Health Psychology Review

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A meta-meta-analysis of the effect of physical

activity on depression and anxiety in non-clinical
adult populations

Amanda L. Rebar, Robert Stanton, David Geard, Camille Short, Mitch J.

Duncan & Corneel Vandelanotte

To cite this article: Amanda L. Rebar, Robert Stanton, David Geard, Camille Short, Mitch J.
Duncan & Corneel Vandelanotte (2015) A meta-meta-analysis of the effect of physical activity on
depression and anxiety in non-clinical adult populations, Health Psychology Review, 9:3, 366-378,
DOI: 10.1080/17437199.2015.1022901

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Health Psychology Review, 2015
Vol. 9, No. 3, 366–378, http://dx.doi.org/10.1080/17437199.2015.1022901

A meta-meta-analysis of the effect of physical activity on depression

and anxiety in non-clinical adult populations
Amanda L. Rebara*, Robert Stantonb, David Geardb, Camille Shorta,c, Mitch J. Duncana,d
and Corneel Vandelanottea
a
School of Human, Health, and Social Sciences, Central Queensland University, Rockhampton,
QLD, Australia; bSchool of Medical and Applied Sciences, Central Queensland University,
Rockhampton, QLD, Australia; cFaculty of Health Sciences, Freemasons Foundation Centre for
Men’s Health, University of Adelaide, Adelaide, SA, Australia; dFaculty of Health and Medicine,
School of Medicine & Public Health; Priority Research Centre in Physical Activity and Nutrition,
The University of Newcastle, Callaghan, NSW, Australia
(Received 12 June 2014; accepted 22 February 2015)

Amidst strong efforts to promote the therapeutic benefits of physical activity for
reducing depression and anxiety in clinical populations, little focus has been directed
towards the mental health benefits of activity for non-clinical populations. The
objective of this meta-meta-analysis was to systematically aggregate and quantify
high-quality meta-analytic findings of the effects of physical activity on depression and
anxiety for non-clinical populations. A systematic search identified eight meta-analytic
outcomes of randomised trials that investigated the effects of physical activity on
depression or anxiety. The subsequent meta-meta-analyses were based on a total of 92
studies with 4310 participants for the effect of physical activity on depression and 306
study effects with 10,755 participants for the effect of physical activity on anxiety.
Physical activity reduced depression by a medium effect [standardised mean difference
(SMD) = −0.50; 95% CI: −0.93 to −0.06] and anxiety by a small effect (SMD = −0.38;
95% CI: −0.66 to −0.11). Neither effect showed significant heterogeneity across meta-
analyses. These findings represent a comprehensive body of high-quality evidence that
physical activity reduces depression and anxiety in non-clinical populations.
Keywords: meta-analysis; exercise; physical activity; mental health; anxiety;
depression

Estimates are that 12–32% of the population in developed countries have depression or
anxiety symptoms (Haller, Cramer, Lauche, Gass, & Dobos, 2014; Karsten et al., 2011;
Shim, Baltrus, Ye, & Rust, 2011; Wittayanukorn, Qian, & Hansen, 2014). The vast
majority of these people have mild symptoms, which are less likely to be treated than
more severe symptoms but can still be debilitating (Cuijpers et al., 2013; Haller et al.,
2014). Additionally, there is an elevated risk that mild symptoms can later develop into
clinical depressive or anxiety disorders (Karsten et al., 2011). There have been many
proclamations about the anti-depressive and anxiolytic effects of physical activity for
clinical populations (Davidson, Feltner, & Dugar, 2010; Morgan, Parker, Alvarez-
Jimenez, & Jorm, 2013; Ravindran & Da Silva, 2013), but the benefits of physical

