Efficacy of Movement Breaks in Real-World Settings
Phase: NA
Conditions: Healthy
Sponsor: University of British Columbia

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
PROJECT TITLE: Efficacy and feasibility movement breaks in real-world settings 
 
 
CENTRAL KEY QUESTION: Are exercise snacks an effective and feasible solution to 
combat physical inactivity and low cardiorespiratory fitness in real-life settings?  
 
BACKGROUND INFORMATION  
Physical inactivity is an independent risk factor for developing various cancers1,2. A 
pooled analysis of 12 prospective cohort studies involving >1.4M participants reported a >20% 
risk reduction for seven different cancers and a 10-20% risk reduction for six additional cancers 
in the most (90th percentile) versus least (10th percentile) physically active individuals after 
adjusting for traditional risk factors3. Improved cardiorespiratory fitness (CRF) is a primary 
mechanism by which physical activity reduces cancer risk2. A strong inverse relationship 
between CRF and the incidence of cancer independent of traditional risk factors is consistently 
reported4–9. A ~1 metabolic equivalent (MET; 3.5 mL/kg/min) increase in CRF is associated 
with a 10% and 21% lower incidence of cancer in men10 and women11, respectively. Although 
these findings suggest that high CRF confers protection against cancer risk, >80% of Canadian 
adults are physically inactive12. Relatedly, while participation in traditional exercise 
interventions involving continuous bouts of activity (e.g., jogging for 30 minutes) can improve 
CRF, adherence to traditional exercise interventions is notoriously poor. Perceived lack of time 
and difficulties accessing equipment/facilities are among the most commonly cited barriers for 
not performing regular exercise13–19. Thus, there is a need for novel, feasible and scalable 
alternatives to traditional exercise that can enhance CRF and help reduce the risk of developing 
cancer in a practical and time-efficient manner. 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
Exercise snacks are an accessible and time-efficient strategy involving short (≤1 min) 
isolated bursts of vigorous exercise performed sporadically during the day. We have recently 
demonstrated in small lab-based studies that three daily ~20-second bouts of cycling or stair-
climbing, performed thrice weekly for 6 weeks, elicit higher CRF in previously inactive adults 
compared to pre-training20 and a no-exercise control group21. In addition to being time-efficient, 
exercise snacks alleviate the need for both specialized equipment and dedicated leisure time for 
structured exercise. Their ability to be incorporated in between activities of daily living (e.g., 
briskly ascending the stairs at home or work) using readily available aspects of a real-world 
environment overcomes major barriers that prevent participation in traditional exercise (e.g., lack 
of time, access to equipment). Exercise snacks appear to be well-tolerated in inactive healthy 
adults20–22 and individuals with overweight/obesity23 further highlighting their potential for 
widespread application in different populations, including those at risk for developing cancer. 
Due to the isolated and periodic nature of exercise snacks, an important added benefit of this 
approach over traditional exercise strategies is their natural ability to interrupt sedentary time – 
itself an independent risk factor for developing cancer24–26. Although our compelling findings 
suggest that exercise snacks may be a practical and time-efficient approach for improving CRF 
and contributing to primary cancer prevention, their feasibility and efficacy outside the 
laboratory has not been determined. As such, the purpose of this study is to test and apply the 
exercise snacks approach in real-world settings.  
 
 
 
 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
PROJECT AIM 
To conduct a proof-of-concept randomized trial to determine the feasibility and efficacy of a 12-
week technology-enabled exercise snacks intervention for improving CRF in previously inactive 
adults. 
 
