Main Outcomes of the FRESH START Trial: A Sequentially Tailored, Diet and Exercise Mailed Print Intervention Among Breast and Prostate Cancer Survivors

Components of multiple health behaviour change interventions for patients with chronic conditions: a systematic review and meta-regression of randomized trials

Interventions addressing more than one health behaviour at a time could be an efficient way of intervening to manage chronic conditions. Within a systematic review of multiple health behaviour change (MBHC) interventions, we identified key components of interventions in patients with chronic conditions, assessed how they are linked to theory, behaviour change techniques implemented, and evaluated their impact on intervention effectiveness. Studies were identified by systematically searching five electronic databases. Subgroup analyses and meta-regressions were conducted to analyse the association between intervention components and behavioural changes. In total, 61 studies were included spanning different chronic conditions (e.g., cardiovascular conditions, type 2 diabetes). Most interventions sought to change behaviours simultaneously (72%), often targeting the 'physical activity, diet and smoking' cluster of behaviours (33%), and were not theory informed (55%). A total of 36 behaviour change techniques were identified, most commonly goal setting behaviour and self-monitoring of behaviour. Subgroup analyses indicated that MHBC interventions delivered entirely face-to-face might not be as effective for physical activity outcomes, and not using goal setting (behaviour) might be more effective for smoking cessation outcomes. Meta-regressions indicated that a longer intervention duration may work best to achieve better physical activity outcomes. This review provides a comprehensive understanding of interventions and contributes to the field of MHBC by facilitating data-driven insights for future optimisation and dissemination.

The Effect of Self-efficacy-Enhancing Interventions on Quality of Life of Cancer Survivors: A Systematic Review

BACKGROUND

The influence of self-efficacy-enhancing interventions on quality of life (QOL) is not clear with recent randomized controlled trials (RCTs) because current reviews only evaluated self-efficacy as an outcome.

OBJECTIVES

We conducted a systematic review to examine the effect of self-efficacy-enhancing interventions on QOL among patients with cancer and to summarize the effective determinants for designing self-efficacy-enhancing interventions.

METHODS

A systematic search was performed on studies published from January 2003 to May 2023 using PubMed, CINAHL, PsycINFO, and Web of Science. Included studies were RCTs, adults diagnosed with cancer, interventions with explicit self-efficacy components, and QOL as the outcome.

RESULTS

Nineteen RCTs were included. Risk-of-bias assessment revealed 12 studies with some concerns and 7 with high risk of bias. The mean intervention adherence rate was 88.2%; the most frequently listed reason for dropout was medical conditions and mortality. Self-efficacy interventions were shown to significantly improve at least 1 subscale of QOL in 9 of 19 studies, of which 7 studies used Bandura's 4 sources of self-efficacy. The interventions with between-session intervals shorter than 2 weeks, of 12-week duration, and with an in-person delivery approach were the most effective.

CONCLUSIONS

Self-efficacy-enhancing interventions show potential beneficial effects on QOL among cancer survivors. Interventions that use Bandura's 4 sources of self-efficacy strategies and have between-session intervals shorter than 2 weeks, an in-person approach, and 12-week intervention duration are recommended.

IMPLICATIONS FOR PRACTICE

Properly designed self-efficacy-enhancing interventions can facilitate behavioral change and improve QOL in cancer survivors.

Twelve Month Efficacy of Computer-Tailored Communication in Boosting Fruit and Vegetable Consumption Among Adults Aged Forty and over: A Three-Level Meta-Analysis and Systematic Review of Randomized Controlled Trials

Computer-tailored health communication (CTC) can enhance fruit and vegetable (F&V) intake and, consequently, health by providing personalized feedback. However, few studies have examined the long-term effects of such interventions in middle-aged and older adults. This research aimed to assess the 12-mo efficacy of CTC in promoting F&V consumption and potentially identify who among middle-aged and older adults changed their diet after the intervention. The protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) on 2021-12-09, code CRD42022330491. The research was performed without external funding. We searched 6 databases (MEDLINE via PubMed, EMBASE, Scopus, Web of Science Core Collection, Cochrane Library, and PsycINFO) for randomized controlled trials (RCTs) comparing CTC interventions for increasing F&V intake with usual care/no intervention control in adults aged ≥40, measured 12 mo after the pretest. The search covered the period from 1 January 1990 to 1 January 2022. We selected 16 RCTs with 25,496 baseline participants for the review systematic literature reviews (SLR) and 11 RCTs with 19 measurements for the meta-analysis (MA). We assessed risk of bias with the JBI Critical Appraisal Checklist. The SLR revealed that at 1-y postCTC intervention, most of the treatment groups increased F&V intake more than the control groups. The overall bias in the data set was not high. The MA model on 11 RCTs revealed a significant effect size for F&V consumption in intervention groups compared with control, standardized mean difference of 0.21 (confidence interval [CI]: 0.12, 0.30), P = 0.0004. The evidence suggests that CTC is a suitable strategy for public interventions aiming to increase F&V intake in adults aged ≥40. The design of CTC for public interventions should consider the process of change and stages of change addressing awareness, attitudes, self-efficacy, and social influence as promising concepts for influencing behavior change.