*Corresponding author. Email: a.rebar@cqu.edu.au

© 2015 Taylor & Francis
 Health Psychology Review 367

activity for reducing depression and anxiety in non-clinical populations have not been
promoted to the same extent – likely because a comprehensive synthesis on the effect of
physical activity on depression and anxiety in non-clinical populations is lacking.
Within clinical populations, many meta-analyses have found that physical activity has
moderate-to-strong anti-depressive effects (Cooney et al., 2013; Josefsson, Lindwall, &
Archer, 2013; Krogh, Nordentoft, Sterne, & Lawlor, 2011; Lawlor & Hopker, 2001;
Rethorst, Wipfli, & Landers, 2009; Rimer et al., 2012; Rosenbaum, Tiedemann, Sher-
rington, Curtis, & Ward, 2014). There have also been several meta-analyses investigating
the effect of physical activity on anxiety symptoms for clinical populations, but the
findings are not consistent. For example, a recent meta-analysis reported that physical
activity had no statistically significant effect on anxiety for people with anxiety disorders
[standardised mean difference (SMD) = 0.02; Bartley, Hay, & Bloch, 2013]; whereas
Wipfli, Rethorst, and Landers (2008) found an anxiolytic effect of −0.52 SMD for
clinical populations. These meta-analyses are valuable towards informing clinical
treatment guidelines for depression and anxiety but they do not provide evidence for
the benefits for physical activity in non-clinical populations in reducing symptoms of
depression or anxiety. This evidence is necessary to guide physical activity promotion
efforts towards the general population.
There have also been several meta-analyses on the anti-depressive and anxiolytic
effects of physical activity without a focus on clinical populations (e.g., Petruzzello,
Landers, Hatfield, Kubitz, & Salazar, 1991; Rethorst et al., 2009; Wipfli et al., 2008).
Despite strict quality criteria for study inclusion, there is little overlap regarding which
studies were included in these meta-analyses. As such, the field is left with several
different meta-analytic findings and is lacking a fully summative analysis of high-quality
evidence on the effects of physical activity on depression and anxiety in non-clinical
populations.
Syntheses of existing reviews on a topic can provide encompassing summaries of
evidence to aid clinician and policy-makers in decision-making. Such reviews can be a
systematic review of reviews, which provides a qualitative narrative of the evidence
(e.g., De Vet, De Ridder, & De Wit, 2011; Greaves et al., 2011; Jepson, Harris, Platt, &
Tannahill, 2010; Kriemler et al., 2011) or a meta-meta-analysis, which provides a quantitative
synthesis of the empirical evidence (e.g., Grissom, 1996; Katerndahl & Lawler, 1999).
There have been two previous review of reviews on the mental health benefits of
physical activity. Biddle and Asare (2011) conducted a review of reviews investigating
physical activity and mental health outcomes in children and adolescents. They found that
physical activity had potential benefits for reducing depression and anxiety, and their
interpretation was that reviews typically reported small to moderate effect sizes, but that
the evidence base was limited and intervention designs were of low quality. Daley (2008)
conducted a review of reviews on exercise and depression in adults with an emphasis on
postnatal depression. Based on Daley’s synthesis of the literature, it was concluded that
exercise was more effective for depression than no treatment and as effective as some
other treatment options for depression (e.g., psychotherapy, antidepressant medication).
However, this review of reviews was limited, as it was not a systematic review and
neither included a systematic rating of quality nor a meta-meta-analysis. Biddle and Asare
(2011) and Daley (2008) provide valuable qualitative narratives about the mental health
benefits of physical activity; however, a comprehensive quantitative synthesis investig-
ating the impact of physical activity on depression and anxiety in non-clinical adult
populations is lacking.
368 A. Rebar et al .

The present meta-meta-analyses

For this meta-meta-analysis, our aim was to aggregate high-quality evidence from
randomised trials and quantify the effects of physical activity on depression and anxiety
in non-clinical populations. These findings will provide a high-quality synthesis of the
evidence to date and provide valuable information for both research and practice
regarding the magnitude of the potential mental health benefits of physical activity for the
general population.

Method
Literature search
A search of meta-analyses published between 1960 and November 2014 was conducted
independently by two co-authors (ALR and RS) using the databases: Google Scholar,
PubMed, SCOPUS and the search terms: meta AND physical activity OR exercise AND
anxiety OR anxiolytic OR depression OR depressive OR mental health and associated
MeSH terms. When available, search filters were set for the publication to report on adult,
human populations, consist of a review format, and be published in English. Reference
lists of the retrieved reviews and government health reports (Britain, Donaldson, &
Britain, 2004; Bull & The Expert Working Groups, 2010; Physical Activity Guidelines
Advisory Committee, 2008) were also scanned for relevant reviews. No protocol exists
for this meta-meta-analysis.

