CRITICAL APPRAISAL of

CROSS-SECTIONAL STUDY
Presented by Dr Sharifah Shakirah As-Sahab bt Wan Muhamad Nasir
Supervised by Dr Malihah
STUDY TYPE & DESIGN
 CROSS-SECTIONAL STUDY
• Examines relationship between exposure/treatment and
diseases/outcome status at one particular point in time or over a
period.
• Exposure and outcomes measure at the same time.
 CROSS-SECTIONAL STUDY
• Measure prevalence, not incidence of disease.
• Prevalence : How much of a disease or condition there is in a
population at a particular point in time (measure
burden)
• Incidence : Measures the rate of occurrence of new cases of
a disease or condition (measure risk)
 CROSS-SECTIONAL STUDY
Advantages
• Quick, less time consuming
• Good for establishing overall
association between exposure & • Temporal sequence of exposure
disease
• Inexpensive
• Less drop out rate
Disadvantages
• Establishes disease prevalence
but not incidence
and effect (causal effect) may be
difficult or impossible to
determine
• Impractical for rare outcomes
• Prone to selection and recall
bias
 TOOLS TO APPRAISE CROSS-
SECTIONAL STUDY
STROBE (Strengthening The Reporting of Observational
Studies in Epidemiology) Checklist
THE ARTICLE
 1. Title and abstract
(a) Indicate the study’s design with a commonly used term in the title or the
abstract
(b) Provide in the abstract an informative and balanced summary of what was done
and what was found
Study objective

What was
done

What was
found
Introduction
 2. Background/rationale
• Research into the effect of exercise on mental health has provided conflicting results.
• RCTs:
• most studies  exercise as an effective treatment for mild and moderate
depression, either alone or in an adjunctive capacity
• Longitudinal observational studies:
• Inconsistent
• Positive associations reported in adults but not in adolescents
• Factors on the conflicting results:
• Small (or non-representative) samples
• Lack statistical power to examine the effect of exercise type
• Difficult to determine the specificity (type, frequency, intensity duration of the
exercise) of the association
 3. Objectives
• To examine the association between exercise and mental health.
• To measure patterns of mental health burden across a diverse set of
exercise types, durations, and frequencies while accounting
statistically for a range of sociodemographic and physical health
characteristics.
Methods
• Setting 5 Describe the setting, locations, and relevant dates, including periods of
recruitment, exposure, follow-up, and data collection Participants 6 (a) Give the eligibility
criteria, and the sources and methods of selection of participants Variables 7 Clearly
define all outcomes, exposures, predictors, potential confounders, and effect modifiers.
Give diagnostic criteria, if applicable Data sources/ measurement 8* For each variable of
interest, give sources of data and details of methods of assessment (measurement).
Describe comparability of assessment methods if there is more than one group Bias 9
Describe any efforts to address potential sources of bias Study size 10 Explain how the
study size was arrived at Quantitative variables 11 Explain how quantitative variables were
handled in the analyses. If applicable, describe which groupings were chosen and why (a)
Describe all statistical methods, including those used to control for confounding (b)
Describe any methods used to examine subgroups and interactions (c) Explain how
missing data were addressed (d) If applicable, describe analytical methods taking account
of sampling strategy Statistical methods 12 (e) Describe any sensitivity analyses
 4. Study design
• Mentioned early in the paper that it is a cross-sectional study.
 5. Setting
• Data collection:
• From the Behavioral Risk Factor Surveillance System survey collected by the Centers
for Disease Control and Prevention
• Data collected through telephone survey
• Information obtained: Demographics, physical health, mental health, and health-
related behaviours.

