Results of the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial: A Behavioral Weight Loss Intervention in Overweight or Obese Breast Cancer Survivors

Cardiovascular risk management in cancer survivors: Are we doing it right?

Although under-recognized, cancer survivors continue to be at an increased risk of death from cardiovascular complications post-remission or cure. This increased burden of cardiovascular disease results from the interplay of various factors. Adequate cardiovascular risk assessment and timely intervention through a multi-disciplinary approach in these patients plays a pivotal role in the prevention of cardiovascular morbidity and mortality. We discuss the shortcomings of using current risk prediction scores in cancer survivors and provide some insights into cardiovascular risk management relevant for primary care physicians, oncologists, and cardiologists alike.

Storying My Lifestyle Change: How Breast Cancer Survivors Experience and Reflect on Their Participation in a Pilot Healthy Lifestyle Intervention

Purpose: Healthy lifestyle interventions after breast cancer treatment have generally been studied in terms of weight-loss outcomes, which leaves a gap in our understanding of the phenomenological experience of such programs. Our knowledge of how or why women recovering from breast cancer engage or do not engage in these programs is limited. Thus, we aimed to share subjective experiences of lifestyle change within a 12-week group intervention entitled "Healthy Lifestyle Modification After Breast Cancer" (HLM-ABC). Methods: The present research entailed a multiple case study of four breast cancer survivors who participated in the HLM-ABC. Participants were interviewed longitudinally at four time-points: (1) pre-intervention; (2) mid-way intervention; (3) post-intervention, and (4) three-months post-intervention. Results: We analysed storytelling of participation in the HLM-ABC program to investigate participants' unique and gradual endeavours towards living a healthier lifestyle. A qualitative, narrative analysis was applied to each participant's set of interviews, which yielded two distinct story-telling patterns while participating in the HLM-ABC program: one "plot-driven" and one "character-driven". Conclusions: These two narrative styles appeared to correspond with differing levels of intervention uptake and perceived success in the program. The implications of these narrative styles and their relationship to healthy lifestyle intervention are discussed.

What do cancer survivors and their health care providers want from a healthy living program? Results from the first round of a co-design project

PURPOSE

Healthy lifestyles are an important part of cancer survivorship, though survivors often do not adhere to recommended guidelines. As part of the co-design of a new online healthy living intervention, this study aimed to understand cancer survivors', oncology healthcare professionals' (HCP) and cancer non-government organisation (NGO) representatives' preferences regarding intervention content and format.

METHODS

Survivors, HCP and NGO representatives participated in focus groups and interviews exploring what healthy living means to survivors, their experience with past healthy living programs and their recommendations for future program content and delivery. Sessions were audio recorded, transcribed verbatim and analysed thematically.

RESULTS

Six focus groups and eight interviews were conducted including a total of 38 participants (21 survivors, 12 HCP, 5 NGO representatives). Two overarching messages emerged: (1) healthy living goes beyond physical health to include mental health and adjustment to a new normal and (2) healthy living programs should incorporate mental health strategies and peer support and offer direction in a flexible format with long-term accessibility. There was a high degree of consensus between participant groups across themes.

CONCLUSIONS

These findings highlight the need for integration of physical and mental health interventions with flexibility in delivery. Future healthy living programs should investigate the potential for increased program adherence if mental health interventions and a hybrid of delivery options were included.

The core components of cardio-oncology rehabilitation

The increased efficacy of cancer therapy has resulted in greater cancer survival and increasing number of people with cancer and cardiovascular diseases. The sharing of risk factors, the bidirectional relationship between cancer and cardiovascular diseases and the cardiotoxic effect of chemotherapy and radiotherapy, are the cause of the rapid expansion of cardio-oncology. All strategies to preserve cardiovascular health and mitigate the negative effect of cancer therapy, by reducing the cardiovascular risk, must be pursued to enable the timely and complete delivery of anticancer therapy and to achieve the longest remission of the disease. Comprehensive cardiac rehabilitation is an easy-to-use model, even in cancer care, and is the basis of Cardio-Oncology REhabilitation (CORE), an exercise-based multi-component intervention. In addition, CORE, besides using the rationale and knowledge of cardiac rehabilitation, can leverage the network of cardiac rehabilitation services to offer to cancer patients exercise programs, control of risk factors, psychological support, and nutrition counseling. The core components of CORE will be discussed, describing the beneficial effect on cardiorespiratory fitness, quality of life, psychological and physical well-being, and weight management. Furthermore, particular attention will be paid to how CORE can counterbalance the negative effect of therapies in those at heightened cardiovascular risk after a cancer diagnosis. Barriers for implementation, including personal, family, social and of the health care system barriers for a widespread diffusion of the CORE will also be discussed. Finally, there will be a call-to-action, for randomized clinical trials that can test the impact of CORE, on morbidity and mortality.

An individualized food-based nutrition intervention reduces visceral and total body fat while preserving skeletal muscle mass in breast cancer patients under antineoplastic treatment

BACKGROUND & AIMS

Breast cancer patients (BCP) during treatment often experience an increase in body weight and fat mass, and a decrease in muscle mass known as sarcopenic obesity, affecting their prognosis and quality of life. We aimed to evaluate the effect of a 6-month individualized food-based nutrition intervention program in nonmetastatic BCP body composition during treatment.

METHODS

This is a pre-post study in recently diagnosed women with invasive ductal/lobular breast carcinoma (clinical stage I-III). The individualized nutrition intervention was based on the dynamic macronutrient meal equivalent menu method (MEM). Dietary plans were developed according to WCRF/AICR guidelines, BCP total energy expenditure, 1.2-1.5 g/kgBW/d of protein intake, 5-9 servings/day of fruits and vegetables, and a caloric restriction (500-1000 kcal/d) when applicable (BMI ≥ 25 kg/m²). Follow-up was every 2-weeks and a different diet menu was provided in each session during 6 months. Baseline and final measurements included the assessment of anthropometry, body composition, and physical activity.

RESULTS

Twenty-two participants completed the study and at diagnosis 68% were overweighed or obese. After the 6-month nutrition intervention program, BCP lost 3.1 kg (p < 0.01) of body weight, 2.7 kg (p < 0.01) of fat-mass, 400 g (p < 0.01) of abdominal fat, 118 g (p < 0.05) of visceral fat, 1.2 kg/m² of body mass index and 1.1 kg/m² of fat mass index (p < 0.01). During the period, no changes were observed in bone mineral density (p = 0.3), fat-free mass (p = 0.1) and appendicular skeletal muscle mass (p = 0.2). Menopausal status in BCP did not modify the effect of the nutrition intervention.

CONCLUSIONS

The individualized food-based nutrition intervention program empowered BCP to make informed healthy food choices within their personal preferences, socioeconomic and cultural background. With this type of intervention, nonmetastatic BCP reduced body weight, fat-mass, fat mass index, visceral and abdominal fat, while preserving skeletal muscle mass, during antineoplastic treatment. ClinicalTrials.govNCT03625635.

Weight loss outcomes in premenopausal versus postmenopausal women during behavioral weight loss interventions: a systematic review and meta-analysis

IMPORTANCE

Weight loss may be difficult for young women with obesity to achieve due to competing priorities (caring for children and/or full-time work), limiting their ability to engage in weight loss interventions. Older or postmenopausal women may also face challenges to weight loss such as caring responsibilities and menopause. Menopausal status may reflect differences in weight loss.

OBJECTIVE

This study compared changes in weight, fat mass, and lean mass in premenopausal versus postmenopausal women in dietary weight loss trials.

EVIDENCE REVIEW

We reviewed publications from January 2000 to June 2020 evaluating a weight loss intervention with a dietary component, with or without exercise, and reporting weight loss of premenopausal and postmenopausal women. Where available, data on mean change from baseline for weight, fat mass, and lean mass of premenopausal and postmenopausal groups were entered into Review Manger for meta-analyses. Differences between menopausal groups were compared in subgroups of studies for intervention characteristics (diet-only vs diet and exercise; dietary modification vs meal replacement; < 24 wks vs ≥24 wks duration).

FINDINGS

Seven publications (10 interventions, n = 791) were included; three single-arm trials, two randomized controlled trials, and two comparative effectiveness trials. In meta-analyses, there were no statistically significant differences between premenopausal and postmenopausal women (shown as premenopausal minus postmenopausal) for change in weight (0.58 [95% confidence interval -0.12 to 1.28] kg, n = 7 interventions), fat mass (0.73 [-0.25 to 1.70] kg, n = 6 interventions), or lean mass (-0.5 6[-1.48 to 0.36] kg, n = 4 interventions). However, a statistically significant subgroup difference was observed for fat mass change between menopausal groups (premenopausal minus postmenopausal) when comparing diet-only (1.28 [0.23 to 2.33] kg, n = 4 interventions) versus diet and exercise interventions (-0.09 [-0.51 to 0.32]kg, n = 2 interventions). No differences were shown in any other subgroups.

CONCLUSIONS AND RELEVANCE

This review provides some evidence to suggest weight loss interventions may not need to be tailored to women's menopausal status. However, given the small number of studies, short intervention duration in most publications (≤ 6 mo) and unclear retention rates in premenopausal versus postmenopausal groups of some publications, menopausal group differences should be examined in existing and future trials where the appropriate data have been collected.