Eligibility criteria
Meta-analyses were screened for inclusion independently by two coders (co-authors
ALR, RS) based on titles and abstracts and again by two authors (ALR, DG) based on
full text. To be included, meta-analyses had to include studies which examined the
influence of physical activity on severity of depression and/or anxiety symptoms in
predominantly adult (>50% of sample 18 years or older), non-clinical populations. Meta-
analyses of randomised trials were included; whereas meta-analyses of correlational
studies (i.e., observational, longitudinal designs) were excluded. For the purposes of this
analysis, physical activity was defined as: any bodily movement produced by skeletal
muscles that require energy expenditure, which encompasses moderate-vigorous exercise
and lower intensity walking (Caspersen, Powell, & Christenson, 1985). Meta-analyses
which targeted populations with a specific chronic physical condition such as cardio-
vascular disease or pulmonary disease or diagnosed mental illnesses including depressive
and anxiety disorders were excluded. Meta-analyses were also excluded if they were
published in a language other than English or were not published in a peer-reviewed
scientific journal (i.e., book chapters, dissertation theses and conferences abstracts were
excluded).

Quality assessment
Quality of the meta-analyses was independently coded by two co-authors (AR and DG)
using the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) tool, which
has shown to have good inter-rater agreement, reliability and content validity (Shea et al.,
2007, 2009). Items such as, ‘Was an “a priori” design provided?’ were provided with
exemplars (e.g., ‘The research question and inclusion criteria should be established before
the conduct of the review’). The coders rated each item on a binary scale, with: 1 (yes),
 Health Psychology Review 369

0 (no/can’t answer/not applicable). Total scores for each meta-analysis were calculated as
the sum of the 11 items. Quality classifications were set as low quality (0–4), moderate
quality (5–8) and high quality (9–11) in accordance with previous reviews that used
AMSTAR (Mikton & Butchart, 2009; Seo & Kim, 2012; van der Linde, Stephan, Savva,
Dening, & Brayne, 2012).
The coders met to discuss coding divergences after independently coding the included
meta-analyses. The intraclass correlation (ICC) was used to determine inter-rater
reliability of the quality assessment scores, in which 1.00 represents perfect agreement
and 0.00 represents complete disagreement (Kottner et al., 2011), and the final quality
assessment score for each meta-analysis was calculated as the average score between
coders. Meta-analyses rated to have a low-quality assessment score (<4) were excluded
from the further processes of the meta-meta-analysis.

Data collection
Information about the study inclusion criteria and conclusions about the effects of
physical activity on depression and anxiety were collected from the meta-analyses that
were rated as moderate or high quality. The meta-meta-analyses of the effect sizes from
the meta-analyses of physical activity on depression and anxiety were conducted as two
separate random effects models with restricted maximum likelihood in R (version 2.15.0)
package metafor (R Core Team, 2013; Viechtbauer, 2010). Effect sizes were quantified as
large (>0.8 SMD), medium (0.5 SMD–0.8 SMD) or small (0.2 SMD−0.5 SMD; Cohen,
1988). Effect sizes were weighted by the adjusted variance estimates accounting for
quality ratings and study sample sizes (i.e., total N) of primary studies. Specifically, the
adjusted variance estimates were calculated as the product of the inverse standard error
and the square root of the independent sample size for that meta-analytic finding. The
adjusted variance estimates were weighted to account for sample dependency across
meta-analyses to avoid violating the independence assumption (Hedges, Tipton, &
Johnson, 2010). When a primary study was included in more than one meta-analysis, the
estimates were weighted so that the sample size only counted towards the meta-analysis
with the highest quality rating.
A weighted estimate of heterogeneity across all meta-analyses was quantified as
I2 (the percentage of total variation across studies due to heterogeneity as opposed to
chance), with heterogeneity estimates of 25%, 50% and 75% representing low, moderate
and high heterogeneity, respectively (Higgins & Thompson, 2002). For any meta-
analyses that presented heterogeneity using Cochran’s Q (Cochran, 1954), the hetero- 
geneity score was recalculated to facilitate cross-review comparison I 2 ¼100%  Qdf Q
(Higgins & Thompson, 2002). Larger values represent more heterogeneity between
studies, and p < .05 was taken to indicate that heterogeneity was significantly different
from zero. Funnel plots were created to examine risk of publication bias; statistical tests
for asymmetry were not used because test power is too low to distinguish asymmetry
unless there are more than 10 eligible effects in the meta-analysis (Sterne et al., 2011).

