Critical Appraisal 1

Critical Appraisal of a Descriptive Study

Jill Radtke

University of Pittsburgh
 Critical Appraisal 2

Worksheet for Critical Appraisal of Descriptive (Correlation, Comparative) Design Study

Citation:

Palmeira, A.L., Teixeira, P.J., Branco, T.L., Martins, S.S., Minderico, C.S, Barata, J.T., et al.

(2007, April 20). Predicting short-term weight loss using four leading health behavior

change theories. International Journal of Behavioral Nutrition and Physical Activity, 4,

Article 14. Retrieved June 15, 2007, from http://www.ijbnpa.org/content/4/1/14.

What type of article is this (e.g., research /data-based, clinical paper, review, editorial?)

Research/data-based

If this is a research article/data-base article, what makes it this type of article? Identify 2-
3 characteristics of the article.

1. End Product: The article presents original findings based on the conception of a study
design and its implementation.
2. Methodology: The article/study seeks to obtain data in a systematic fashion (e.g., the
introduction’s literature search, the attempt to measure variables consistently and
accurately in the methods section, the summation of findings in the results sections,
etc.).
3. Style: The article’s findings and design are presented in an objective and frank manner
(also discussing the limitations) in order that the reader may judge, implement, question,
and/or disregard the evidence.

State the research question posed by the authors:

How do key exercise and weight management psychosocial variables, derived from four health
behavior change theories, predict weight change during a short-term behavioral obesity
intervention?

What is my clinical question?

Can the same exercise and weight management psychosocial variables found in this study to
predict short-term weight loss in women predict weight loss in women six weeks postpartum?

Using PICO, identify the following if applicable:

P (= population): Premenopausal women from a community who are greater than 24 years of
age, not pregnant, free from major disease, and have a BMI greater than 24.9 kg/m2

I (=intervention): 15 weekly weight management meetings of 120 minutes each where the
groups of 32-35 participants met with a mix of PhD and Master’s level exercise physiologists, as
well as dieticians and psychologists who administered to the participants exercise, behavioral,
and nutrition content. The content included didactic material (e.g., information on caloric
content of food), motivational tools (e.g., giving pedometers), self-awareness instruments (e.g.,
food log, exercise log), and goal-setting (e.g., dietary and physical activity). The intervention
was based on Social Cognitive Theory (SCT), but designed to include constructs from three

other behavior change theories: Self-Determination Theory (SDT), Transtheoretical Model
(TTM), and the Theory of Planned Behavior (TPB).
C (= comparison group): N/A
O (=outcome): Weight change (and the specific behavioral change theories and psychosocial
constructs yielding the most predictive power for weight change)
APPRAISAL GUIDE
I. Are the methods valid/trustworthy?
1. Was the research question
clear? Was the need for the study
adequately substantiated?
Explain
Critical Appraisal 3
COMMENTS
The research question was stated clearly both in the
abstract and the “background” section of the research
report (not under a separate “purpose” section), “…the
purpose of this study was to investigate the predictive
value of changes in exercise and weight management
related variables on weight change, in a sample of
overweight and moderately obese women participating in a
University-based weight management program,”
(“background” section). However, it was less clearly
delineated how the content of the intervention parlayed
into improvement of the psychosocial variables and weight
loss. Although some examples were given (e.g., “…the
intervention had the underlying goals of improving
autonomy…These are highly motivational factors that
should have an effect on SDT constructs…”), it seems that
the study did not include, or at least did not mention, how
constructs from each behavioral change theory would be
incorporated into the intervention. Thus, the reader
remains unsure as to what type of weight loss intervention
program (i.e., which variables/constructs should be
incorporated and how) would yield the same predictive
power of certain behavioral change theories, as well as
improvements in psychosocial variables and weight loss as
found by the study team.
The need for the study was adequately substantiated in
several instances in the “background” section. The
authors comment that obesity has become an epidemic in
industrialized countries, yet there has been a great void in
the integration of biological, psychosocial, and
environmental solutions in weight management programs.
The authors hold that several psychosocial variables that
they incorporate into the present study (and the basis of
the four behavioral change theories in the study) are
widely believed to explain weight management in this
integration context, yet are underserved in weight
management literature. For example, in the background
section, “Questions remain about which model or set of
variables could better explain the outcomes of choice,
which constructs may overlap, or if a set of variables from
different theories could delineate the way to a new
paradigm. Rothmam highlights this last aspect as a likely
cause of some of the disappointing results for most studies