Body weight management in overweight and obese breast cancer survivors

BACKGROUND

Studies suggest that overweight and obese breast cancer survivors are at increased risk of cancer recurrence and have higher all-cause mortality. Obesity has an impact on breast cancer survivor's quality of life (QOL) and increases the risk of longer-term morbidities such as type 2 diabetes mellitus and cardiovascular disease. Many cancer guidelines recommend survivors maintain a healthy weight but there is a lack of evidence regarding which weight loss method to recommend.

OBJECTIVES

To assess the effects of different body weight loss approaches in breast cancer survivors who are overweight or obese (body mass index (BMI) ≥ 25 kg/m²).

SEARCH METHODS

We carried out a search in the Cochrane Breast Cancer Group's (CBCG's) Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6), MEDLINE (2012 to June 2019), Embase (2015 to June 2019), the World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP) and Clinicaltrials.gov on 17 June 2019. We also searched Mainland Chinese academic literature databases (CNKI), VIP, Wan Fang Data and SinoMed on 25 June 2019. We screened references in relevant manuscripts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and randomised cross-over trials evaluating body weight management for overweight and obese breast cancer survivors (BMI ≥ 25 kg/m²). The aim of the intervention had to be weight loss.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed data extraction and assessed risk of bias for the included studies, and applied the quality of the evidence using the GRADE approach. Dichotomous outcomes were analysed as proportions using the risk ratio (RR) as the measure of effect. Continuous data were analysed as means with the measure of effect being expressed as the mean differences (MDs) between treatment groups in change from baseline values with 95% confidence intervals (CIs), when all studies reported exactly the same outcomes on the same scale. If similar outcomes were reported on different scales the standardised mean difference (SMD) was used as the measure of effect. Quality of life data and relevant biomarkers were extracted where available.

MAIN RESULTS

We included a total of 20 studies (containing 23 intervention-comparisons) and analysed 2028 randomised women. Participants in the experimental groups received weight loss interventions using the core element of dietary changes, either in isolation or in combination with other core elements such as 'diet and exercise', 'diet and psychosocial support' or 'diet, exercise and psychosocial support'. Participants in the controls groups either received usual care, written materials or placebo, or wait-list controls. The duration of interventions ranged from 0.5 months to 24 months. The duration of follow-up ranged from three months to 36 months. There were no time-to-event data available for overall survival, breast cancer recurrence and disease-free survival. There was a relatively small amount of data available for breast cancer recurrence (281 participants from 4 intervention-comparisons with 14 recurrence events; RR 1.95, 95% CI 0.68 to 5.60; low-quality evidence) and the analysis was likely underpowered. Overall, we found low-quality evidence that weight loss interventions for overweight and obese breast cancer survivors resulted in a reduction in body weight (MD: -2.25 kg, 95% CI: -3.19 to -1.3 kg; 21 intervention-comparisons; 1751 women), body mass index (BMI) (MD: -1.08 kg/m², 95% CI: -1.61 to -0.56 kg/m²; 17 intervention-comparisons; 1353 women), and waist circumference (MD:-1.73 cm, 95% CI: -3.17 to -0.29 cm; 13 intervention-comparisons; 1193 women), and improved overall quality of life (SMD: 0.74; 95% CI: 0.20 to 1.29; 10 intervention-comparisons; 867 women). No increase was seen in adverse events for women in the intervention groups compared to controls (RR 0.94, 95% CI: 0.76 to 1.17; 4 intervention-comparisons; 394 women; high-quality evidence). Subgroup analyses revealed that decreases in body weight, BMI and waist circumference were present in women regardless of their ethnicity and menopausal status. Multimodal weight loss interventions (which referred to 'diet, exercise and psychosocial support') appeared to result in greater reductions in body weight (MD: -2.88 kg, 95% CI: -3.98 to -1.77 kg; 13 intervention-comparisons; 1526 participants), BMI (MD: -1.44 kg/m², 95% CI: -2.16 to -0.72 kg/m²; 11 studies; 1187 participants) and waist circumference (MD:-1.66 cm, 95% CI: -3.49 to -0.16 cm; 8 intervention-comparisons; 1021 participants) compared to dietary change alone, however the evidence was low quality.

AUTHORS' CONCLUSIONS

Weight loss interventions, particularly multimodal interventions (incorporating diet, exercise and psychosocial support), in overweight or obese breast cancer survivors appear to result in decreases in body weight, BMI and waist circumference and improvement in overall quality of life. There was no increase in adverse events. There is a lack of data to determine the impact of weight loss interventions on survival or breast cancer recurrence. This review is based on studies with marked heterogeneity regarding weight loss interventions. Due to the methods used in included studies, there was a high risk of bias regarding blinding of participants and assessors. Further research is required to determine the optimal weight loss intervention and assess the impact of weight loss on survival outcomes. Long-term follow-up in weight loss intervention studies is required to determine if weight changes are sustained beyond the intervention periods.

Bone Health in Premenopausal Chinese Patients after Adjuvant Chemotherapy for Early Breast Cancer

BACKGROUND

In this cohort study, the objectives were to determine bone mineral density (BMD) and potential associated factors for bone health among young premenopausal patients after adjuvant chemotherapy.

METHODS

Eligibility criteria included premenopausal Chinese aged <45 years who had received adjuvant chemotherapy. At study entry, background demographics and menstrual history were collected; BMD was measured. Factors associated with reduced BMD and fracture risk were analyzed.

RESULTS

A total of 271 patients entered the study. The median time from breast cancer diagnosis to study entry was 5.0 years. The median ages at breast cancer diagnosis and at study entry were 41 and 47 years, respectively. The median BMDs for femoral neck (FN) and lumbar spine (LS) were 0.72 and 0.91 g/cm2, respectively; 40.2% had abnormal Z-scores (defined as ≤-1) and 50.2% had osteopenia/osteoporosis of either FN or LS. On multivariate analyses, factors that were identified to have a positive association with bone health (higher BMD) included higher family income (OR [95% CI] for LS = 1.573 [1.091-2.268]), taller stature (OR for LS = 2.975 [1.723-5.137]), and higher BMI (OR for FN = 2.156 [1.599-2.907]), while negatively associated factors included longer interval since last adjuvant treatment (OR for LS: 0.435 [0.250-0.757]), peri-/postmenopausal status at study entry (OR for LS = 0.443 [0.255-0.768]; OR for FN = 0.353 [0.205-0.609]), and having received adjuvant tamoxifen (OR for FN = 0.452 [0.243-0.841]).

CONCLUSION

About 5 years after breast cancer diagnosis and adjuvant chemotherapy, >50% of premenopausal patients who had received adjuvant chemotherapy were detected to have osteopenia/osteoporosis and 40% had abnormal Z-scores for FN/LS.

Brief Hospital Supervision of Exercise and Diet During Adjuvant Breast Cancer Therapy Is Not Enough to Relieve Fatigue: A Multicenter Randomized Controlled Trial

Supervised exercise dietary programs are recommended to relieve cancer-related fatigue and weight increase induced by adjuvant treatment of early breast cancer (EBC). As this recommendation lacks a high level of evidence, we designed a multicenter randomized trial to evaluate the impact of an Adapted Physical Activity Diet (APAD) education program on fatigue. We randomized 360 women with EBC who were receiving adjuvant chemotherapy and radiotherapy to APAD or usual care at eight French cancer institutions. Data were collected at baseline, end of chemotherapy, end of radiotherapy, and 6 months post-treatment. The primary endpoint was the general cancer-related fatigue score using the MFI-20 questionnaire. Fatigue correlated with the level of precariousness, but we found no significant difference between the two groups in terms of general fatigue (p = 0.274). The APAD arm has a smaller proportion of patients with confirmed depression at the end of follow-up (p = 0.052). A transient modification in physical activity levels and dietary intake was reported in the experimental arm. However, a mixed hospital- and home-based APAD education program is not enough to improve fatigue caused by adjuvant treatment of EBC. Cancer care centers should consider integrating more proactive diet-exercise supportive care in this population, focusing on precarious patients.

Landmark trials in the medical oncology management of early stage breast cancer

With the advent of breast cancer screening programs, the majorities of patients with newly diagnosed breast cancer are diagnosed with early stage disease and are likely to experience cure with proper treatment. Significant advances have been made in the management of early-stage breast cancer to personalize treatment according to disease biology. This progress has led to improvement in survival outcomes and quality of life for our patients. In this review, we discuss landmark clinical trials in medical oncology that have shaped the current standard of care for early stage ER-positive, HER2-positive, and triple negative breast cancer.

Effect of a Workplace Weight-Loss Program for Overweight and Obese Healthcare Workers

PURPOSE

Examining the effect of a workplace weight-loss program on weight loss, and physical, behavioral and mental well-being among overweight/obese healthcare workers.

DESIGN

Quasi experimental design.

SETTING

Single healthcare setting.

PARTICIPANTS

Forty-one (48.0 ± 11.2 years) day-time shift healthcare employees with body mass index [BMI] >29 kg/m².

INTERVENTION

Sixteen-week program with weekly group meetings/activities and individual appointments with nutrition/health experts.

MEASURES

Objective (weight, BMI, blood pressure) and self-reported measures were collected at baseline, conclusion of the intervention and 3 to 6 months post-intervention.

ANALYSIS

Repeated measure analysis accounting for confounders.