Long-term efficacy of a computer-tailored physical activity intervention for prostate and colorectal cancer patients and survivors: A randomized controlled trial

BACKGROUND

Physical activity (PA) can improve the physical and psychological health of prostate and colorectal cancer survivors, but PA behavior change maintenance is necessary for long-term health benefits. OncoActive is a print- and web-based intervention in which prostate and colorectal cancer patients and survivors receive automatically generated, personalized feedback aimed at integrating PA into daily life to increase and maintain PA. We evaluated the long-term outcomes of OncoActive by examining the 12-month follow-up differences between OncoActive and a control group, and we explored whether PA was maintained during a 6-month non-intervention follow-up period.

METHODS

Prostate or colorectal cancer patients were randomly assigned to an OncoActive (n = 249) or a usual care waitlist control group (n = 229). OncoActive participants received PA advice and a pedometer. PA outcomes (i.e., ActiGraph and self-report moderate-to-vigorous intensity PA (MVPA) min/week and days with ≥30 min PA) and health-related outcomes (i.e., fatigue, depression, physical functioning) were assessed at baseline, 6 months, and 12 months. Differences between groups and changes over time were assessed with multilevel linear regressions for the primary outcome (ActiGraph MVPA min/week) and all additional outcomes.

RESULTS

At 12 months, OncoActive participants did not perform better than control group participants at ActiGraph MVPA min/week, self-report MVPA min/week, or ActiGraph days with PA. Only self-report days with PA were significantly higher in OncoActive compared to the control group. For health-related outcomes only long-term fatigue was significantly lower in OncoActive. When exploratively examining PA within OncoActive, the previously found PA effects at the end of the intervention (6 months follow-up) were maintained at 12 months. Furthermore, all PA outcomes improved significantly from baseline to 12 months. The control group showed small but non-significant improvements from 6 months to 12 months (and from baseline to 12 months), resulting in a decline of differences between groups.

CONCLUSION

The majority of previously reported significant between-group differences at 6 months follow-up were no longer present at long-term follow-up, possibly because of natural improvement in the control group. At long-term follow-up, fatigue was significantly lower in OncoActive compared to control group participants. Computer-tailored PA advice may give participants an early start toward recovery and potentially contributes to improving long-term health.

Effectiveness of Computer-Tailored Health Communication in Increasing Physical Activity in People With or at Risk of Long-Term Conditions: Systematic Review and Meta-Analysis

BACKGROUND

Regular physical activity (PA) is beneficial for enhancing and sustaining both physical and mental well-being as well as for the management of preexisting conditions. Computer-tailored health communication (CTHC) has been shown to be effective in increasing PA and many other health behavior changes in the general population. However, individuals with or at risk of long-term conditions face unique barriers that may limit the applicability of CTHC interventions to this population. Few studies have focused on this cohort, providing limited evidence for the effectiveness of CTHC in promoting PA.

OBJECTIVE

This systematic review and meta-analysis aims to assess the effectiveness of CTHC in increasing PA in individuals with or at risk of long-term conditions.

METHODS

A systematic review and meta-analysis were conducted to evaluate the effect of CTHC in increasing PA in people with or at risk of long-term conditions. Hedges g was used to calculate the mean effect size. The total effect size was pooled and weighted using inverse variance. When possible, potential moderator variables were synthesized, and their effectiveness was evaluated by subgroups analysis with Q test for between-group heterogeneity Qb. Potential moderator variables included behavior change theories and models providing the fundamental logic for CTHC design, behavior change techniques and tailoring strategies to compose messages, and computer algorithms to achieve tailoring. Several methods were used to examine potential publication bias in the results, including the funnel plot, Egger test, Begg test, fail-safe N test, and trim-and-fill method.