EXPERIMENTAL DESIGN 
Rationale  
The design of this real-world intervention is a natural extension of our lab-based studies 
showing improved CRF after exercise snack interventions in previously inactive adults20,21. In 
one of our studies21, participants completed a supervised 6-week intervention involving either 
three daily bouts of vigorous stair climbing (~20 seconds each) performed 1-4 h apart thrice 
weekly (n=12; male/female = 3/9, age = 20±2 yrs) or performed no exercise (n=12; male/female 
= 2/10, age = 19.3±1.6 yrs). CRF measured using the gold standard peak oxygen uptake 
(VO2peak) test was ~5% higher after the exercise snacks intervention compared to the control 
group (Cohen’s d=0.46). The exercise snacks intervention elicited perceived exertion values 
corresponding to a “hard” effort (~5/10 on the Borg scale) and mean heart rate responses 
equating ~85% of the age-predicted maximum21 while being well-tolerated with 100% 
adherence. In a subsequent lab-based study, inactive adults (n=12, male/female=5/7, age = 22±4 
yrs) performed a 6-week cycling-based exercise snacks intervention involving three daily ~20 
second bouts of vigorous exercise 1-4 hours apart on three days per week. Similarly to our first 
study, CRF was ~4% higher after the intervention compared to baseline (Cohen’s d=0.57). 
Although seemingly modest, the ~0.5 MET CRF gain in these studies is impressive for a young 
healthy population over a relatively short training period. We anticipate that recruiting inactive 
middle-aged adults (who are typically less fit than their younger counterparts27) and increasing 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
the dose (e.g., number, duration and/or intervention length) of exercise snacks will elicit even 
larger gains in CRF (e.g., ~1 MET) that correspond with a greater estimated reduction (>10%) in 
cancer risk10,11.  
In the proposed study, participants will perform 3-4 isolated bouts of vigorous exercise 
per day (on 3-4 days per week) with the exercise stimulus being increased (either via increased 
exercise duration, complexity, and/or intensity) progressively over the course of the intervention 
to ensure continuous improvements in health and fitness. To ensure the intervention is 
individualized to exercise preferences and physical abilities (e.g., fitness, musculoskeletal 
issues), adaptable to multiple environments (e.g., home, work), and scalable, we will integrate 
exercise snacks into the well-established, customizable online platform developed by industry 
partner Seven Movements. The platform provides participants with targeted motivation, support, 
and feedback to facilitate strong adherence to the intervention. Our approach is backed by 
evidence supporting the feasibility and efficacy of technology-based applications for improving 
home-based exercise adherence in adults28–31. Co-I Jung is an expert in theory-based exercise 
adherence trials, including studies of vigorous interval training32–36 and technology-enabled 
interventions37–41.  
 
Study Design 
We will conduct a two-centre proof-of-concept parallel arm randomized trial where 
participants will be randomized (1:1 allocation ratio stratified by sex and centre) into an Exercise 
Snacks or Placebo Exercise Control group for 12 weeks. Interventions will be delivered at home 
or work via the functioning Seven Movements platform (www.sevenmovements.com) and 
individualized via onboarding sessions to develop an action plan for incorporating exercise 

Research Protocol 
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Version 2 – April 11, 2022  
snacks or placebo exercise into their daily routines (details below). Efficacy (i.e., the ability to 
improve CRF) and feasibility (i.e., rates of uptake and adherence) will be measured before and 
after the intervention with CRF as the pre-defined primary outcome measure. All pre- and post-
intervention testing will be performed at UBC Okanagan (Kelowna, BC) or McMaster 
University (Hamilton, ON); running the trial at two sites will facilitate recruitment, ensuring we 
can complete the study within the one-year grant timeline. Co-PIs Little (UBCO) and Gibala 
(McMaster) have an established history of collaboration20,21,42–44 – including the two exercise 
snacks studies providing rationale for this project20,21 and a previous multi-site exercise trial45. 
 
COVID-19 Safe Research Protocols 
This study will follow the Safe Research Protocols in place for research in the Arts and 
Reichwald Health Sciences Building at UBC Okanagan for all pre- and post-intervention testing. 
Currently we are using the Safe Work Plan developed and approved for our research by both the 
Faculty of Health and Social Development and Southern Medical Program for in-person research 
at these locations. Of course, all research staff and participants will need to follow the latest 
Public Health Orders. In order to follow these protocols and guidelines (which are ever 
changing), we will email participants prior to their first visit to remind them of: a) the 
requirement to wear a mask throughout the visit, and b) reminder to complete a health check on 
the morning of their visit; and c) ask their vaccination status. Participants must respond to the 
email indicating that they understand and confirming their completion of the health check and 
vaccination status.  
 