RESULTS

Participants had an average of 13 pounds (5.6%) weight loss (224.2 ± 6.4 vs. 211.6 ± 6.4 lbs.; P < 0.0001) upon program completion with significant decreases in BMI (37.7 ± 1.0 vs. 35.1 ± 1.0 kg/m²; P < 0.0001). Extreme obesity (BMI≥40 kg/m²) rate was reduced from 36.6% to 17.1% (P < 0.0001). There were decreases in diastolic blood pressure (76.0 ± 1.4 vs. 68.7 ± 1.5 mmHg; P = 0.001) and self-reported blood glucose (119.9 ± 4.4 vs. 105.5 ± 4.6 mg/dL; P = 0.03). Participants had improvements in weekly physical activity (25% change; P = 0.01), nutrition behavior (33% change, P < 0.0001), sleep quality (23% change, P = 0.005), and depression (72% change, P < 0.0001). Twenty-seven participants had post-intervention follow-up data. On average participants regained 8 pounds, which was less than the initial weight loss (16 lbs., N = 27).

CONCLUSION

The results suggest the program may benefit healthcare employees. Further emphasis should be placed on post-intervention weight management to prevent weight regain.

Psychological correlates of physical activity and exercise preferences in metropolitan and nonmetropolitan cancer survivors

OBJECTIVE

Interventions to increase physical activity (PA) in cancer survivors have often adopted a "one-size-fits-all" approach and may benefit from being tailored to psychological constructs associated with behavior. The study objective was to investigate the exercise preferences and psychological constructs related to PA among cancer survivors.

METHODS

Posttreatment colorectal, endometrial, and breast cancer survivors (n = 183) living in metropolitan and nonmetropolitan areas completed survey measures of PA, exercise preferences, attitudes, self-efficacy, perceived behavioral control (PBC), and intention toward PA.

RESULTS

A structural equation model with adequate fit and quality indices revealed that instrumental attitude and self-efficacy were related to PA intention. Intention was related to behavior and mediated the relationship between self-efficacy and behavior. Preferred exercise intensity was related to self-efficacy, PBC, attitudes, and intention, while preferred exercise company was related to self-efficacy and PBC. Participants preferred moderate-intensity PA (71%), specifically self-paced (52%) walking (65%) in an outdoor environment (58%).

CONCLUSIONS

Since instrumental attitude and self-efficacy were associated with PA, incorporating persuasive communications targeting attitudes in PA interventions may promote PA participation. As cancer survivors who prefer low-intensity exercise and exercising with others report lower self-efficacy and PBC, interventions targeting confidence and successful experience in this group may also be warranted.

Randomized phase II study of a home-based walking intervention for radiation-related fatigue among older patients with breast cancer

BACKGROUND

Fatigue is a common side effect of radiation therapy and can dramatically affect the quality of life in older cancer patients. We compared a home-based graduated walking intervention with a fixed walking recommendation.recommendation to exercise to determine the effects of these interventions during adjuvant radiotherapy (RT) on older women with breast cancer.

METHODS

A randomized phase 2 trial in women ≥65 years, with stage 0-3 breast cancer. Prior to initiating breast RT, women were randomized to a Home-Based Graduated Walking Program (HBGWP) or a fixed walking recommendation. The primary outcome of fatigue was measured by the Total Disruption Index (TDI) of the Fatigue Symptom Inventory (FSI). Secondary outcomes including a short physical performance battery (SPPB) and questionnaires on exercise, physical function, fatigue (PROMIS Fatigue), and fatigue-related symptoms were collected at 3 time points. The primary goal was to compare the change in TDI between arms at the end of RT. Random coefficients models were used to determine the association between arm, fatigue, and exercise over time. Linear regression models were used to describe the change in outcome variables between visits.

RESULTS

Median age of the 54 participants (27 per arm) was 69 years (range 65-84). The baseline characteristics were similar between study arms. The number of minutes walking per week increased in both arms (mean 21 min/wk. baseline to 83 min/wk. end of RT, p < 0.01) and physical function improved over time in both arms (median 10.5 at baseline to 12 at end of RT, p < 0.01).There was no significant difference in change in TDI between arms (2.7 ± 9.9 vs. 1.8 ± 14.0, p = 0.61)between baseline and end of RT. However, in our linear regression model increasing walking over time was associated with statistically significant lower levels of fatigue (-2.44+/- 1.04, p = 0.04), but not in posthoc subgroup analyses.

CONCLUSION

The HBGWP did not decrease fatigue more than the fixed recommendation to exercise. Both the graduated intervention and fixed recommendation lead to increased walking which was associated with lower fatigue in this study of older adult breast cancer patients.

Rationale and description of a lifestyle intervention programme to achieve moderate weight loss in women with non-metastatic breast cancer: the lifestyle intervention part of the SUCCESS C Study

Objective

There is growing evidence from observational studies that lifestyle factors such as obesity, an unhealthy diet and lack of physical activity are associated with poor long-term outcome in women with breast cancer. The primary objective of the lifestyle modification part of the Simultaneous Study of Docetaxel Based Anthracycline Free Adjuvant Treatment Evaluation, as well as Life Style Intervention Strategies (SUCCESS C) Trial is to investigate the effect of an individualised lifestyle intervention programme aiming at moderate weight loss on disease-free survival in women with HER2/neu-negative breast cancer. Secondary objectives include the effect of the intervention on body weight, cardiovascular risk and quality of life.

Methods

The SUCCESS C Trial is an open-label, multicentre, randomised controlled phase III study using a 2×2 factorial design in women with newly diagnosed HER2/neu-negative intermediate-risk to high-risk breast cancer. The first randomisation served to compare disease-free survival in patients treated with two different chemotherapy regimens (3642 participants). The second randomisation served to compare disease-free survival in patients with a body mass index of 24–40 kg/m² (2292 participants) receiving either a telephone-based individualised lifestyle intervention programme for moderate weight loss or general recommendations for a healthy lifestyle for 2 years. Outcome analyses will be conducted after 5 years of follow-up.

Perspective

This study will provide information on the efficacy and safety of a comprehensive lifestyle intervention programme on disease-free survival in a large cohort of women with breast cancer. EU Clinical Trials Identifier: 2008-005453-38.

Effects of physical training on anthropometrics, physical and physiological capacities in individuals with obesity: A systematic review

Increasing the amount of physical activity is an important strategy for weight loss. This systematic review summarizes recent findings on the effects of physical training on anthropometric characteristics, physical performances and physiological capacities in individuals with overweight and obesity. A systematic literature search strategy was conducted from inception until June 2019 using four electronic databases that identified 2,708 records. After screening for titles, abstracts and full texts, 116 studies were included in our final analysis. Both aerobic (e.g., endurance training) and anaerobic training (e.g., high-intensity training, resistance training) improved body composition and physical fitness indicators in adults, adolescents and children with obesity (effect size: 0.08 < d < 2.67, trivial to very large). This systematic review suggests that both low- and high-intensity training significantly reduced body weight and fat mass while increasing fat-free mass in individuals with obesity (effect size: 0.04 <d <3.2, trivial to very large). A significant increase in VO_2max also occurs in individuals with obesity in response to aerobic training or high-intensity interval training (effect size: 0.13 < d < 6.24, trivial to very large). Further studies are needed to define the optimal combination of training intensity and duration needed to produce the most efficacious results in individuals with obesity.

Mediators of physical activity adoption and maintenance among breast cancer survivors

The purpose of this study is to explore the mediators associated with physical activity (PA) within the adoption and maintenance phase of a PA intervention trial among breast cancer survivors. Overall, 192 breast cancer survivors (average age = 55.9 years) were randomized to an Intervention or Control group. Both groups received 8 calls in the first 3-months, 3 monthly calls, and then entered a no-contact maintenance phase for the remaining 6-months. Assessments were completed at baseline, 3-months, 6-months and 12-months. On average, participants were 55.9 years of age (SD = 9.8) and 2.9 years since diagnosis (SD = 2.2). In the adoption phase, all significant univariate mediators (self-efficacy, cognitive and behavioral processes and decisional balance cons) were included in the multivariate model. Results suggest self-efficacy (ab = 13.56, SE = 7.04) and behavioral processes (ab = 36.10, SE = 12.22) were significant for PA adoption. No mediators were identified in the maintenance phase. In the adoption phase, there were significant indirect effects of group on PA adoption through self-efficacy and behavioral processes. There were no indirect effects of group on PA maintenance.

A Remotely Delivered, Peer-Led Physical Activity Intervention for Younger Breast Cancer Survivors (Pink Body Spirit): Protocol for a Feasibility Study and Mixed Methods Process Evaluation

Background

Younger breast cancer survivors consistently report a greater impact of their cancer experience on quality of life compared with older survivors, including higher rates of body image disturbances, sexual dysfunction, and fatigue. One potential strategy to improve quality of life is through physical activity, but this has been understudied in younger breast cancer survivors, who often decrease their activity during and after cancer treatment.

Objective

The aim of this study is to explore the feasibility and acceptability of a technology-based, remotely delivered, peer-led physical activity intervention for younger breast cancer survivors. We will also assess the preliminary impact of the intervention on changes in physical activity and multiple aspects of quality of life.

