits/vegetables and water to be served every day, while eliminating sugar-sweetened beverages and foods. The purpose of this study was to evaluate the 2-year changes in the types of foods and beverages served during a community-based intervention designed to achieve the Healthy Eating Standards.Study Design: Randomized delayed treatment trial with an immediate (1-year baseline and 2-year intervention) or delayed (2-year baseline and 1-year intervention) group.Setting/participants: Twenty ASPs serving 1,700 children (aged 5-12 years) were recruited, with baseline occurring spring 2013, and outcome assessment occurring spring 2014 and 2015.Intervention: The multistep intervention, Strategies To Enhance Practice for Healthy Eating, assisted ASP leaders/staff to serve foods/beverages that meet the nutrition standards.Main Outcome Measures: The foods and beverages served for snack were observed directly.Results: Compared with non-intervention years, both the immediate and delayed groups increased the number of days/week that fruits/vegetables (0.6 vs 1.7 days/week and 0.6 vs 4.4 days/week, OR=3.80, 95% CI=1.45, 9.95) and water (2.3 vs 3.7 days/week and 2.7 vs 4.8 days/week, OR=4.65, 95% CI=1.69, 12.79) were served. Sugar-sweetened beverages were almost eliminated by post-assessment (1.2 vs 0.2 days/week and 3.2 vs 0.0 days/week, OR=0.05, 95% CI=0.02, 0.13). Only the immediate group decreased the number of days/week desserts were served (2.9 vs 0.6 days/week, OR=0.10, 95% CI=0.03, 0.33). Implementation barriers for the delayed group included once/month delivery schedules for fruits/vegetables and limited storage space for foods meeting the Healthy Eating Standards.Conclusions: Improvements in the foods/beverages served in ASPs can be made, yet were hindered by structural barriers related to procurement and storage of perishable foods. Additional efforts are needed to support ASPs as they work toward fully achieving the Healthy Eating Standards. [ABSTRACT FROM AUTHOR]

Introduction: National physical activity standards call for all children to accumulate 60 minutes/day of moderate to vigorous physical activity (MVPA). The contribution of summer day camps toward meeting this benchmark is largely unknown. The purpose of this study was to provide estimates of children's MVPA during summer day camps.Methods: Children (n=1,061, 78% enrollment; mean age, 7.8 years; 46% female; 65% African American; 48% normal weight) from 20 summer day camps wore ActiGraph GT3x+ accelerometers on the wrist during camp hours for up to 4 non-consecutive days over the summer of 2015 (July). Accumulated MVPA at the 25th, 50th, and 75th percentile of the distribution was estimated using random-effects quantile regression. All models were estimated separately for boys and girls and controlled for wear time. Minutes of MVPA were dichotomized to ≥60 minutes/day of MVPA or <60 minutes/day to estimate percentage of boys and girls meeting the 60 minutes/day guideline. All data were analyzed in spring 2016.Results: Across the 20 summer day camps, boys (n=569) and girls (n=492) accumulated a median of 96 and 82 minutes/day of MVPA, respectively. The percentage of children meeting 60 minutes/day of MVPA was 80% (range, 41%-94%) for boys and 73% (range, 30%-97%) for girls.Conclusions: Summer day camps are a setting where a large portion of boys and girls meet daily physical activity guidelines. Public health practitioners should focus efforts on making summer day camps accessible for children in the U.S. [ABSTRACT FROM AUTHOR]