 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
Participants 
80 physically inactive male and female adults will be recruited from Kelowna, BC and 
Hamilton, ON using online advertisements and emails to local campus community.  
Eligibility criteria are as follows: 1) aged 40-64 years; 2) physically inactive (performing 
<150 minutes of moderate-to-vigorous intensity aerobic exercise per week, assessed by pre-
screening Get Active Questionnaire); 3) body mass index: 18.5-30.0 kg/m2; 4) not currently 
diagnosed with or being treated for cardiometabolic disease (e.g., coronary artery disease, 
diabetes); 5) not a current smoker; 6) cleared to engage in physical activity using the Get Active 
Questionnaire and, if applicable, consultation with a CSEP CEP Qualified Exercise Professional; 
7) access to a computer, tablet or smartphone for intervention delivery and tracking. Given our 
targeted age-group, it would be impractical to recruit drug-naïve individuals only; we will 
therefore include participants taking ≤2 commonly prescribed medications for the prevention of 
cardiometabolic disease (e.g., statins, antihypertensives) but will ask participants to maintain 
doses throughout the trial. 
Exclusion criteria include: 1) chronic health condition preventing participation in 
exercise; 2) current or previous diagnosis of cancer; 3) lack of access to internet connection.  
 
  
Protocol  
Once deemed eligible for participation based on the above-mentioned criteria, they will 
be randomized (1:1 allocation ratio stratified by sex and centre) into an Exercise Snacks or 
Placebo Exercise Control group for 12 weeks. Following baseline testing (Visit 1 details below), 
individualized interventions will be delivered at home or work via the functioning Seven 
Movements platform (www.sevenmovements.com) where participants will be instructed to 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
perform 3-4 isolated bouts of vigorous exercise per day (on 3-4 days per week) with the exercise 
stimulus being increased (either via increased exercise duration, complexity, and/or intensity) 
progressively over the course of the intervention to ensure continuous improvements in health 
and fitness. To ensure the intervention is individualized to exercise preferences and physical 
abilities (e.g., fitness, musculoskeletal issues), adaptable to multiple environments (e.g., home, 
work) participants will have a virtual or phone pre-intervention meeting (Step 3) wherein any 
physical limitations will be documented and a research assistant will discuss the exercise snacks 
(or placebo stretching) concept with participants in order to determine when and where the 
participants will plan to perform their exercises. This information will be used to create an 
individualized exercise prescription for each participant detailing exercise options and suggested 
time of day to perform them. This prescription will be inputted and integrated into the well-
established, customizable online and app-based platform developed by industry partner Seven 
Movements. Subsequently, participants will start the intervention with a virtual onboarding visit 
(Step 4) wherein a research assistant will introduce the Seven Movements platform, provide their 
login information, discuss their individualized prescription, and guide the participant through 
their first exercise snack. The same approach and individualized exercise prescription and 
platform structure will be used for both groups, with the only difference being the exercise 
snacks group will be prescribed movements that increase heart rate with the intention of 
improving fitness whereas the placebo stretching group will be provided with static stretching 
and low-intensity mobility exercises (e.g., ankle flexion/extension, neck mobility) that are 
designed to not raise heart rate. After 12 weeks, participants will be asked to return to the lab for 
follow-up testing (Step 6 details below).  

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
While participants cannot be blinded in exercise interventions, specific study hypotheses 
(e.g., exercise snacks improving CRF) will not be disclosed to participants as the study will be 
pitched as testing low versus high-intensity “movement breaks”. Given the known detrimental 
impact of prolonged uninterrupted sedentary behavior on various mental and physical health 
outcomes, we anticipate that participants in both groups will achieve some benefit from breaking 
up their sedentary time. Outcome assessors will be blinded to the participants’ group allocation. 
Researchers administering VO2peak tests assessing the primary outcome (CRF) and interviews 
for feasibility outcomes will not be involved in trial administration or interact with participants 
during the intervention. Biological samples used for the assessment of cardiometabolic health 
markers will be coded so researchers remain blinded until completion of all analyses. 
 
STEP 1: Online Assessment of Eligibility (30 minutes)  
Participants will be asked to log-in to the REDCap platform - a secure virtual application 
for research data collection instruments - and complete the following questionnaires online:  
a) Provide informed consent;  
b) CSEP Get Active Questionnaire;  
c) International Physical Activity Questionnaire (IPAQ) 
 
STEP 2: In-Person Visit 1 – Baseline Testing Day (80 minutes)  
This visit will be scheduled in advance, and participants will be asked to come into the 
laboratory in room 115 of the Arts building (ART) at UBC Okanagan. Participants will be asked 
to report to the lab in a fasted state (no food or drink except for water for ≥8 hours) for this visit.  