2. What was the design of the
study? How were the data
collected (one time (cross-
sectional) or repeated over time
(longitudinal)? What were the
limitations of the data collection
methods?
3. Describe the sample. How was
the sample selected (eligibility
criteria)? How is the sample
representative of the population?
Critical Appraisal 4
of behavior change interventions conducted to date.”
The design of this study was descriptive correlational, and
the data were collected in a prospective manner at two
different time points, baseline and four months (the study is
not longitudinal, per se, as it only collected at two time
points during a short span of time).
There were several limitations to data collection. One
such limitation may be the weighing procedure. The article
states that a “standardized procedure” was utilized in the
weighing process and cites a specific scale used. Further
elaboration is not provided. However, we are unsure how
much clothing participants wore during weighing, what time
of day they were weighed (e.g., morning versus later in the
day), after what activities they were weighed (e.g., after
working out, after eating, etc.), how the scale was
calibrated, if participants weighed themselves on the scale
without the study team (i.e., self-report—this is not
specified in the article), etc. Moreover, we are unsure
whether the conditions for weighing were similar for all
participants.
Another limitation in data collection was the self-report
used in the psychosocial variable questionnaires (as stated
in the article). Although the instruments were validated,
there is always a subjective limitation in self-report. For
example, a participant may mark feeling competent and
autonomous on an instrument at the follow-up because
they feel that this is what the researchers would like to see,
whether the researchers are communicating this
subconsciously (experimenter effect) or not (Hawthorne
effect).
Another limitation in the data collection (but could be
considered a design limitation), as stated in the article, was
only measuring the participants twice: at baseline and at
follow-up at four months. Perhaps there was more
fluctuation between the baseline and follow-up. Perhaps,
as the authors suggest is likely, the predictive power of the
weight management and exercise variables in weight loss
would be reversed if the data were collected more long-
term (i.e., at 16 months).
Other limitations in this study are discussed under
“sources of bias” in this paper, as they seemed to be more
of design limitations than data collection limitations, per se.
At the beginning of the program, the sample consisted of
142 women with BMI’s 30.2 ± 3.7 kg/m2 (overweight and
obese) and ages 38.3 ± 5.8 years (the sample had 133
completers at the end of the program). The women were
free of major disease, premenopausal, not pregnant, and

4. Describe the variables of
interest. If a comparison study, on
what variable(s) are the groups
being compared? How were the
groups similar? How were the
groups different? If it is a
correlation study, on what
variables are associations being
examined? Were there any
confounding variables?
Critical Appraisal 5
recruited from a particular community. The sample was a
purposive sample (due to the very specific eligibility criteria
used for selection), recruited using advertisements in the
community: newspaper ads, a website, email messages on
listservs, and announcement flyers. These recruitment
methods were presumed by the reader (myself) to list
eligibility criteria, though this is not explicitly stated
(perhaps directly stated on the poster or the interested
party is directed to call a number for eligibility criteria). The
eligibility criteria given by the authors is: premenopausal
women greater than 24 years of age, not pregnant, free
from major disease, and have a BMI greater than 24.9
kg/m2. It is unclear whether the participants self-selected
(i.e., if they called and met criteria they were in the study)
or were specifically chosen among all applicants who met
eligibility criteria, although the article seems to assume
self-selection.
This sample is somewhat representative of the population,
in that it satisfies all the eligibility criteria. However, the
age range is relatively tight between about 10 years of
young to middle adulthood. There are no individuals
greater than 45, nor any younger than 32, despite the
population requirement only specifying greater than 24
years old. Thus, the age of the sample is not very
representative of the population. Additionally, the BMI’s of
the sample constituted overweight individuals to obese
individuals. There were no participants who were severely
or morbidly obese. Thus, BMI is not completely
representative of the population (population requirement:
BMI great than 24.9 kg/m2). Also, we are not given
demographics of the sample. Therefore, we cannot be
sure that the sample can be generalized or applied to
different communities (populations) that differed from the
sample significantly on these variables.
There were multiple variables of interest in this study. One
variable was weight (at baseline and at 4 months; the
average taken of two readings each time and rounded to
the nearest 0.1 kg). There were also weight management
psychosocial variables from each behavioral change
theory (except SDT) measured as scores on instruments
administered to the participants, including self-efficacy and
outcome expectancy from SCT; self-efficacy, stages of
change (SOC), and processes of change (POC), including
both behavioral processes and cognitive processes, from
TTM; and intentions, attitudes, subjective norms, and
perceived behavioral control (PBC) from TPB. There were
exercise psychosocial variables also from each behavioral
change theory measured as scores on instruments
administered to the participants, including self-efficacy,
perceived barriers, and social support from SCT; self-
efficacy, SOC, and POC, including both behavioral and
cognitive processes from TTM; intentions, attitudes,