Methods

This study is a community-academic partnership between University of California, San Diego and Haus of Volta, a nonprofit organization that promotes positive self-image in younger breast cancer survivors. This ongoing pilot study aims to recruit 30 younger breast cancer survivors across the United States (<55 years old, >6 months post primary cancer treatment, self-report <60 min of moderate-to-vigorous-intensity physical activity [MVPA]) into a 3-month peer-delivered, fully remote exercise program. Participants will complete 6 biweekly video chat sessions with a trained peer mentor, a fellow younger breast cancer survivor. Participants will receive a Fitbit Charge 3; weekly feedback on Fitbit data from their peer mentor; and access to a private, in-app Fitbit Community to provide and receive support from other participants and all peer mentors. At baseline, 3 months, and 6 months, participants will complete quality of life questionnaires, and MVPA will be measured using the ActiGraph accelerometer. Feasibility and acceptability will be explored through a mixed methods approach (ie, quantitative questionnaires and qualitative interviews). Intervention delivery and adaptations by peer mentors will be tracked through peer mentor self-evaluations and reflections, review of video-recorded mentoring sessions, and monthly templated reflections by the research team.

Results

Recruitment began in September 2019. As of February 2020, the physical activity intervention is ongoing. Final measures are expected to occur in summer 2020.

Conclusions

This study explores the potential for physical activity to improve sexual function, body image, and fatigue, key quality of life issues in younger breast cancer survivors. Using peer mentors extends our reach into the young survivor community. The detailed process evaluation of intervention delivery and adaptations by mentors could inform a future hybrid-effectiveness implementation trial. Finally, remote delivery with commercially available technology could promote broader dissemination.

Trial Registration

ClinicalTrials.gov NCT04064892; https://clinicaltrials.gov/ct2/show/NCT04064892

International Registered Report Identifier (IRRID)

DERR1-10.2196/18420

Lifestyle Intervention on Body Weight and Physical Activity in Patients with Breast Cancer can reduce the Risk of Death in Obese Women: The EMILI Study

Background obesity and sedentary lifestyle have been shown to negatively affect survival in breast cancer (BC). The purpose of this study was to test the efficacy of a lifestyle intervention on body mass index (BMI) and physical activity (PA) levels among BC survivors in Modena, Italy, in order to show an outcome improvement in obese and overweight patients. Methods: This study is a single-arm experimental design, conducted between November 2009 and May 2016 on 430 women affected by BC. Weight, BMI, and PA were assessed at baseline, at 12 months, and at the end of the study. Survival curves were estimated among normal, overweight, and obese patients. Results: Mean BMI decreased from baseline to the end of the study was equal to 2.9% (p = 0.065) in overweight patients and 3.3% in obese patients (p = 0.048). Mean PA increase from baseline to the end of the study was equal to 125% (p < 0.001) in normal patients, 200% (p < 0.001) in overweight patients and 100% (p < 0.001) in obese patients. After 70 months of follow-up, the 5-year overall survival (OS) rate was 96%, 96%, and 93%, respectively in normal, obese, and overweight patients. Overweight patients had significantly worse OS than normal ones (HR = 3.69, 95%CI = 1.82–4.53 p = 0.027) whereas no statistically significant differences were seen between obese and normal patients (HR 2.45, 95%CI = 0.68–8.78, p = 0.169). Conclusions: A lifestyle intervention can lead to clinically meaningful weight loss and increase PA in patients with BC. These results could contribute to improving the OS in obese patients compared to overweight ones.

The role of metabolic diseases in cardiotoxicity associated with cancer therapy: What we know, what we would know

Metabolic diseases, such as obesity and type 2 diabetes, are known risk factors for cardiovascular (CV) diseases. Thus, patients with those comorbidities could be at increased risk of experiencing cardiotoxicity related to treatment with Anthracyclines and the other new generation targeted anticancer drugs. However, investigations addressing the mechanisms underlying the development of CV complications and poor outcome in such cohort of patients are still few and controversial. Given the importance of a personalized approach against chemotherapy-induced cardiomyopathy, this review summarizes our current knowledge on the pathophysiology of chemotherapy-induced cardiomyopathy and its association with obesity and type 2 diabetes. Along with clinical evidences, future perspectives of preclinical research around this field and its role in addressing important open questions, including the development of more proactive strategies for prevention, and treatment of cardiotoxicity during and after chemotherapy in the presence of metabolic diseases, is also presented.

The Use of Behavior Change Theories in Dietetics Practice in Primary Health Care: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Behavior change theories frameworks provide the theoretical underpinning for effective health care. The extent to which they are applied in contemporary dietetics interventions has not been explored.

OBJECTIVE

To systematically review the evidence of behavior change theory-based interventions delivered by credentialed nutrition and dietetics practitioners in primary health care settings.

METHODS

Medline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Embase, and Cochrane databases were searched for English language, randomized controlled trials before August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Eligible interventions included adults (aged ≥18 years) receiving face-to-face dietetics care underpinned by behavior change theories in primary health care settings with outcome measures targeting changes in health behaviors or health outcomes. Screening was conducted independently in duplicate and data were extracted using predefined categories. The quality of each study was assessed using the Cochrane Risk of Bias tool. The body of evidence was assessed using the Academy of Nutrition and Dietetics Evidence Analysis Manual Conclusion Grading Table.

RESULTS

Thirty articles reporting on 19 randomized controlled trials met the eligibility criteria, representing 5,172 adults. Thirteen studies (68%) showed significant improvements for the primary outcome measured. Social cognitive theory was the behavior change theory most commonly applied in interventions (n=15) with 11 finding significant intervention effects. Goal setting, problem solving, social support, and self-monitoring were the most commonly reported techniques (n=15, n=14, n=11, and n=11, respectively). Most studies had a high (n=11) or unclear (n=8) risk of bias. There was fair evidence (Grade II) supporting the use of behavior change theories to inform development of dietetics interventions.

CONCLUSIONS

Interventions delivered by credentialed nutrition and dietetics practitioners that were underpinned by behavior change theories and utilizing various behavior change techniques were found to have potential to be more effective at improving patient health outcomes than dietary interventions without theoretical underpinnings. Findings from this review should inform future primary health care research in the area of dietary behavior change. In addition, findings from this review highlight the need for stronger documentation of use of behavior change theory and techniques that map on to the theory within dietetics practice.

Effect of Preoperative Nutritional Risk Screening on Postoperative Recovery in Patients with Laparoscopic-Assisted Radical Resection for Colorectal Cancer

Results

There were statistically significant differences in BMI, albumin, total cholesterol, and lymphocyte count between patients from the two groups (all P < 0.05). There was no difference in the incidence rate of postoperative complications between the two groups, but there was a statistically significant difference in the total number of complications (P < 0.05). There were no significant differences between the two groups regarding abdominal drainage volume, exhaust (flatus) time, hospitalization cost, morbidity, or 60 d readmission rate (all P > 0.05). However, patients with nutritional risk had higher postoperative blood transfusion volumes, albumin infusions, weight difference before and after surgery, and postoperative hospital stays than the nonnutritional risk group (all P < 0.05). Smoking, diabetes, and preoperative nutritional risk were the risk factors by the univariate and multivariate logistic regression analyses.

Conclusions

The postoperative complication rate was increased, and the short-term efficacy was decreased in the preoperative nutritional risk group compared with those without nutritional risk.

The LISA randomized trial of a weight loss intervention in postmenopausal breast cancer

Obesity has been associated with poor breast cancer (BC) outcomes. We investigated whether a standardized, telephone-based weight loss lifestyle intervention in the adjuvant setting would impact BC outcomes. We conducted a multicenter trial randomizing women 1:1 to mail-based educational material alone (control) or combined with a standardized, telephone-based lifestyle intervention that focused on diet, physical activity, and behavior and involved 19 calls over 2 years to achieve up to 10% weight loss. In all, 338 (of 2150 planned) T1-3, N0-3, M0 hormone receptor positive BC patients with body mass index (BMI) ≥24 kg/m2 receiving adjuvant letrozole were randomized (enrolment ended due to funding loss). The primary outcome was disease-free survival (DFS); secondary outcome was Overall Survival (OS). At 8 years' median follow-up, in a planned analysis, DFS and OS were compared using the Kaplan-Meier method. Baseline BMI and other characteristics were similar between study arms. In all, 22 of 171 (12.9%) in the lifestyle intervention arm versus 30 of 167 (18.0%) in the education had DFS events; the hazard ratio (HR) was 0.71 (95% confidence interval [CI]: 0.41-1.24, p = 0.23). Although loss of funding reduced sample size, we view these hypothesis generating results as compatible with our hypothesis of a potential beneficial effect of a lifestyle intervention on DFS. They provide support for completion of ongoing randomized controlled trials of the effect of lifestyle interventions in BC outcomes.

The Effects of a Remote-based Weight Loss Program on Adipocytokines, Metabolic Markers, and Telomere Length in Breast Cancer Survivors: the POWER-Remote Trial

PURPOSE

We initiated a clinical trial to determine the proportion of breast cancer survivors achieving ≥5% weight loss using a remotely delivered weight loss intervention (POWER-remote) or a self-directed approach, and to determine the effects of the intervention on biomarkers of cancer risk including metabolism, inflammation, and telomere length.

EXPERIMENTAL DESIGN

Women with stage 0-III breast cancer, who completed local therapy and chemotherapy, with a body mass index ≥25 kg/m² were randomized to a 12-month intervention (POWER-remote) versus a self-directed approach. The primary objective was to determine the number of women who achieved at least 5% weight loss at 6 months. We assessed baseline and 6-month change in a panel of adipocytokines (adiponectin, leptin, resistin, HGF, NGF, PAI1, TNFα, MCP1, IL1β, IL6, and IL8), metabolic factors (insulin, glucose, lipids, hs-CRP), and telomere length in peripheral blood mononuclear cells.