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
During this visit we will measure body composition (height and body mass), a fasting 
blood sample will be obtained from a vein in the arm (approximately ~2.5 tablespoon, 24-30 
millilitres) and collected into 4-5 separate blood tubes, and a peak oxygen uptake (VO2peak) test 
will be performed using a maximal-graded cycling test. In addition, all Personnel will follow 
Health and Safety recommendations, a maximum of two people will be allowed in the laboratory 
using the personal protective equipment necessary and, as always, all tool/materials, surfaces and 
materials will be decontaminated with 70% ethanol before and after each visit. 
 
STEP 3: Virtual/Phone Interview for Intervention Planning (30 minutes) 
Following pre-intervention testing, a virtual or phone interview will be scheduled at the 
participant’s convenience to discuss participants’ daily schedules, physical limitations (e.g., 
injuries) and/or exercise preferences. This discussion will be used to explain the concept and 
determine the mode, time of day, and location that is best for participants to complete the 
exercise snacks for their individual lifestyles. This information will be used to create an 
individualized exercise prescription for each participant detailing exercise options and suggested 
time of day to perform them. This prescription will be inputted and integrated into the well-
established, customizable online platform developed by industry partner Seven Movements. 
 
STEP 4: Virtual Onboarding (30 minutes)  
To introduce the Seven Movements platform and to further individualize the intervention 
and to promote adherence, an onboarding session will be conducted. During this session, we will 
provide participants with detailed instructions on how to use the Seven Movements platform 
using their computer, smartphone, or tablet, allowing them to access instructional videos 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
detailing their customized movement breaks and to complete post-activity assessment for 
recording their effort and enjoyment after each movement break. 
 
STEP 5: Intervention Period (12 weeks)  
Exercise Snacks Group (referred to as “high-intensity movement breaks” in the consent form) – 
Participants will be prescribed 3-4 exercise snacks performed periodically throughout the day (at 
the participants discretion to fit their daily schedules based on the onboarding session) on 3-4 
days per week. Our lab-based studies used 3 snacks per day for 3 days per week20,21 but we have 
included flexibility in prescription for real-world application. Snack duration, complexity and/or 
intensity will be increased over the course of the intervention to facilitate progression and 
accommodate increases in fitness. These adjustments have been designed by the research team in 
consultation with the Seven Movements team who have a track record of designing “activity 
breaks” for previously inactive adults in real-world settings. Exercises will be tailored to 
participant preferences, physical abilities, and environments and include body-weight exercises 
(e.g., marching in place, step ups, jumping jacks, air squats, lunges), stair-climbing and other 
aerobically conditioning activities designed to increase heart rate. Instructional videos developed 
by Seven Movements will be provided for each exercise ensuring participants are comfortable 
performing the movements safely and effectively. 
 
Placebo Exercise Control (referred to as “low-intensity movement breaks” in the consent form) 
– An identical intervention delivery approach including the same technology and pre-trial virtual 
planning/onboarding sessions will be implemented for the placebo group with the exercise 
snacks being replaced with mobility/stretching based-exercises designed not to stimulate 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
increases in heart rate and CRF. We selected this as the most appropriate control group in 
attempts to balance randomization expectations, retention, and ethical considerations compared 
to a true “hands off” or “no exercise” control.  
 
Technology – Participants will be able to log the timing, duration, and number of exercise snacks 
completed daily as well as the perceived effort (Borg CR-10 scale 47) and enjoyment (Exercise 
Enjoyment Scale48) of each snack into the platform. Participants will also be sent weekly self-
report adherence surveys via email RedCap link wherein adherence will be assessed by asking 
participants the total number of snacks completed each week. If participants miss the weekly 
adherence self-assessment, we will follow-up with an email reminder and (if necessary) a follow-
up telephone call to help address any concerns/issues that may have prevented them from 
completing the weekly assessment. To characterize exercise adherence and track changes in 
daily physical activity, sedentary time, and sleep patterns, we will provide participants with 
validated49,50 thigh-worn triaxial accelerometers (activPAL4) in line with our previous work51,52. 
Accelerometer data will be obtained during two, separate 7-day periods (intervention weeks 2 
and 11) and extrapolated to the rest of the intervention. As exercise adherence generally 
diminishes over an intervention53, obtaining this data during both early and late stages of the 
intervention will provide valuable information relating to changes in adherence over the 
intervention.  
 
Virtual check-ins: To help participants complete their customized movement break plan and to 
address any potential barriers/challenges that you may encounter of the course of the 
intervention, we will conduct virtual (phone or zoom) sessions at the 4 and 8 week point of the 

Research Protocol 
Ethics Application # H21-03417 
Version 2 – April 11, 2022  
intervention. During these sessions, we can also discuss the possibility of adjusting their plan 
based on your experience performing the activities during the preceding 4-week period (e.g., 
they initially thought they would prefer performing the activities at work but change their mind 
and decide they would like to do them at home for the remainder of the intervention). 
 