5. Was the sample size large
enough to detect a statistically
significant association or
difference? Was a power analysis
performed?
6. Were there any potential
sources of bias? (Differences
between groups not accounted for
in the analysis, drop-outs,
discounting outcomes, funding
agency, etc.)
Critical Appraisal 6
subjective norms, and PBC from TPB; and
interest/enjoyment, perceived competence,
importance/effort, pressure/tension, and intrinsic motivation
from SDT. Typically, the higher the score on the
instruments for the exercise and weight management
psychosocial variables indicated greater embodiment of
that variable by the participant. Additionally, the four
behavioral change theories (SCT, SDT, TTM, and TPB)
served as variables of interest in the study. Time was also
a variable of interest (from baseline measures to four
months). Generally, weight, psychosocial variables, and
the behavior change theories acted as dependent
variables, while time served as the independent variable.
This was a correlation study, and several associations
among these variables were examined. First, weight was
examined for its association with time (i.e., weight change
from baseline to four months). The exercise and weight
management psychosocial variables were also each
individually studied for their association with time (change
from baseline to four months). Then weight change was
correlated with baseline exercise and weight management
psychosocial variables in order to determine any possible
moderator variables. Weight change was also correlated
with four-month change in exercise and weight
management psychosocial variables. Finally, the
correlation between weight change and the four different
behavioral change theories (SCT, SDT, TTM, and TPB)
was examined by entering the psychosocial variable
scores present in each theory into separate regression
models for each theory.
The study did not note any confounding variables.
Yes, the sample size was large enough to detect
statistically significant associations with 142 subjects to
start and 133 completers. It was not mentioned that a
power analysis had been performed.
There were many potential sources of bias in this study.
One such bias involves the method of recruitment: through
advertisements in the newspaper, on a website,
announcement flyers, and email messages on listservs in
one community. This is a sampling bias, in that study
participants appear to self-select for a purposive sample.
These study participants, due to their presence in one
particular community and willingness to volunteer for the
study (i.e., they likely desire to lose weight), may differ
from the population in several fundamental aspects. This
limits the generalizability of the study findings.
Another source of bias may be that the SDT was not
accounted for in the weight management psychosocial
variables. The authors state that this is due to the fact that
a valid Portuguese instrument had not been validated for
 Critical Appraisal 7

the constructs in this theory with weight management.

However, it is plausible that psychosocial variables in this
theory still affect weight change (even though they are not
tested).

A source of bias also possibly existed in questionable

construct validity. In fact, the article states that some
variables were measured with less than ideal instruments,
such as outcomes expectancies. The article does not tell
us the reliability and validity of the instruments used to
measure the psychosocial variables, and we are left to
look up the instruments on our own or just accept the
authors’ judgment.

Also it is mentioned that there was a 6.3% attrition rate

from baseline to four months, with 142 women starting the
study and 133 completing it. This is not an especially high
attrition rate, but if the subjects dropping out differed in
some fundamental way from those staying in the study,
then we would have attrition bias (i.e., our results would
not reflect the population of interest, but those individuals
that had had certain characteristics that allowed or
motivated them to complete the study). Because the
characteristics of those dropping out (or those staying in)
were not elucidated, and the point in the study when the
drop-out occurred was not discussed, the reader is unable
to make an informed decision as to whether attrition bias
existed. Bias could also exist in the relatively small sample
size in the study, which affects external validity.

Another potential source of bias is testing effects. The

same instruments (questionnaires) were apparently given
at baseline and at four months. It is entirely feasible that
the subjects became sensitized to the material on the
instruments at baseline, and then answered the same
questions differently at four months due to the pre-test
rather than an actual intervention effect.