Results
Study selection
A flow diagram of the study selection is presented in Figure 1. The literature searches
resulted in the retrieval of 399 publications. An additional 20 publications from the
370 A. Rebar et al .

Figure 1. Flow diagram of the inclusion of meta-analyses from the literature search, through two
inclusion criteria screenings and the quality assessment.
 Health Psychology Review 371

reference searches were retrieved. The 419 publications were screened by abstract and
title for inclusion criteria, which resulted in the exclusion of 315 publications.
Publications were mostly excluded because they focused on special populations
(n = 150) or did not focus on physical activity (n = 70). The full text screening
conducted on the remaining 104 publications resulted in a further exclusion of 97
publications, mostly because they were not a meta-analysis (n = 34) or focused on clinical
populations (n = 32). The remaining seven meta-analyses were assessed for quality. There
was high inter-rater reliability of the quality assessment ratings (ICC = 0.95, 95% CI:
0.92 to 0.97). The screening based on the quality assessment is depicted in Figure 1. One
meta-analysis received a low-quality rating, leaving a total of six meta-analyses for the
final calculation. Two of the included meta-analyses were on depression (Conn, 2010b;
Rethorst et al., 2009), with the remaining four on anxiety (Conn, 2010a; Petruzzello et al.,
1991; Wang et al., 2014; Wipfli et al., 2008). One meta-analysis reported separate effects
for supervised and unsupervised physical activity programmes on depression outcomes
(Conn, 2010b) and one meta-analysis reported separate effects for state and trait anxiety
outcomes (Petruzzello et al., 1991); therefore the final meta-meta-analysis consisted of
three depression outcomes (from two meta-analyses) and five anxiety outcomes (from
four meta-analyses). The summaries of these meta-analyses and the associated quality
ratings are included in Table 1.

Physical activity and depression

The meta-analytic findings of physical activity and depression are summarised in the top
of Table 1. The main findings of Rethorst et al. (2009) included both clinical and non-
clinical populations so only the meta-analysis of the 41 randomised trials with a
combined 2408 non-clinical participants were used in the present meta-meta-analysis.
Conn (2010b) focused on non-clinical populations but calculated separate effects for
supervised and unsupervised physical activity programmes, so both effects were
independently included in the meta-meta-analysis. The effect calculated for supervised
physical activity programmes included 38 randomised controlled trials (RCTs) with 1598
participants and the effect calculated for unsupervised physical activity programmes
included 22 RCTs with 1081 participants.
After accounting for the overlap in studies between meta-analyses, the final meta-
meta-analysis was based on a total of 92 studies with 4310 participants. The results are
depicted in Figure 2. Overall, the findings show a significant, medium anti-depressive
effect of physical activity (SMD = −0.50; 95% CI: −0.93 to −0.06, p = .02) with no
significant heterogeneity across meta-analyses (I2 = 0%, p = 0.89). The funnel plot
depicted in Figure 3 revealed low asymmetry, representing low risk of publication bias
for the effect.

Physical activity and anxiety

The included meta-analyses of physical activity and anxiety are summarised in the
bottom of Table 1. Five effect sizes from four meta-analyses were included in the
analysis, because one study (Petruzzello et al., 1991) reported effects for both state and
trait anxiety. Conn (2010a) included 15 RCTs with 2786 participants. Wang et al. (2014)
Table 1. Summary of meta-analyses of physical activity and depression or anxiety outcomes.
372

Quality
Reviews Populations Included studies Main findings rating

Depression
Rethorst N = 2408; no criteria reported Forty-one RCTs that used exercise (moderate Depression was reduced by an effect size (ES) 11
et al. (2009) to vigorous, aerobic or resistance) as a of −0.59 (95% CI: −0.50 to −0.67),
treatment condition in comparison to a no- heterogeneity could not be calculated
treatment control condition for non-clinical
populations
Conn (2010b) N = 1598 for supervised physical activity Thirty-eight supervised physical activity Depression was reduced by an ES of −0.37 9.5
trials; N = 1081 for unsupervised; male intervention RCTs and 22 unsupervised (95% CI: −0.50 to −0.24) for the supervised
and female adults, without clinical physical activity intervention RCTs interventions and by an ES of −0.52 (95%
depression; no reported age criteria CI: −0.77 to −0.28) for the unsupervised
interventions, low–moderate heterogeneity
(supervised: I2 = 30%, unsupervised:
I2= 64%)
Anxiety
Conn (2010a) N = 2786; healthy adults (≥18 years) Fifteen two-group RCTs comparing physical Anxiety was reduced by an ES of −0.22 10
A. Rebar et al .