RESULTS

From 2013 to 2015, 96 women were enrolled, and 87 were evaluable for the primary analysis; 45 to POWER-remote and 42 to self-directed. At 6 months, 51% of women randomized to POWER-remote lost ≥5% of their baseline body weight, compared with 12% in the self-directed arm [OR, 7.9; 95% confidence interval (CI), 2.6-23.9; P = 0.0003]; proportion were similar at 12 months (51% vs 17%, respectively, P = 0.003). Weight loss correlated with significant decreases in leptin, and favorable modulation of inflammatory cytokines and lipid profiles. There was no significant change in telomere length at 6 months.

CONCLUSIONS

A remotely delivered weight loss intervention resulted in significant weight loss in breast cancer survivors, and favorable effects on several biomarkers.

Mediterranean Diet and Naltrexone/Bupropion Treatment for Weight Loss in Overweight and Obese Breast Cancer Survivors and Non-Cancer Participants: A Pilot Randomized Controlled Trial

INTRODUCTION

The objective of this pilot randomized controlled trial was to investigate the combined effect of a Mediterranean diet and naltrexone/bupropion treatment on body weight, metabolic parameters, and quality of life in overweight or obese breast cancer survivors.

METHODS

Forty-four breast cancer survivors were randomly assigned to receive the Mediterranean diet plus naltrexone/bupropion medication (breast cancer survivor MeDiet+NB group) or the Mediterranean diet alone (breast cancer survivor MeDiet-only group). Twenty-eight age-matched non-cancer patients were instructed to consume the Mediterranean diet plus naltrexone/bupropion medication (non-cancer MeDiet+NB group). After the 8-week intervention, changes in body weight, metabolic parameters, nutrient intake, and quality of life of the three groups were assessed.

RESULTS

Significant weight loss of 2.8 kg was noted for the breast cancer survivor MeDiet+NB group, 1.8 kg for the breast cancer survivor MeDiet-only group, and 2.5 kg for the non-cancer MeDiet+NB group after 8 weeks (P < 0.05 versus baseline by Wilcoxon's signed-rank test). All three groups also exhibited significantly lower fasting glucose, insulin, and homeostasis model assessment of insulin resistance levels (P < 0.05). Quality of life as assessed by self-reported questionnaires showed improvement in all participants (P < 0.05). However, there were no significant differences of changes in body weights, metabolic parameters, and quality of life among the three groups or between the MeDiet+NB and MeDiet-only groups.

CONCLUSION

We found that the Mediterranean diet, with or without naltrexone/bupropion treatment, facilitates weight loss, improves metabolic parameters, and increases quality of life. The combination of the Mediterranean diet with naltrexone/bupropion treatment did not produce superior changes when compared to the Mediterranean diet alone.

TRIAL REGISTRATION

This trial was retrospectively registered on 10 July 2018 as NCT03581630 at ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03581630).

Dietary interventions for adult cancer survivors

BACKGROUND

International dietary recommendations include guidance on healthy eating and weight management for people who have survived cancer; however dietary interventions are not provided routinely for people living beyond cancer.

OBJECTIVES

To assess the effects of dietary interventions for adult cancer survivors on morbidity and mortality, changes in dietary behaviour, body composition, health-related quality of life, and clinical measurements.

SEARCH METHODS

We ran searches on 18 September 2019 and searched the Cochrane Central Register of Controlled trials (CENTRAL), in the Cochrane Library; MEDLINE via Ovid; Embase via Ovid; the Allied and Complementary Medicine Database (AMED); the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and the Database of Abstracts of Reviews of Effects (DARE). We searched other resources including reference lists of retrieved articles, other reviews on the topic, the International Trials Registry for ongoing trials, metaRegister, Physicians Data Query, and appropriate websites for ongoing trials. We searched conference abstracts and WorldCat for dissertations.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that recruited people following a cancer diagnosis. The intervention was any dietary advice provided by any method including group sessions, telephone instruction, written materials, or a web-based approach. We included comparisons that could be usual care or written information, and outcomes measured included overall survival, morbidities, secondary malignancies, dietary changes, anthropometry, quality of life (QoL), and biochemistry.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Two people independently assessed titles and full-text articles, extracted data, and assessed risk of bias. For analysis, we used a random-effects statistical model for all meta-analyses, and the GRADE approach to rate the certainty of evidence, considering limitations, indirectness, inconsistencies, imprecision, and bias.

MAIN RESULTS

We included 25 RCTs involving 7259 participants including 977 (13.5%) men and 6282 (86.5%) women. Mean age reported ranged from 52.6 to 71 years, and range of age of included participants was 23 to 85 years. The trials reported 27 comparisons and included participants who had survived breast cancer (17 trials), colorectal cancer (2 trials), gynaecological cancer (1 trial), and cancer at mixed sites (5 trials). For overall survival, dietary intervention and control groups showed little or no difference in risk of mortality (hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.77 to 1.23; 1 study; 3107 participants; low-certainty evidence). For secondary malignancies, dietary interventions versus control trials reported little or no difference (risk ratio (RR) 0.99, 95% CI 0.84 to 1.15; 1 study; 3107 participants; low-certainty evidence). Co-morbidities were not measured in any included trials. Subsequent outcomes reported after 12 months found that dietary interventions versus control probably make little or no difference in energy intake at 12 months (mean difference (MD) -59.13 kcal, 95% CI -159.05 to 37.79; 5 studies; 3283 participants; moderate-certainty evidence). Dietary interventions versus control probably led to slight increases in fruit and vegetable servings (MD 0.41 servings, 95% CI 0.10 to 0.71; 5 studies; 834 participants; moderate-certainty evidence); mixed results for fibre intake overall (MD 5.12 g, 95% CI 0.66 to 10.9; 2 studies; 3127 participants; very low-certainty evidence); and likely improvement in Diet Quality Index (MD 3.46, 95% CI 1.54 to 5.38; 747 participants; moderate-certainty evidence). For anthropometry, dietary intervention versus control probably led to a slightly decreased body mass index (BMI) (MD -0.79 kg/m², 95% CI -1.50 to -0.07; 4 studies; 777 participants; moderate-certainty evidence). Dietary interventions versus control probably had little or no effect on waist-to-hip ratio (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; 106 participants; low-certainty evidence). For QoL, there were mixed results; several different quality assessment tools were used and evidence was of low to very low-certainty. No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

Evidence demonstrated little effects of dietary interventions on overall mortality and secondary cancers. For comorbidities, no evidence was identified. For nutritional outcomes, there was probably little or no effect on energy intake, although probably a slight increase in fruit and vegetable intake and Diet Quality Index. Results were mixed for fibre. For anthropometry, there was probably a slight decrease in body mass index (BMI) but probably little or no effect on waist-to-hip ratio. For QoL, results were highly varied. Additional high-quality research is needed to examine the effects of dietary interventions for different cancer sites, and to evaluate important outcomes including comorbidities and body composition. Evidence on new technologies used to deliver dietary interventions was limited.

Combined test of third lumbar skeletal muscle index and prognostic nutrition index improve prognosis prediction power in resected colorectal cancer liver metastasis

Background: In this paper, we aim to explore clinical value of skeletal muscle index (SMI) and prognostic nutrition index (PNI) on resected colorectal cancer liver metastasis (CRLM).

Results: Among the 539 patients, 355 were males. Baseline lower SMI was associated with smaller BMI, smaller PNI, smaller pre-albumin and longer hospitalization days (P<0.05). Patients with lower SMI and PNI had significantly shorter duration of PFS and OS (P<0.05). SMI can reflect the postoperative treatment response. Postoperative 6-month’s and 12-month’s SMI and PNI can indicate overall prognosis. When combined SMI and PNI, prognostic AUC of ROC curves improved significantly.

Conclusion: Combined monitor of SMI and PNI can improve the power at predicting prognosis. Postoperative 6-month’s record of SMI and PNI was more accurate and predictive for CRLM prognosis.

Method: A total of 539 resected CRLM patients between January 2013 to December 2016 with complete clinical data were included. Computed tomography image was collected from each patient. Receiver-operating characteristic (ROC) curves were constructed; area under curves (AUC) were also determined. All clinical variables were analyzed in proper way.

Impact of a Tailored Nutrition and Lifestyle Intervention for Overweight Cancer Survivors on Dietary Patterns, Physical Activity, Quality of Life, and Cardiometabolic Profiles

Survivors of cancer often experience treatment-related toxicity in addition to being at risk of cancer recurrence, second primary cancers, and greater all-cause mortality. The objective of this study was to test the safety and efficacy of an intensive evidence-based garden intervention to improve outcomes for cancer survivors after curative therapy. To do so, a clinical trial of adult overweight and obese cancer survivors within 2 years of completing curative therapy was completed. The 6-month intervention, delivered within the context of harvesting at an urban garden, combined group education with cooking demonstrations, remote motivational interviewing, and online digital resources. Data on dietary patterns, program satisfaction, and quality of life were collected via questionnaires; anthropometrics, physical activity, and clinical biomarkers were measured objectively. Of the 29 participants, 86% were white, 83% were female, and the mean age was 58 years. Compared to baseline, participants had significant improvements in Healthy Eating Index (HEI) scores (+5.2 points, p = 0.006), physical activity (+1,208 steps, p = 0.033), and quality of life (+16.07 points, p = 0.004). Significant improvements were also documented in weight (−3.9 kg), waist circumference (−5.5 cm), BMI (−1.5 kg/m²), systolic BP (−9.5 mmHg), plasma carotenoids (+35%), total cholesterol (−6%), triglycerides (−14%), hs-CRP (−28%), and IGFBP-3 (−5%) (all p < 0.010). These findings demonstrate a tailored multifaceted garden-based biobehavioral intervention for overweight and obese cancer survivors after curative therapy is safe and highly effective, warranting larger randomized controlled trials to identify program benefits, optimal maintenance strategies, program value relative to cost, and approaches for integration into a survivor's oncology management program. This trial is registered on ClinicalTrials.gov NCT02268188.