Bias could also result from maturation effects. The

subjects could have changed from baseline to four months,
regardless of the intervention. For example, as women
move into middle age, their metabolism slows and weight
gain occurs more easily. This weight gain (or lack of
weight loss) would have little to do with the intervention.

Validity may have been affected in the study by the

Hawthorne effect (i.e., the subject answered the
instruments in a certain way or lost more weight because
they knew they were in a weight loss study). Experimenter
effects could have also been present if the subjects
perceived, for example, that the researchers wanted them
to lose weight or answer the instruments indicating that
their self-efficacy was improving.

7. Describe the reliability and
validity of the measures.
Were the measures appropriate
for the population or the variable
being studied? Explain
Critical Appraisal 8
Also, the study (as mentioned in “limitations”) did not
include a control group. This is a source of bias—if a
control group had been present and exposed to the
possible Hawthorne effect, experimenter effects, and had
differed as much as the intervention group on fundamental
aspects (such as race, income, etc.), we could say that the
intervention was likely the cause of the changes in weight
and psychosocial variables. However, one has to also
keep in mind that this is a correlation study and it did not
claim causation.
Finally, a source of bias could exist in the outcome that the
weight management psychosocial variables better
explained weight change from baseline to four months as
opposed to the exercise psychosocial variables. In fact,
the authors note that in a similar study that was carried to
16 months, exercise psychosocial variables were better
correlates of weight loss. If this study had been extended,
perhaps they would have also found exercise psychosocial
variables as more powerful predictors of weight change.
Biases could also exist in the data collection methods
(e.g., self-report) as described in this paper previously.
The first instrument used, the Weight Efficacy Lifestyle
Questionnaire has shown significant validity in a 1991
study using cross-validation with two different samples of
subjects and with a different instrument measuring self-
efficacy, the Eating Self-Efficacy Scale (convergence
construct validity). The study also showed the instrument
to have good reliability with Cronbach alpha coefficients
ranging from .70-.90 for internal consistency. However, the
article states its subjects were women, the great majority
over 40 years of age (Clark, Abrams, Niaura, & Eaton).
Therefore, this instrument may not be appropriate for our
subjects in this study under 40. Additionally, the instrument
is over 15 years old, and it is reasonable to expect that the
instrument’s constructs may be outdated.
The dream weight outcome expectancy score used in this
study, derived from a portion of the Goals and Relative
Weights Questionnaire, I feel is mostly appropriate for this
study population. The women that the instrument was
tested on were in the same general age range as our
subjects, however, the test subjects were all obese women
(Foster, Wadden, Vogt, & Brewer, 1997). In our study we
had overweight to obese women. However, data regarding
reliability and validity of the instrument and construct of
“dream weight” was difficult to come by. The 1997 study
mentioned above did state that there was questionable
reliability of the “dream weight” for the same subjects
measured one week apart. This seems to indicate that
“dream weight” can fluctuate based on changing
expectations as one goes along in life and in a study.
 Critical Appraisal 9

Thus, by measuring the “dream weight” expectancy at the

beginning and end of this study, we see how expectations
change. This particular usage of “dream weight,” however,
has not been adequately validated or shown reliable.

For the SOC measure, the article states that SOC was
measured by four questions developed by Suris (Suris,
Trapp, DiClemente, & Cousins, 1998). However, the
questions are not stated explicitly in the article cited. One
has to assume that the questions are part of the URICA
short form, which does demonstrate considerable
reliability, measured by internal consistency (Suris, et al.,
1998). For the POC, the Suris article states that the
original form of the Weight Processes of Change Scale
(which was used in our article) has good reliability and
validity, although the shortened form (used by Suris, et al.)
has questionable reliability. Because the SOC in our
article is measured by the four questions developed by
Suris, et al., who used a small sample of Mexican-
American women, we have to question the validity of the
measure, as we do not know the ethnic origin of our
sample.

The specific scales using 18 and 17 items to address the

constructs of intention, attitude, subjective norms, and
PBC in the TPB for weight management and exercise,
respectively, could not be located. However, these
constructs are the basis of TPB, as stated in the article.
The constructs seem to have good reliability as measured
by internal consistency in this particular study, judging by
the alpha levels given in the article. However, because the
articles containing the specific scales used could not be
located, we are unable to measure the scale’s true validity
and reliability.