without emotional, mental or physical activity treatment to control (95% CI: −0.41 to −0.03), moderate
illnesses heterogeneity (I2 = 56%)
Wang N = 398; healthy adults (defined as those Four RCTs examining the immediate effects Anxiety was reduced by an ES of −0.75 10
et al. (2014) who may have psychological distress but of qigong exercise on trait anxiety with no (95% CI: −1.11 to −0.40), low heterogeneity
not psychiatric symptoms or chronic criteria reported for control group (I2 = 41%)
illnesses)
Wipfli N = 3324; no criteria reported Forty-six RCTs that used exercise as a Anxiety was reduced by an ES of −0.40 9
et al. (2008) treatment condition in comparison to a no- (95% CI: −0.47 to −0.32)
treatment control condition for non-clinical
populations
Petruzzello N = 3408; no criteria reported One hundred and four randomised trials State anxiety was reduced by an ES of −0.24 8.5
et al. (1991) reporting 207 effects for state anxiety and 62 (95% CI: −0.32 to −0.16), moderate
for trait anxiety heterogeneity (I2 = 56%) and trait anxiety was
reduced by an ES of −0.34 (95% CI: −0.46 to
−0.22), low heterogeneity (I2 = 41%)
 Health Psychology Review 373

Figure 2. Meta-meta-analysis of the effects of physical activity on depression. The variance of the
review effect sizes was adjusted based on the reported effect size variability across studies and the
unique sample sizes of the included studies.

Figure 3. Funnel plot of the meta-analysis of physical activity and depression.

focused on the effects of qigong and included 4 RCTs with 398 participants. Wipfli et al.
(2008) included 48 RCTs with 3324 participants. The effects of Petruzzello et al. (1991)
were based on 3408 participants and 207 effects of state anxiety and 62 of trait anxiety.
After accounting for the overlap in studies between meta-analyses, the final meta-
meta-analysis was based on a total of 306 study effects with 10,755 participants. As
depicted in Figure 4, the meta-meta-analysis indicated that physical activity reduces
anxiety by a significant, small effect size (SMD = −0.38; 95% CI: −0.66 to −0.11) with
no significant heterogeneity across meta-analyses (I2 = 4%, p = 0.63). The funnel plot
depicted in Figure 5 revealed low asymmetry, representing low risk of publication bias
for the effect.

Figure 4. Meta-meta-analysis of the effects of physical activity on anxiety. The variance of the
review effect sizes was adjusted based on the reported effect size variability across studies and the
unique sample sizes of the included studies.
374 A. Rebar et al .

Figure 5. Funnel plot of the meta-analysis of physical activity and anxiety.

Discussion
The aim of this meta-meta-analysis was to quantify the effects of physical activity on
depression and anxiety for non-clinical populations by pooling previous moderate and
high-quality meta-analytic findings. Based on the effects of nearly 400 randomised trial
effects and more than 14,000 participants, it was found that physical activity had a
significant, medium reductive effect on depression and a significant, small reductive
effect on anxiety. These findings provide a comprehensive summary of the evidence for
the reductive effects of physical activity on depression and anxiety for non-clinical
populations, extending on a large body of evidence demonstrating the potential
therapeutic benefits of physical activity for clinical populations.
In clinical populations, the anti-depressive effects of physical activity has been
estimated as medium and large (Cooney et al., 2013; Josefsson et al., 2013; Krogh et al.,
2011; Lawlor & Hopker, 2001; Rethorst et al., 2009; Rimer et al., 2012). The present
findings suggest the effects of physical activity on depression may be somewhat weaker
for non-clinical populations. This is supported by previous meta-analytic findings which
estimated the effects of physical activity on depression in clinical populations at
SMD = −1.03 and in non-clinical populations at SMD = −0.59 (Rethorst et al., 2009).
The population differences in effect sizes are likely partially the result of floor effects.
That is, the severity of depression is greater in clinical populations and, thereby has more
allowance for large reduction effects than in non-clinical populations (Rose, Koshman,
Spreng, & Sheldon, 1999). Overall, the current findings and previous meta-meta-analyses
(Cooney et al., 2013; Josefsson et al., 2013; Krogh et al., 2011; Lawlor & Hopker, 2001;
Rethorst et al., 2009; Rimer et al., 2012; Rosenbaum et al., 2014) establish that physical
activity has antidepressant effects for both clinical and non-clinical populations.
The present findings provide evidence that physical activity has a significant, small
reductive effect on anxiety for non-clinical populations, but evidence on the effect of
physical activity on anxiety in clinical populations is mixed (Bartley et al., 2013; Wipfli
et al., 2008). Clinical anxiety can manifest in quite divergent disorders (e.g., panic
disorders, phobias, generalised anxiety disorder), so it may be that the effects of physical
activity differ across these disorders. Wipfli et al. (2008) found no statistically significant
difference between the effect of physical activity on anxiety for clinical and non-clinical
populations. It may be that physical activity has similar effects for clinical and non-
clinical populations, or, alternatively it may be that the difference is true but small in
magnitude, so is masked without sufficient power (Cohen, 1988). Overall, the evidence of
the clinical benefits of physical activity for reducing anxiety remains unclear, but our
 Health Psychology Review 375