• Location: Across 50 states in USA

• Periods of recruitment: Between 2011 – 2015 (specifically 2011, 2013, 2015 –
why? - included a module about patterns of physical exercise)
 6. Participants
• Individuals aged ≥ 18
• Total participants: 1 439 696
• Exclusion: Missing data
• Final participants: 1 237 194
 7. Variables
• Demographics
• Physical health
• Previous diagnosis of depression or depressive episode (effect modifier)
• Exposure:
• Participation in any physical activities or exercises during past month.
• Type of physical activity or exercise spend the most (75 types of exercises; grouped
into 8 categories).
• Number of times per week or month spent on the exercise.
• Number of minutes or hours spent exercising each time.
• Outcomes:
• Mental health burden
• Did not mention predictors and potential confounders.
• Harmonised the responses:
• Frequency into times per month (multiplying weekly by 4)
• Converted duration from hours into minutes
• Reduce spurious outliers:
• Applied 99% winsorisation:
• Frequency > 76x/month
• Duration > 360 min
• Reduce sparsity and minimise estimation errors:
• Durations were rounded to the nearest 15 min
• Frequencies were rounded to the nearest 2 days per month.
Did not mention:
8. Data sources/ measurement
• For each variable of interest, give sources of data and details of methods of
assessment (measurement). Describe comparability of assessment methods if
there is more than one group.
• The study only mentioned on the question asked regarding the variable. It did
not mentioned how to measure it.
9. Bias
• Describe any efforts to address potential sources of bias
10. Study size
• Explain how the study size was arrived at
 12.Statistical methods
Explain in details all of the following:
(a) The statistical methods, including those used to control for
confounding
(b) Methods used to examine subgroups and interactions
(c) Explain how missing data were addressed (not applicable)
(d) Describe analytical methods taking account of sampling strategy
(e) Describe any sensitivity analyses
Results
 13. Participants
• Analysis were based on 1 237 194 of all participants (86% from total
of 1 439 696).
• The remaining is not analysed because of missing data.
 14. Descriptive data
• The mean mental health burden was 3·36 days (SD 7·7) of poor mental health in the
past month (median 0 [IQR 0–2]).
• 852 068 individuals has lower self-reported mental health burden per month.
• 73.6% (n=627 510) of them exercised.

• 110 194 individuals who has lower self-reported mental health burden per month,
HAVE a previous depression diagnosis;
• 64.5% (n=71 111) of them exercised.