STEP 6: In-Person Visit 2 – Post-Intervention Testing Day (90 minutes)  
Twelve weeks later, participants will be asked to return to the laboratory to complete follow-up 
testing and self-reported physical activity using the IPAQ. The testing order and procedures will 
be completed exactly as they will be at Visit 1. Following testing, semi-structured interviews will 
be conducted with a subset of 10-12 participants to explore barriers and facilitators of the 
intervention and identify its most effective/ineffective aspects. 
 
OUTCOME MEASUREMENTS & METHODS  
Cardiorespiratory Fitness  
Participants will perform an incremental maximal oxygen uptake (VO2peak) test on a cycle 
ergometer (Load Excalibur Sport) as we perform routinely in our studies21-23. The test will start 
at 30 W and increase at a rate of 15 W / min until volitional exhaustion. A metabolic cart with an 
online gas collection system (Parvo Medics, TrueOne 2400) will be used to collect expired gas 
samples continuously. VO2peak will be calculated using the mean of the highest average oxygen 
consumption over a 30-s period.   
 
Exercise adherence 

Research Protocol 
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Self-reported adherence to the prescribed intervention will be determined using the 
automated weekly REDCap surveys. 9 exercise snacks or placebo exercises per week (equivalent 
to performing at least 3 per day on at least 3 days of the week) will be considered the minimum 
prescription. Participants completing 6 or more, 1-5, or 0 exercises will be classified as adherent, 
partially adherent, or non-adherent, respectively.  
 
Anthropometric Measurements  
Waist circumference (cm), height (cm) and weight (kg), and blood pressure (average of lowest 2 
of 3 measurements) will be measured using the standard procedures. Body mass index (BMI) 
will be calculated as kg/m2. 
 
Questionnaires  
a. Medical screening questionnaire by CSEP Get Active Questionnaire (CSEP GAQ); 
b. Pre- and post-intervention International Physical Activity Questionnaire (IPAQ) used to 
evaluate self-reported physical activity; 
c. Rating of perceived exertion (Borg CR-10 scale47), and exercise enjoyment (Exercise 
Enjoyment Scale48) after each snack; 
d. Customized Weekly Questionnaire that will be used to assess adherence and uptake of the 
intervention,  
 
Blood Collection  
 Following an overnight fast (after ≥ 8 hours of the last meal), a single blood sample will 
be obtained by venipuncture of an antecubital vein and collected into sodium heparin, ethylene-

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Version 2 – April 11, 2022  
diaminetetraacetic acid (EDTA - BD Vacutainer), and sodium citrate tubes for subsequent 
analyses. A total of 4-5 tubes (~4-6 mL each) will be collected. In addition, all Personnel will 
follow Health and Safety recommendations, a maximum of two people will be allowed in the 
laboratory using the personal protective equipment necessary and, as always, all surfaces and 
materials will be decontaminated with 70% ethanol before and after each visit. 
 
Plasma Analyses 
 
Plasma will be prepared by centrifugation for 15 minutes at 1200Xg and frozen for 
analyses of standard metabolic markers (e.g., blood glucose, insulin, triglycerides) and 
inflammatory cytokines (IL-6, IL-10 and TNF-α) by MSD multiplex technology, enzyme-linked 
immunosorbant assays (ELISA), or biochemical assay according to manufacturer’s instructions. 
To explore additional mediators of altered inflammation and immune function, we will also 
measure IL-10 function (details below) and profile extracellular vesicles (small membrane bound 
vesicles containing cellular DNA/RNA and proteins) using standard techniques in our lab. EVs 
will be quantified and characterized using resistive pulse sensing, flow cytometry and cargo 
profiling. Samples will be stored for 5 years after publication before destroying (additional 
markers in the stored samples may be measured during this time). 
Human whole blood culture  
For whole blood stimulation, we will use our published protocol for IL-10 function 
experiments74. Briefly, whole blood will be diluted in a serum-free RPMI media (Sigma) 
containing 5mM glucose, 50 U/ml penicillin and 50µl/ml streptomycin. Diluted 540µl whole 
blood will be seeded in 24-well plate (Costar) and stimulated using lipopolysaccharide (LPS, 
Escherichia coli 055:B5; L6529, Sigma) at 1 or 10 ng/ml with or without recombinant human IL-
10. The cultures will be incubated at 37°C in 5% CO2 and supernatants will be collected at six 