findings provide comprehensive evidence that physical activity reduces anxiety in non-
clinical populations.
The focus of the present meta-meta-analysis was to provide a broad-scoping aggregate
of high-quality evidence from randomised trials examining the effect of physical activity
on depression and anxiety. This is beneficial because it provides a highly encompassing
aggregate of evidence; however, it is limited in that it does not provide evidence for
specific recommendations regarding the most beneficial duration, intensity, mode or
frequency of physical activity for these mental health benefits. Such evidence has been
presented elsewhere, although many questions remain unanswered including what is the
minimal or optimal type and amount of physical activity for reducing depression and
anxiety (Morgan et al., 2013; Physical Activity Guidelines Advisory Committee, 2008;
Stanton & Reaburn, 2013). Importantly, the evidence seems to strongly suggest these
effects are not dependent on changes in fitness levels; even small incremental increases in
physical activity can have significant benefits for mental health.
It is likely that the reductive effects of physical activity on depression and anxiety
cannot be explained by a single mechanism acting in isolation; rather the effects are most
likely due to the contribution of several mechanisms manifesting at psychological (e.g.,
mood, feelings of mastery, self-efficacy) and neurophysiological (e.g., hippocampal
neurogenesis, hypothalamic-pituitary adrenal axis regulation) levels (Faulkner & Carless,
2006; Matta Mello Portugal et al., 2013; Wegner et al., 2014). The evidence from this
meta-meta-analysis adds further weight to the argument that there is a need for well-
conducted investigations into the mechanisms underlying the mental health benefits of
physical activity.

Conclusions and important future directions

The present meta-meta-analysis provides evidence that physical activity reduces
depression by a medium amount and anxiety by a small amount in non-clinical
populations. This extends previous population-level correlational evidence that people
who are regularly physically active have 45% lower odds of an onset of clinical
depression symptoms and between 28% and 48% lower odds of an onset of clinical
anxiety symptoms (Physical Activity Guidelines Advisory Committee, 2008). As such, it
can be concluded that there is a strong body of evidence that increasing physical activity
in non-clinical populations can reduce depression and anxiety symptoms, as well as
preventing the onset of clinical depression and anxiety.
Research focus now should turn towards establishing a theory-driven approach for
how to help people that are experiencing non-clinical depression or anxiety symptoms to
engage in regular physical activity (Gourlan et al., 2014). When people are feeling
depressed or anxious, they typically have a hard time getting motivated to be physically
active; however, once initiated, the maintenance of physical activity may be no more
difficult for people with symptoms than without (Amireault, Godin, & Vézina-Im, 2013).
Given the likely reciprocal nature of the relation of physical activity and mental health,
enhancing mental health through increasing physical activity may have the added benefit
of enhancing people’s motivation to maintain regular physical activity (Cuijpers, de Wit,
& Taylor, 2014; Jerstad, Boutelle, Ness, & Stice, 2010).

Disclosure statement
No potential conflict of interest was reported by the authors.
376 A. Rebar et al .

Funding
This manuscript has been supported by the CQUniversity HEALTH CRN and the Australian
Government’s Collaborative Research Networks Programme. MJD is supported by a Future Leader
Fellowship (ID 100029) from the National Heart Foundation of Australia.

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