Self-efficacy for Exercise Behaviors Scale (SEEB) was not

able to be located through the authors’ citation, nor through
an OVID search, but the abstract to the article was given in
a different database (although one had to purchase the
article to receive full-text). The abstract stated that the
scale demonstrates good reliability and validity for
measuring self-efficacy behaviors relating to exercise.

The Exercise Perceived Barriers Scale (EPB) has shown

considerable reliability and validity in measuring exercise
perceived barriers in a 1989 study. However, the study
was based on two large samples including undergraduates
from a college and a group of workers from a company
classified as white, upper-middle class (Steinhardt &
Dishman). This sample differs considerably from the
middle-aged overweight and obese women in our sample.
Additionally, the study was conducted 18 years ago. It
would be remiss to cite the same barriers today.
 Critical Appraisal 10

The Exercise Social Support Scale’s (ESS) validity and

reliability could not be located using the author’s citation on
OVID. However, our article and another (Marquez &
McAuley, 2006) cite good internal consistency and, thus,
reliability in measuring social supports of exercise
behaviors in this scale.

Again, for the exercise SOC and POC, the exact scales
could not be located using the authors’ citations. Thus,
there is no way to evaluate the validity and reliability of the
measures here. Although, the Exercise Processes of
Change (EPC) did have good internal consistency in the
cognitive and behavioral domains in our article, indicating
reliability for this study.

The study cited for the scale used for the Intrinsic
Motivation Theory was accessed in its abstract form. The
full article could not be. However, it was stated that the
scale had good validity (in that divergent models used to
test motivation did not improve the goodness-of-fit as
compared to the Intrinsic Motivation Theory model). It also
stated that the model had adequate reliability. The make-
up of the sample was not discussed in the abstract,
however the theory was tested on a sport team in 1989
(McAuley, Duncan, & Tammen, 1989). It should be noted
that our population differs considerably from this type of
sample. However, the constructs within the model did
show good internal consistency, and thus, reliability in our
article.

Finally, weight at baseline and at four months was

measured and had several potential limitations discussed
under “data collection limitations” earlier. I would suspect
that the weighing procedure had good validity, in that the
subject’s weight in kilograms (to the nearest 0.1 kg) was
obtained at two set time periods during the study using an
electronic scale, which is perceived to be an accurate and
appropriate means of measuring weight. However,
reliability could have been an issue with the weighing,
although we are told that a “standardized procedure” is
used. However, we do not know whether all subjects were
weighed with clothes on or off, what time of day they were
measured, etc. If these measurement conditions differed
for any subjects, weight could be affected and we would
not have a reliable measure. Finally, the authors might
have considered measures such as waist circumference or
skin fold caliper measurements obtained at baseline and
four months instead of, or in addition to, weight. These
measures may offer added validity and reliability in
measuring true body mass/fat.

8. Were the analysis plans
(statistical methods) described in
detail?
How were the data distributed
(e.g., normal versus skewed)?
Were the correlative and
comparative tests appropriate for
the type of data analyzed and the
questions asked? Explain
II. What are the results/findings?
1. What were the findings?
2. Was there clinical significance?
Statistical significance?
Critical Appraisal 11
The statistical methods were described in some detail in a
separate section called “Statistical analysis.” More detail
was divulged about the analysis in the results section. We
were told which statistical tests were used for each result,
and in some cases, why they were used (for example, in
the results section, “The first set of correlation was done
between baseline values in predictors and weight change,
to explore possible moderator effects.”).
We are not told if the data was distributed normally or not.
However, in order to do the regressions and t-tests, one
would make the assumption that the psychosocial
variables and weight changes for the subjects were
distributed normally.
We cannot be sure that the correlative tests were
appropriate for our data, as we were not made privy to
detail about the actual tests.
There was a significant decrease in weight overall from
baseline to four months among group members, though
there was wide individual variability. Most of the exercise
and weight management psychosocial variables improved
from baseline to four months, with the most improvement
in the exercise variables. However, weight management
variables predicted weight change more strongly and
significantly than the exercise variables. Self-efficacy was
the strongest statistically significant individual psychosocial
variable predictor of weight change. Weight change was
significantly predicted by each of the four behavior change
theories noted above.
The SCT was the strongest model, followed by the TTM,
though the only psychosocial variable that added
statistically significant power to these theories was self-
efficacy.
The importance/effort psychosocial variable was a strong
independent predictor of weight change and was
statistically significant (accounting for 4.8% of weight
change variance), although its theory, the SDT, did not
significantly predict weight change.
As stated under the “findings” section, there was statistical
significance found in this study. However, I would be
weary of clinical significance. Most of the psychosocial
measures were based on small scales, some only
measuring four or five items. Therefore, because a large
number of people (by statistical standards) participated in
the study, a difference of less than one point/position on an
item could and did yield statistical significance (e.g., the
attitude exercise psychosocial variable change over time in
the TPB). In reality, we would probably not consider this a
significant difference and confidently predict that with a
similar weight loss intervention an individual would see a