Changes in Body Mass Index and Physical Activity Predict Changes in Vitality During a Weight Loss Trial in Breast Cancer Survivors

Background

Breast cancer survivors rank fatigue (e.g., decreased vitality) as their number one concern affecting quality of life. Excess adiposity is associated with decreased vitality in breast cancer survivors, yet weight loss intervention trials report inconsistent effects on this parameter.

Methods

This is a secondary analysis of the Exercise and Nutrition to Enhance Recovery and Good Health for You trial, in which 692 overweight or obese breast cancer survivors ≤5 years from diagnosis, initiated weight loss interventions, and completed assessments semi-annually for 2 years. Assessments included the Godin Leisure-Time Exercise Questionnaire and the SF-36 MOS vitality subscale as an inverse measure of fatigue. Multilevel structural equation models estimated the direct effects of physical activity on vitality and indirect effects through body mass index (BMI) changes.

Results

Within-person findings show that at assessments with greater physical activity, BMI was significantly lower (B = -0.07, p < 0.001) and vitality was higher (B = 0.22, p < 0.001). However, there was no direct relationship between lower BMI and higher vitality (B = -0.11, p = 0.262) after controlling for the relationship of physical activity with BMI and physical activity with vitality. The between-person indirect effect of physical activity change through BMI change to vitality was significant (B = 0.03, p < 0.001). Participants whose physical activity was above the mean (B = 0.37, p < 0.001) and whose BMI was below the mean (B = -1.05, p < 0.001) were more likely to report greater vitality.

Conclusion

Improvements in vitality are primarily associated with increases in physical activity rather than BMI changes in this trial. Vitality was lower among survivors with higher BMI, although within-individual changes in BMI had no effect on vitality. Physical activity and weight loss share mechanistic links to vitality with physical activity potentially increasing (e.g., in an additive or synergistic manner) the effect of BMI reduction on vitality.

AACR White Paper: Shaping the Future of Cancer Prevention - A Roadmap for Advancing Science and Public Health

The recent pace, extent, and impact of paradigm-changing cancer prevention science has been remarkable. The American Association for Cancer Research (AACR) convened a 3-day summit, aligned with five research priorities: (i) Precancer Atlas (PCA). (ii) Cancer interception. (iii) Obesity-cancer linkage, a global epidemic of chronic low-grade inflammation. (iv) Implementation science. (v) Cancer disparities. Aligned with these priorities, AACR co-led the Lancet Commission to formally endorse and accelerate the NCI Cancer Moonshot program, facilitating new global collaborative efforts in cancer control. The expanding scope of creative impact is perhaps most startling-from NCI-funded built environments to AACR Team Science Awarded studies of Asian cancer genomes informing global primary prevention policies; cell-free epigenetic marks identifying incipient neoplastic site; practice-changing genomic subclasses in myeloproliferative neoplasia (including germline variant tightly linked to JAK2 V617F haplotype); universal germline genetic testing for pancreatic cancer; and repurposing drugs targeting immune- and stem-cell signals (e.g., IL-1β, PD-1, RANK-L) to cancer interception. Microbiota-driven IL-17 can induce stemness and transformation in pancreatic precursors (identifying another repurposing opportunity). Notable progress also includes hosting an obesity special conference (connecting epidemiologic and molecular perspectives to inform cancer research and prevention strategies), co-leading concerted national implementation efforts in HPV vaccination, and charting the future elimination of cancer disparities by integrating new science tools, discoveries and perspectives into community-engaged research, including targeted counter attacks on e-cigarette ad exploitation of children, Hispanics and Blacks. Following this summit, two unprecedented funding initiatives were catalyzed to drive cancer prevention research: the NCI Cancer Moonshot (e.g., PCA and disparities); and the AACR-Stand Up To Cancer bold "Cancer Interception" initiative.

The Mediterranean Diet and Breast Cancer: A Personalised Approach

There have been many original and review articles summarizing the impact of nutrition and diet on breast cancer risk. However, very few consider the implication of genetic background and the effect of personalised nutrition on the risk and prognosis of breast cancer. A literature search was performed using the following databases: MEDLINE (Ovid), PubMed, Scopus and EMBASE (Ovid). The ensuing search terms were selected: genomics, nutrigenomics, breast cancer, breast neoplasms, cancer, nutrigenetics, diet-gene interaction, and Mediterranean, nutrition, polyphenols and diet. In this review, we discuss the Mediterranean-style diet and associated nutrients, evidence of benefit, impact on gene expression and evidence of interactions with genotype and how this interaction can modify breast cancer risk and progression. In addition, the impact of nutrients commonly associated with a Mediterranean-style diet, on breast cancer treatment, and synergistic effects are mentioned when modified by genotype. Some evidence exists around the benefit of a gene-based personalised diet based on a Mediterranean-style dietary pattern, but further evidence in the form of clinical trials is required before such an approach can be comprehensively implemented.

The Many Faces of Obesity and Its Influence on Breast Cancer Risk

Obesity is associated with increased risk of breast and other cancers. However, the complexity of the underlying mechanisms, together with the interplay of diet and physical activity—contributing to energy balance—and the role of adipose tissue, pose challenges to our understanding of the basis of this increased risk. Epidemiologic studies have documented a higher obesity prevalence in US black women compared to white women. Elucidation of the contribution of potential biological differences among racially distinct groups to their differences in breast cancer (BC) risk and mortality have been topics of considerable interest in recent years. The racial and ethnic variation in body fat distribution may account for at least part of the differences in breast cancer rates in these populations. Yet, while black women exhibit higher rates of obesity compared to white women, this does not translate directly into higher rates of BC. In fact, overall, BC in black women occurs with a lower incidence than BC in white women. Obesity is a known risk factor for postmenopausal breast cancer, and growing evidence suggests that abdominal obesity, also known as central obesity, may increase risk for triple negative breast cancer, which is more common in premenopausal women. The positive association of postmenopausal BC risk and specifically estrogen receptor (ER)-positive BC, is presumably due largely to accumulation of estrogen in the adipose tissue of the breast and other tissues. Of the two main types of adipose tissue—subcutaneous and visceral—visceral adipocytes are more active metabolically. Such adipose tissue harbors multiple molecular entities that promote carcinogenesis: endocrine molecules/hormones, immunologic factors, inflammatory cytokines, metabolic alterations, and other components of the microenvironment. Expression of these culpable entities is largely regulated by epigenetic mechanisms. The interrelationship between these entities and drivers of epigenetic alteration are critical to the regulation of pathways connecting obesity and cancer risk. Initiatives to counteract the carcinogenic effects of obesity have primarily involved modulation of energy balance by diet. However, targeting of specific molecular abnormalities characterizing adiposity offers an alternative approach to preventing cancer. Our goal in this review is to first discuss the major mechanisms contributing to the obesity-breast cancer link. We will also consider race, specifically black/white differences, as they relate to the association of obesity with breast cancer risk. Then we will enumerate strategies targeting these mechanisms to reduce BC risk, in large part by way of dietary interventions with potential to mitigate the cancer-promoting components of adiposity.

Motivational interviewing in eHealth and telehealth interventions for weight loss: A systematic review

The alarming prevalence of adult obesity warrants consideration of treatments with broad reach; digital health interventions meet this need and have demonstrated efficacy for weight loss. One approach that can be delivered remotely is motivational interviewing - a counseling style that helps resolve ambivalence to change unhealthy behavior. This is the first review to systematically examine eHealth and telehealth interventions that incorporate motivational interviewing for weight loss. We searched four electronic databases (PubMed, Embase, PsycInfo, CINAHL) for publications from November 2009-May 2018. Included papers were weight loss RCTs conducted among adults with overweight or obesity that examined eHealth or telehealth interventions with motivational interviewing, compared to any type of treatment arm without it. Results were presented separately by comparison arm (control vs. active comparator). Sixteen papers (15 trials) were included. Twelve used telephone-based counseling to deliver motivational interviewing, two used email and phone, and one used online chats. When compared to a no-treatment control arm, the motivational interviewing arm was associated with greater weight loss on 6 of 11 occasions, but performed better than an active comparator on only 1 of 7 occasions. Retention and engagement were generally high, though few trials examined the relation with weight loss. No trial had high risk of bias, but five lacked power calculations and only two reported fidelity to motivational interviewing. Telephone-based interventions that incorporate motivational interviewing hold promise as effective obesity treatments. There is a dearth of evidence to support the use of motivational interviewing via eHealth, signaling a needed research area.

Effect of home-based high-intensity interval training and behavioural modification using information and communication technology on cardiorespiratory fitness and exercise habits among sedentary breast cancer survivors: habit-B study protocol for a randomised controlled trial

INTRODUCTION

Maintaining high levels of physical activity helps to maintain and improve physical health and quality of life, and plays a role in reducing adverse effects due to cancer treatments. Moreover, a greater degree of cardiorespiratory fitness is associated with reduced risk of all-cause mortality. However, there are no home-based programme for improving cardiorespiratory fitness using body weight exercises for breast cancer survivors. This study will assess the efficacy of the newly developed habit-B programme on maximum oxygen uptake compared with treatment as usual with wearable device. The effects of this programme on exercise habits, level of physical activity, physical fitness and subjective indices will also be investigated.