Introduction In the U.S., afterschool programs are asked to promote moderate to vigorous physical activity. One policy that has considerable public health importance is California’s afterschool physical activity guidelines that indicate all children attending an afterschool program accumulate 30 minutes each day the program is operating. Few effective strategies exist for afterschool programs to meet this policy goal. The purpose of this study was to evaluate a multistep adaptive intervention designed to assist afterschool programs in meeting the 30-minute/day moderate to vigorous physical activity policy goal. Design A 1-year group randomized controlled trial with baseline (spring 2013) and post-assessment (spring 2014). Data were analyzed 2014. Setting/participants Twenty afterschool programs, serving >1,700 children (aged 6–12 years), randomized to either an intervention ( n =10) or control ( n =10) group. Intervention The employed framework, Strategies To Enhance Practice, focused on intentional programming of physical activity opportunities in each afterschool program’s daily schedule and included professional development training to establish core physical activity competencies of staff and afterschool program leaders with ongoing technical assistance. Main outcome measures The primary outcome was accelerometry-derived proportion of children meeting the 30-minute/day moderate to vigorous physical activity policy. Results Children attending intervention afterschool programs had an OR of 2.37 (95% CI=1.58, 3.54) to achieve the physical activity policy at post-assessment compared to control afterschool programs. Sex-specific models indicated that the percentage of intervention girls and boys achieving the physical activity policy increased from 16.7% to 21.4% (OR=2.85, 95% CI=1.43, 5.68) and 34.2% to 41.6% (OR=2.26, 95% CI=1.35, 3.80), respectively. At post-assessment, six intervention afterschool programs increased the proportion of boys achieving the physical activity policy to ≥45% compared to one control afterschool program, whereas three intervention afterschool programs increased the proportion of girls achieving physical activity policy to ≥30% compared to no control afterschool programs. Conclusions The Strategies To Enhance Practice intervention can make meaningful changes in the proportion of children meeting the moderate to vigorous physical activity policy within one school year. Additional efforts are required to enhance the impact of the intervention. [ABSTRACT FROM AUTHOR]

National and state organizations have developed policies calling upon afterschool programs (ASPs, 3-6 pm) to serve a fruit or vegetable (FV) each day for snack, while eliminating foods and beverages high in added-sugars, and to ensure children accumulate a minimum of 30 min/d of moderate-to-vigorous physical activity (MVPA). Few efficacious and cost-effective strategies exist to assist ASP providers in achieving these important public health goals. This paper reports on the design and conceptual framework of Making Healthy Eating and Physical Activity (HEPA) Policy Practice in ASPs, a 3-year group randomized controlled trial testing the effectiveness of strategies designed to improve snacks served and increase MVPA in children attending community-based ASPs. Twenty ASPs, serving over 1800 children (6-12 years) will be enrolled and match-paired based on enrollment size, average daily min/d MVPA, and days/week FV served, with ASPs randomized after baseline data collection to immediate intervention or a 1-year delayed group. The framework employed, STEPs (Strategies To Enhance Practice), focuses on intentional programming of HEPA in each ASPs' daily schedule, and includes a grocery store partnership to reduce price barriers to purchasing FV, professional development training to promote physical activity to develop core physical activity competencies, as well as ongoing technical support/assistance. Primary outcome measures include children's accelerometry-derived MVPA and time spend sedentary while attending an ASP, direct observation of staff HEPA promoting and inhibiting behaviors, types of snacks served, and child consumption of snacks, as well as, cost of snacks via receipts and detailed accounting of intervention delivery costs to estimate cost-effectiveness. [ABSTRACT FROM AUTHOR]

Context: The majority of children do not participate in sufficient amounts of daily, health-enhancing physical activity. One strategy to increase activity is to promote it within the after-school setting. Although promising, the effectiveness of this strategy is unclear. A systematic review was performed summarizing the research conducted to date regarding the effectiveness of after-school programs in increasing physical activity. Evidence acquisition: Databases, journals, and review articles were searched for articles published between 1980 and February 2008. Meta-analysis was conducted during July of 2008. Included articles had the following characteristics: findings specific to an after-school intervention in the school setting; subjects aged ≤18 years; an intervention component designed to promote physical activity; outcome measures of physical activity, related constructs, and/or physical fitness. Study outcomes were distilled into six domains: physical activity, physical fitness, body composition, blood lipids, psychosocial constructs, and sedentary activities. Effect sizes (Hedge''s g) were calculated within and across studies for each domain, separately. Evidence synthesis: Of the 797 articles found, 13 unique articles describing findings from 11 after-school interventions were reviewed. Although physical activity was a primary component of all the tested interventions, only eight studies measured physical activity. From the six domains, positive effect sizes were demonstrated for physical activity (0.44 [95% CI=0.28–0.60]); physical fitness (0.16 [95% CI=0.01–0.30]); body composition (0.07 [95% CI=0.03–0.12]); and blood lipids (0.20 [95% CI=0.06–0.33]). Conclusions: The limited evidence suggests that after-school programs can improve physical activity levels and other health-related aspects. Additional studies are required that provide greater attention to theoretical rationale, levels of implementation, and measures of physical activity within and outside the intervention. [Copyright &y& Elsevier]