3. Did the authors put their
findings in the context of the
broader literature on this topic?
Explain
III. How can I apply the results/findings?
1. What relevance do the findings
have to nursing practice?
2. Discuss how the findings can be These findings may be applied in practice to create hospital
applied to practice.
Critical Appraisal 12
significant improvement in attitude toward exercise.
The authors did put their findings in the context of the
broader literature on weight loss and psychosocial
variables in the results and discussion sections. The
authors discussed how this study was different from similar
studies, in that it compared several psychosocial variables
from behavioral change theories in the same intervention
and study. They also discussed how other theories have
used different change variables, e.g., pre-post subtractions
versus this study’s residuals, but still found similar results.
Additionally, the authors discuss how this study’s findings
may be limited, in that subjects were only measured to four
months. They state that in a similar study which followed
participants 16 months, exercise psychosocial variables
were found to be more predictive of weight loss than
weight management psychosocial variables at 16 months,
though similar to our study, the trend was reversed in the
first four months. The authors suggest if this study were
extended, they might find results comparable to the
comparison study.
As stated above, the results may not yield as much clinical
significance as statistical significance. However, the
findings are relevant to nursing practice, in that obesity is a
major health concern that brings with it a host of
comorbidities and issues that affect nursing care (e.g.,
being aware of the risk for Type II diabetes development,
the propensity of these individuals toward developing
bedsores and being mindful of turning the patient
frequently). Therefore, it is to the nurse’s advantage that
she be cognizant of emergent literature, like this study, that
strives to understand the associations behind motivation for
behavior change leading to weight loss. From this study,
the nurse can internalize the fact that increasing her
patient’s self-efficacy (i.e., the feeling that he or she has
the power to affect change in his or her own life) increases
the patient’s weight loss likelihood.
or community weight-loss programs that focus on
increasing the self-efficacy of participants toward weight
loss and exercise (e.g., giving the participants tips to avoid
over-eating on holidays and pointers on how to read food
labels, providing pedometers to the participants to track
exercise progress). Additionally, the programs could
include modules that focus on the intrinsic motivation of the
importance/effort of exercise (another strong psychosocial variable
predictor of weight loss). For example, participants
might be asked to self-organize a weekly plan for exercise,
according to the types of exercises, times, and days that
they feel they can achieve the best results.
 Critical Appraisal 13

References

Clark, M.M., Abrams, D.B., Niaura, R.S., Eaton, C.A., & Rossi, J.S. (1991).

Self-efficacy in weight management. Journal of Consulting and Clinical

Psychology, 59(5), 739-44.

Foster, G.D., Wadden T.A., Vogt, R.A., & Brewer, G. (1997). What is

reasonable weight loss? Patients’ expectations and evaluations of

obesity treatment outcomes. Journal of Consulting and Clinical

Psychology, 65(1), 79-85.

Marquez, D.X., & McAuley, E. (2006). Social cognitive correlates of leisure

time physical activity among Latinos. Journal of Behavioral Medicine,

29(3), 281-9.

McAuley, E., Duncan, T., Tammen, V.V. (1989). Psychometric properties of

the Intrinsic Motivation Inventory in a competitive sport setting: A

confirmatory factor analysis. Research Quarterly for Exercise and

Sport, 60(1), 48-58.

Steinhardt, M.A., & Dishman, R.K. (1989). Reliability and validity of

expected outcomes and barriers for habitual physical activity. Journal

of Occupational Medicine, 31(6), 536-46.

Suris, A.M., Trapp, M.C., DiClemente, C.C., & Cousins, J. (1998). Application

of the transtheoretical model of behavior change for obesity in Mexican

American women. Addictive Behaviors, 23(5), 655-668.