Research Protocol 
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hours for analyses of secreted TNF-α on duplicate samples by enzyme-linked immunosorbent 
assay - ELISA (Human TNF-α DuoSet, R&D System) according to the manufacturer’s 
instructions. The % maximal stimulation is taken as an index of how well the anti-inflammatory 
cytokine function to inhibit inflammation. A reduction in the ability of IL-10 to inhibit TNF-α 
production will be an indicative of “resistance” to their anti-inflammatory action. 
 
Flow cytometry 
To examine potential changes in anti-inflammatory signalling pathways in circulating 
immune cells, the proportion of phosphorylated STAT3 (pSTAT3) positive cells will be 
measured by flow cytometric analysis. Briefly, whole blood samples and isolated monocytes will 
be stimulated within exogenous IL-10 for 15 minutes at 37°C in a dose-depended manner (0, 1, 
10, 50, 100, 1000 ng/ml), 1ml of Lyse/Fix Buffer (BD Phosflow) will be added for erythrocyte 
lysis and fixation of the phosphorylated status of intracellular proteins. Next, cells will be 
permeabilized with 1ml of Perm Buffer (BD Phosflow), washed and stained for 60 minutes at 
room temperature in the dark with the following fluorophore-labelled monoclonal antibodies: 
anti-CD4-phycoerythrin (PE)-Cy7 (BD Pharmingen, Franklin Lakes, NJ, USA), anti-STAT3 
(py705)-AF488 (BD Phosflow), anti-pAMPK (ab23875, Abcam) anti-CD14 (130-094-364, 
Miltenyi Biotech) and anti-CD210 (BD Biosciences). Stained cells will be analysed by flow 
cytometry (Cytoflex S, Beckman Coulter).  
 
PBMC isolation 
  
PBMCs will be isolated by gradient density centrifugation to determine changes in 
immune cell gene expression in response to the intervention. Briefly, whole blood will be diluted 

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1:1 with warm PBS and layered onto 3 mL of Histopaque-1077 (10771, Sigma) in a sterile 12 
mL LeucoSep tube (Greiner Bio-One, Austria) and centrifuged at 800 g for 20 min at room 
temperature. The enriched PBMC layer will be recovered and washed twice with warm PBS with 
an additional centrifugation step (300 g for 10 min) after each wash. Isolated PBMCs will be 
stimulated with IL-10 and/or liposaccharide for ~1 hour and stored at -80°C until transcriptomics 
analysis.  
 
Haematology Analysis of Blood 
 
Whole blood specimens will be analysed for complete blood count (e.g., total white blood 
cells, haematocrit, haemoglobin, monocytes, neutrophils) using a haematology analyser (DxH 
520, Beckman Coulter) to determine changes in clinically relevant health markers before and 
after the intervention.   
 
Semi-Structured Interviews  
 
Semi-structured interviews will be conducted in a subset of 10-12 participants to explore 
barriers and facilitators of the intervention and identify its most effective/ineffective aspects; this 
will help refine the approach and future intervention delivery. 
 
Statistical Analysis  
 
Descriptive statistics will be calculated and data will be assessed for skewness and 
normality using Q-Q plots and Shapiro-Wilk tests (non-normal distributions will be log 
transformed as needed). The primary data analyses will be intention-to-treat. We will define 
feasibility of the exercise snacks intervention as >70% of participants completing at least 67% 

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(i.e., 6 exercise snacks per week) on at least 9 out of 12 weeks. All quantitative dependent 
variables will be analyzed using linear mixed-effects models with group and time as fixed 
effects, participant and study site as random effects, and age and baseline fitness as covariates. 
The between group treatment effect at 12 weeks with 95% confidence intervals will be the main 
analyses of interest. Although the study is not powered for detecting sex differences, sex will be 
included in the model to explore its interaction with the treatment effect. Significance will be set 
at p<0.05 and Cohen’s d effect sizes will be calculated to estimate the magnitude of between-
group differences in pre-post change scores. For qualitative outcomes, an inductive thematic 
analysis will be conducted on interview transcripts by Co-I Jung to ascertain main barriers and 
facilitators to acceptability66,67. 
 
 
 
 
 
 
 
 
 
 

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