METHODS AND ANALYSIS

This is a 12-week, parallel-group, single-blind, randomised controlled trial. Allocation will be managed by a central server using a computer-generated random allocation sequence provided by an independent data centre. Participants will be assigned to the habit-B programme (high-intensity interval training, exercise counselling + guidance, home-based exercise support using information and communication technology, and a wearable device) or treatment as usual with a wearable device. Subjects will be sedentary women aged 20-59 years who have received breast surgery in the past 2-13 months after the diagnosis of invasive breast cancer (stages I-IIa) and have never received chemotherapy except for hormone therapy. The primary endpoint is the change in peak oxygen uptake (VO_2peak; mL/kg/min) between the groups after 12 weeks of intervention.

ETHICS AND DISSEMINATION

The study protocol was approved by the Institutional Review Board of the National Cancer Center Japan on 28 February 2019 (ID: 2018-347). The findings will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

UMIN000036400.

Lifestyle change experiences among breast cancer survivors participating in a pilot intervention: A narrative thematic analysis

PURPOSE

Healthy lifestyle adoption among breast cancer (BC) survivors remains a poorly understood process. This study aimed to qualitatively examine the unique change trajectories of BC survivors who partook in a pilot version of the Healthy Lifestyle Modification After Breast Cancer (HLM-ABC) intervention.

METHODS

A sample of four BC survivors were studied intensively through longitudinal interviews conducted at four time points with each participant: (1) pre-treatment, (2) mid-way treatment, (3) post-treatment, and (4) three-months following their participation in the HLM-ABC. A multiple-case study, narrative analysis was applied to 15 interviews, resulting in individual narratives as well as shared 'thematic intersections' elucidating cross-participant experiences.

RESULTS

The findings showed that participants offered unique styles of authorship, characterized by diverse struggles, victories, and motivational insights, organized around the following intersecting themes: (1)Weight management prescription as a motivator or deterrent, (2) 'Time for me' is time away from my family, and (3) Patterns of opposition to lifestyle change. These women's rich, storied accounts suggest experiences of personal growth and imply that existential concerns can be both motivating and deterring in relation to health behavior change.

CONCLUSION

This research provides a comprehensive and nuanced grasp of healthy lifestyle modification in the survivorship stage of BC.

Short- and long-term impact of adapted physical activity and diet counseling during adjuvant breast cancer therapy: the "APAD1" randomized controlled trial

BACKGROUND

Patients with breast cancer undergoing chemotherapy and radiotherapy experience fatigue and other treatment side effects. Integrative therapies combining physical activity and dietary counseling are recommended; however to date no large randomized controlled trial has been conducted during adjuvant therapy. The Adapted Physical Activity and Diet (APAD) intervention was evaluated for its ability to decrease fatigue (primary outcome), anxiety, depression, body mass index (BMI), and fat mass, and enhance muscular and cognitive performances, and quality-of-life (QoL).

METHODS

Women diagnosed with early breast cancer (N = 143, mean age = 52 ± 10 years) were randomized to APAD or usual care (UC). APAD included thrice-weekly moderate-intensity mixed aerobic and resistance exercise sessions and 9 dietetic consultations. Patient-reported outcomes (PROs) and anthropometric, muscular, and cognitive variables were measured at baseline, 18 weeks (end of chemotherapy), and 26 weeks (end of radiotherapy and intervention), and at 6- and 12-month post-intervention follow-ups. Multi-adjusted linear mixed-effects models were used to compare groups over time.

RESULTS

Significant beneficial effects of the APAD intervention were observed on all PROs (i.e., fatigue, QoL, anxiety, depression) at 18 and 26 weeks. The significant effect on fatigue and QoL persisted up to 12-month follow-up. Significant decreases in BMI, fat mass, and increased muscle endurance and cognitive flexibility were observed at 26 weeks, but did not persist afterward. Leisure physical activity was enhanced in the APAD group vs UC group at 18 and 26 weeks. No significant effect of the intervention was found on major macronutrients intake.

CONCLUSIONS

A combined diet and exercise intervention during chemotherapy and radiotherapy in patients with early breast cancer led to positive changes in a range of psychological, physiological and behavioral outcomes at the end of intervention. A beneficial effect persisted on fatigue and QoL at long term, i.e., 1 year post-intervention. Diet-exercise supportive care should be integrated into the management of early breast cancer patients.

TRIAL REGISTRATION

The APAD study was prospectively registered on ClinicalTrials.gov (NCT01495650; date of registration: December 20, 2011).

Effects of Physical Exercise Intervention on Psychological and Physical Fitness in Lymphoma Patients

Background and objectives: Lymphoma patients experience a psychological and physiological decline that could be reversed by exercise. However, little is known about the effects of the exercise on psychological and physical fitness variables. Therefore, the purpose of this longitudinal study was to assess self-efficacy, fatigue and physical fitness before and after an eight-week exercise intervention. Materials and Methods: Thirty-six participants (54.4 ± 19.1 years) performed a supervised exercise program (~60 min, 2d·wk^-1). Each session included a combined progressive training of cardiorespiratory, resistance, flexibility and postural education exercises. Self-efficacy and fatigue were measured with the Regulatory Emotional Self-Efficacy scale and 0-10 rating scale, respectively. Physical fitness was assessed with the body mass index, lower back flexibility, static balance, muscle strength and functional mobility. Results: Adherence to exercise was high (91.2% ± 4.8%) and no major health problems were noted in the patients over the intervention period. At baseline, significant differences were found between Hodgkin's lymphoma and non-Hodgkin's lymphoma patients by age and all dependent measures (p < 0.05). Fatigue significantly decreased and the perceived capability to regulate negative affect and to express positive emotions improved after exercise (p < 0.001). Significant improvements were found for body mass index, trunk lateral flexibility, monopodalic balance, isometric handgrip force and functional mobility (p < 0.001). Fatigue was significantly correlated with handgrip force (r = -0.56, p < 0.001) and functional mobility (r = -0.69, p < 0.001). Conclusions: The supervised exercise program improved psychological and physical fitness without causing adverse effects and health problems. Therefore, exercise to improve fitness levels and reduce perceived fatigue should be considered in the management of lymphoma patients.

Effectiveness of a 12-month Exercise Intervention on Physical Activity and Quality of Life of Breast Cancer Survivors; Five-year Results of the BREX-study

BACKGROUND/AIM

This is a report of the 5-year quality of life (QoL) findings of the BREX-study (n=444).

PATIENTS AND METHODS

A 12-month exercise intervention was arranged shortly after adjuvant treatments. Physical activity (PA) was assessed by PA diary, physical performance by a 2- km walking test, QoL by the EORTC QLQC30 and BR-23 questionnaires, fatigue by the FACIT-Fatigue scale and depression by the Beck's 13-item depression scale (BDI).

RESULTS

Participants who improved their PA from baseline to 5-year follow-up were more likely to improve their global health score (RRR=1.02, p=0.016), physical (RRR=1.02, p=0.009), social (RRR=1.03, p=0.013), role functioning (RRR=1.03, p=0.005), and fatigue (RRR=1.02, p=0.002). An improved 2-km walking test was associated to improved global health, physical and role functioning, body image, future perspectives, and fatigue (p=0.011, p<0.001, p=0.001, p=0.021, p=0.012 and p=0.003). No significant difference between the groups was found.

CONCLUSION

Improvement in PA or physical performance yields a positive change in QoL of breast cancer patients.

The science of peer support as applied to behavioral medicine and the care of individuals surviving with cancer: a commentary on "Peer mentors delivering a physical activity intervention for cancer survivors: effects among mentors by Pinto et al."

There is a critical gap between the resources available to promote health and wellness after cancer and services that address these public health goals. Researchers, policy makers, healthcare providers, and community stakeholders increasingly recognize the benefits of filling this gap with trained peer mentors who can provide health-promotion services to fellow cancer survivors. This commentary addresses a mixed-method study by Pinto and colleagues that investigated the responses and experiences of trained peer mentors who delivered their telephone-based physical activity intervention for breast cancer survivors. Their findings suggested that peer mentors did not experience harms from their role while revealing that peer mentors reported benefits related to helping themselves and helping others. Drawing on our expertise in peer support provision and peer mentoring, we address the significant opportunity offered by training peer mentors to deliver behavioral interventions, draw connections to relevant literatures and theoretical perspectives on potential benefits for peer mentors, and highlight the need for rigorous, theory-based research to determine the circumstances under which peer mentoring benefits mentors and the mechanisms underlying these benefits.