• 741 874 individuals who has lower self-reported mental health burden per month,
DOES NOT HAVE a previous depression diagnosis;
• 75% (n=556 399) of them exercised
 16. & 17. Main results & Other analyses
• Analysis of 852 068 matched individuals who has lower self-reported mental
health burden per month:
• Exercise was associated with a 1·49 day (43·2%) lower self-reported mental health burden
per month (W=7·42 × 10¹⁰, p<2·2 × 10-16) for individuals who exercised than those who did
not.
• Analysis for matched individuals with and without a previous depression diagnosis.
• Exercise was associated with a 3·75 day (34·5%) lower mental health burden (W=1·61 × 10⁹,
p<2·2 × 10-16) than among people who reported a previous diagnosis of depression but did
not exercise.
• The association between exercise and mental health burden was seen across the
full age span, for men and women, across all racial groups and all levels of
household income.
• All types of exercise were associated with a reduction in mental health burden
(minimum reduction of 11·8%, p<2·2×10-16 for all exercise types) compared with
no exercise.
• The strongest associations were found for popular sports (22·3% lower), cycling
(21·6% lower), and aerobic and gym exercises (20·1% lower).
• A similar ranking was found when previous depression subsample alone was
analysed.
• Mindful exercises (yoga and tai chi) were associated with a significantly greater
reduction in mental health burden than not exercising (22·9%), walking (17·4%),
or engaging in any other exercise (17·8%).
• These associations were larger than many modifiable social or demographic
factors.
• Exercise durations between 30 min and 60 min (peaking around 45 min) were associated
with the lowest mental health burden.
• This pattern of optimal duration was consistent across many exercise types.
• Small reductions were seen for individuals who exercise longer than 90 min
• Durations of more than 3h were associated with worse mental health burden than
exercising for either 45 min or not exercising at all.
• Frequency of exercise between 3 – 5 times a week had a lower mental health burden than
those who exercised < 3 or > 5 times;
• This is consistent across all exercise types.
• Intensity of exercise:
• Vigorous exercise associated with a more favourable burden than either light or
moderate exercise.
Discussion
 18. Key results
• Shows a meaningful association between exercise and mental health
• The largest cross-sectional sample to date (even after adjusting for
several sociodemographic and physical health characteristics that
themselves are known to contribute to mental health burden).
• Individuals who exercised had about 1·5 (about 43%) fewer days of
poor mental health in the past month than individuals who did not
exercise.
• The association was strongest for individuals who exercised between
30min and 60min/session, 3 to 5 times/week.
• Engaging in popular (team) sports and cycling was associated with the
lowest mental health burden, both in the whole sample and in the
subsample of individuals with a previous diagnosis of depression.
• Exercises of > 23x/month or > 90min/session were associated with
worse mental health.
• These effects were large relative to other modifiable factors.
 19. Limitations
• Limits the ability to establish the direction of causality for the association
between exercise and mental health.
• As inactivity might be both a symptom of and contributor to poor mental
health & activity might be an indicator of and contributor to resilience.
• These statistical procedures done cannot account for confounding by
unmeasured factors.
• Underestimation of the duration and frequency of exercise as only primary
exercise is considered.
• The dose of exercise was not randomised, it is possible that subgroups at the high
end of exercise dose might be enriched for psychopathological risk beyond
socioeconomic risks (eg, individuals with obsessive characteristics or personality
traits).
• This study:
• Relies on a participant’s own assessment of mental health burden in a given
month
• Does not use structured interviews or standardised rating scales to determine
mental health burden. A
• Unable to relate current mental state (eg, measured by PHQ or Hamilton
Depression Rating Scale) to exercise.
• Precludes identification of specific contributions to overall burden, such as
depression, anxiety, or stress.
 20. Interpretation
• It is plausible that these findings are causal.
• Because they are consistent with randomised controlled trials
indicating positive effects of exercise on mental health outcomes,
anxiety & PTSD, as well as cohort studies suggesting that exercise
protects against the incidence of depression.
• In research samples, exercise has been shown to specifically relieve
symptoms of fatigue and amotivated behaviour in individuals with
major depressive disorder, with changes in motivated behaviour
tightly coupled to changes in severity of depressive symptoms.
• Finding in this study that popular sports, mostly team based, were associated
with the lowest mental health burden is in line with studies showing that social
activity promotes resilience to stress and reduces depression and the prosocial
benefits of minimising social withdrawal and feelings of isolation might contribute
an additional benefit for mental health over other forms of physical exercise.
• That mindful exercises (ie, yoga and tai chi) were associated with lower mental
health burden than walking or other exercises supports literature around the
benefits of mindfulness-based techniques for mental health.
• These data suggest that all exercise groups, including social and non-social forms,
were associated with lower mental health burden.
 21. Generalisability
• It did mentioned that this study replicates some of the studies done
previously and contradicts some.
• The finding of this study also in line with public health guidelines;
people exercising between 120 min and 360 min per week had the
lowest mental health burden.
 Further direction
• Collect longitudinal passive mobile or wearable sensor data (eg, Fitbit),
which are not affected by self-report, to investigate the precise
association between the actual frequency, duration, and intensity of
exercise and mental health burden.
• Allow to measure physical exertion during both work hours and leisure
and hence parse out effects relating to exertion versus an appropriate
balance in leisure time.
• It could be possible to personalise exercise recommendations in order to
identify what format of exercise will best help an individual to reduce their
mental health burden.
Other information
 22. Funding
• Cloud computing resources were provided by Microsoft.
• However, the funders had no role in study design, data collection,
data analysis, data interpretation, or writing of the report.
• The corresponding author had full access to all the data in the study
and had final responsibility for the decision to submit for publication.
THANK YOU