Health Behaviors and Lifestyle Interventions in African American Breast Cancer Survivors: A Review

Background: African American breast cancer survivors have a higher incidence of estrogen receptor negative and basal-like (e.g., triple negative) tumors, placing them at greater risk for poorer survival when compared to women of other racial and ethnic groups. While access to equitable care, late disease stage at diagnosis, tumor biology, and sociodemographic characteristics contribute to health disparities, poor lifestyle characteristics (i.e., inactivity, obesity, and poor diet) contribute equally to these disparities. Lifestyle interventions hold promise in shielding African American survivors from second cancers, comorbidities, and premature mortality, but they are often underrepresented in studies promoting positive behaviors. This review examined the available literature to document health behaviors and lifestyle intervention (i.e., obesity, physical activity, and sedentary behavior) studies in African American breast cancer survivors. Methods: We used PubMed, Academic Search Premier, and Scopus to identify cross-sectional and intervention studies examining the lifestyle behaviors of African American breast cancer survivors. Identified intervention studies were assessed for risk of bias. Other articles were identified and described to provide context for the review. Results: Our systematic review identified 226 relevant articles. The cross-sectional articles indicated poor adherence to physical activity and dietary intake and high rates of overweight and obesity. The 16 identified intervention studies indicated reasonable to modest study adherence rates (>70%), significant reductions in weight (range -1.9 to -3.6%), sedentary behavior (-18%), and dietary fat intake (range -13 to -33%) and improvements in fruit and vegetable intake (range +25 to +55%) and physical activity (range +13 to +544%). The risk of bias for most studies were rated as high (44%) or moderate (44%). Conclusions: The available literature suggests that African American breast cancer survivors adhere to interventions of various modalities and are capable of making modest to significant changes. Future studies should consider examining (a) mediators and moderators of lifestyle behaviors and interventions, (b) biological outcomes, and (c) determinants of enhanced survival in this population.

Obesity, Leptin and Breast Cancer: Epidemiological Evidence and Proposed Mechanisms

The prevalence of obesity has been steadily increasing over the past few decades in several developed and developing countries, with resultant hazardous health implications. Substantial epidemiological evidence has shown that excessive adiposity strongly influences risk, prognosis, and progression of various malignancies, including breast cancer. Indeed, it is now well recognized that obesity is a complex physiologic state associated with multiple molecular changes capable of modulating the behavior of breast tumor cells as well of the surrounding microenvironment. Particularly, insulin resistance, hyperactivation of insulin-like growth factor pathways, and increased levels of estrogen due to aromatization by the adipose tissue, inflammatory cytokines, and adipokines contribute to breast cancerogenesis. Among adipokines, leptin, whose circulating levels increase proportionally to total adipose tissue mass, has been identified as a key member of the molecular network in obesity. This review summarizes the current knowledge on the epidemiological link existing between obesity and breast cancer and outlines the molecular mechanisms underlying this connection. The multifaceted role of the obesity adipokine leptin in this respect is also discussed.

Effect of chemotherapy and aromatase inhibitors in the adjuvant treatment of breast cancer on glucose and insulin metabolism-A systematic review

INTRODUCTION

Breast cancer (BC) is the most common cancer among women worldwide. With increasing survival rates, focus has expanded to long-term adverse effects of adjuvant chemotherapy and/or aromatase inhibitors. Weight gain during chemotherapy has been well documented, but the underlying mechanisms remain unclear. A change in glucose and insulin metabolism is a possible consequence.

METHODS

We searched PubMed on the 4th of May 2018, and found eight articles that compared measurements of glucose and insulin before and after chemotherapy and/or aromatase inhibitors in woman with BC.

RESULTS

A general trend of increased glucose and insulin is seen and likely to be caused by weight gain and/or changes in body composition as a consequence of adjuvant treatment of BC.

DISCUSSION

Due to methodological limitations including short follow-up times and small sample sizes, further studies are required to better describe metabolic consequences of adjuvant chemotherapy and/or aromatase inhibitors. Future studies could help identify patients in high-risk of developing cardiometabolic disease after BC treatment.

The evolution of body composition in oncology-epidemiology, clinical trials, and the future of patient care: facts and numbers

There is growing interest from the oncology community to understand how body composition measures can be used to improve the delivery of clinical care for the 18.1 million individuals diagnosed with cancer annually. Methods that distinguish muscle from subcutaneous and visceral adipose tissue, such as computed tomography (CT), may offer new insights of important risk factors and improved prognostication of outcomes over alternative measures such as body mass index. In a meta-analysis of 38 studies, low muscle area assessed from clinically acquired CT was observed in 27.7% of patients with cancer and associated with poorer overall survival [hazard ratio: 1.44, 95% CI: 1.32-1.56]. Therapeutic interventions such as lifestyle and pharmacotherapy that modify all aspects of body composition and reduce the incidence of poor clinical outcomes are needed in patients with cancer. In a meta-analysis of six randomized trials, resistance training exercise increased lean body mass assessed from dual-energy X-ray absorptiometry [mean difference (MD): +1.07 kg, 95% CI: 0.76-1.37; P < 0.001] and walking distance [MD: +143 m, 95% CI: 70-216; P < 0.001] compared with usual care control in patients with non-metastatic cancer. In a meta-analysis of five randomized trials, anamorelin (a ghrelin agonist) significantly increased lean body mass [MD: +1.10 kg, 95% CI: 0.35-1.85; P = 0.004] but did not improve handgrip strength [MD: 0.52 kg, 95% CI: -0.09-1.13; P = 0.09] or overall survival compared with placebo [HR: 0.99, 95% CI: 0.85-1.14; P = 0.84] in patients with advanced or metastatic cancer. Early screening to identify individuals with occult muscle loss, combined with multimodal interventions that include lifestyle therapy with resistance exercise training and dietary supplementation combined with pharmacotherapy, may be necessary to provide a sufficient stimulus to prevent or slow the cascade of tissue wasting. Rapid, cost-efficient, and feasible methods to quantify muscle and adipose tissue distribution are needed if body composition assessment is to be integrated into large-scale clinical workflows. Fully automated analysis of body composition from clinically acquired imaging is one example. The study of body composition is one of the most provocative areas in oncology that offers tremendous promise to help patients with cancer live longer and healthier lives.

Phase II Feasibility Study of a Weight Loss Intervention in Female Breast and Colorectal Cancer Survivors (SWOG S1008)

OBJECTIVE

This study aimed to test the feasibility of a 12-month weight loss intervention using telephone-based counseling plus community-situated physical activity (PA) in female breast cancer (BC) and colorectal cancer (CRC) survivors.

METHODS

This multisite cooperative group study enrolled sedentary, female, postmenopausal BC and CRC survivors with BMI ≥ 25 kg/m2 to receive 12-month fitness center memberships and telephone counseling encouraging 150 min/wk of PA and a 500-kcal/ddecrease in energy intake. Feasibility criteria included accrual, adherence, and retention. Target weight loss was ≥ 5%.

RESULTS

Among 25 BC survivors, median baseline BMI was 37.2 (range: 27.7-54.6), accrual occurred in 10 months, 60% and 28% met diet and exercise goals, 80% provided 12-month measures, and average weight loss was 7.6% (95% CI: -3.9%, 19.2%). Among 23 CRC survivors, median BMI was 31.8 (range: 26.4-48.7), accrual occurred in 24 months, 61% and 17% met diet and exercise goals, 87% provided measures, and average weight loss was 2.5% (95% CI: -8.2%, 13.3%).

CONCLUSIONS

It is feasible to recruit and retain BC survivors in a cooperative group diet and PA weight loss trial. BC survivors achieved clinically meaningful weight loss but did not meet a priori adherence goals. In CRC survivors, recruitment was more difficult, and the intervention was less effective.

Behavioral and Pharmacotherapy Weight Loss Interventions to Prevent Obesity-Related Morbidity and Mortality in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Overweight and obesity have been associated with adverse health effects.

OBJECTIVE

To systematically review evidence on benefits and harms of behavioral and pharmacotherapy weight loss and weight loss maintenance interventions in adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed Publisher-Supplied Records, PsycINFO, and the Cochrane Central Register of Controlled Trials for studies published through June 6, 2017; ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials through August 2017; and ongoing surveillance in targeted publications through March 23, 2018. Studies from previous reviews were reevaluated for inclusion.

STUDY SELECTION

Randomized clinical trials (RCTs) focusing on weight loss or weight loss maintenance in adults.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted by one reviewer and confirmed by another. Random-effects meta-analyses were conducted for weight loss outcomes in behavior-based interventions.

MAIN OUTCOMES AND MEASURES

Health outcomes, weight loss or weight loss maintenance, reduction in obesity-related conditions, and adverse events.

RESULTS

A total of 122 RCTs (N = 62 533) and 2 observational studies (N = 209 993) were identified. Compared with controls, participants in behavior-based interventions had greater mean weight loss at 12 to 18 months (-2.39 kg [95% CI, -2.86 to -1.93]; 67 studies [n = 22065]) and less weight regain (-1.59 kg [95% CI, -2.38 to -0.79]; 8 studies [n = 1408]). Studies of medication-based weight loss and maintenance interventions also reported greater weight loss or less weight regain in intervention compared with placebo groups at 12 to 18 months (range, -0.6 to -5.8 kg; no meta-analysis). Participants with prediabetes in weight loss interventions had a lower risk of developing diabetes compared with controls (relative risk, 0.67 [95% CI, 0.51 to 0.89]). There was no evidence of other benefits, but most health outcomes such as mortality, cardiovascular disease, and cancer were infrequently reported. Small improvements in quality of life in some medication trials were noted but were of unclear clinical significance. There was no evidence of harm such as cardiovascular disease from behavior-based interventions; higher rates of adverse events were associated with higher dropout rates in medication groups than in placebo groups.

CONCLUSIONS AND RELEVANCE

Behavior-based weight loss interventions with or without weight loss medications were associated with more weight loss and a lower risk of developing diabetes than control conditions. Weight loss medications, but not behavior-based interventions, were associated with higher rates of harms. Long-term weight and health outcomes data, as well as data on important subgroups, were limited.