RESULTS

In total, 24 studies were included in the systematic review for qualitative analysis and 18 studies were included in the meta-analysis. Significant small to medium effect size values were found when comparing CTHC to general health information (Hedges g=0.16; P<.001) and to no information sent to participants (Hedges g=0.29; P<.001). Half of the included studies had a low to moderate risk of bias, and the remaining studies had a moderate to high risk of bias. Although the results of the meta-analysis indicated no evidence of publication bias, caution is required when drawing definitive conclusions due to the limited number of studies in each subgroup (N≤10). Message-tailoring strategies, implementation strategies, behavior change theories and models, and behavior change techniques were synthesized from the 24 studies. No strong evidence was found from subgroup analyses on the effectiveness of using particular behavior change theories and models or from using particular message-tailoring and implementation strategies.

CONCLUSIONS

This study demonstrates that CTHC is effective in increasing PA for people with or at risk of long-term conditions, with significant small to medium effects compared with general health information or no information. Further studies are needed to guide design decisions for maximizing the effectiveness of CTHC.

Randomized Trial Evaluating a Self-Guided Lifestyle Intervention Delivered via Evidence-Based Materials versus a Waitlist Group on Changes in Body Weight, Diet Quality, Physical Activity, and Quality of Life among Breast Cancer Survivors

Background: Lifestyle interventions for breast cancer survivors have proved effective at stimulating positive behavior change and promoting healthy weight loss, although integrating these programs into clinical practice is challenging. We evaluated the effect of a 6-month, unsupervised, self-guided, lifestyle intervention using printed materials and online videos vs. waitlist group on body weight for breast cancer survivors. Methods: The Lifestyle, Exercise and Nutrition (LEAN) Self-Guided trial randomized breast cancer survivors with a body mass index ≥25 kg/m2 to a 6-month lifestyle intervention (N = 102) or waitlist group (N = 103). Effects of the intervention on self-reported body weight, physical activity (PA), diet quality (via Health Eating Index-2010 (HEI-2010)), and quality of life were assessed using mixed model repeated measures analysis. Results: At 6 months, the intervention arm had significantly greater weight loss compared with the waitlist group (mean difference = -1.3 kg, 95% confidence interval [CI] = -2.5, -0.13). We observed suggestive improvements in PA (mean difference = 18.7 min/week, 95% CI = -24.2, 61.6), diet quality (mean difference in HEI = 3.2 points, 95% CI = -0.20, 6.5), and fatigue (mean difference in Functional Assessment of Chronic Illness Therapy-Fatigue scale = 1.4 points, 95% CI = -1.1, 3.9). Conclusions: The LEAN Self-Guided intervention led to favorable weight changes over 6 months. Low-resource-intensive programs have the potential to be delivered in diverse healthcare settings and may support breast cancer survivors in achieving a healthy body weight.

Mi Vida Saludable: Content Validity and Reliability of The Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW) for Cancer Survivors

The purpose of this study is to conduct validity and reliability testing of a new instrument, the Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW), which is for women who identify as Latina and are breast cancer survivors. PSEDPALW measures preferences and self-efficacy for four behaviors: physical activity (PA), fruit and vegetable (FV) intake, dietary fat (DF) intake, and added sugar (AS) intake (eight scales in total). Validity testing was conducted through an expert panel review and a cognitive interviewing focus group (n = 4). Reliability was tested via internal consistency reliability (n = 118) and test-retest reliability (n = 30). Validity testing was used to refine PSEDPALW. Reliability testing was conducted on three versions with 104, 47, and 41 items. PA scales had acceptable Cronbach's α (>0.70) but low ICC (NS). FV and DF scales had acceptable Cronbach's α (>0.70), with preferences for the shorter (47- and 41-item) versions (Cronbach's α < 0.70), and all scales had moderate ICC (p < 0.05, except the FV scale on the 104-item version (p = 0.07)). The AS preferences scale had Cronbach's α < 0.70, with self-efficacy > 0.70 for all versions and ICC moderate for all versions (p ≤ 0.01). PSEDPALW may be useful to assess diet and physical activity preferences and self-efficacy in theory-based diet and physical activity interventions in women who identify as Latina and are breast cancer survivors.

Physical activity maintenance among young adult cancer survivors in an mHealth intervention: Twelve-month outcomes from the IMPACT randomized controlled trial

BACKGROUND

Most physical activity (PA) interventions in young adult cancer survivors (YACS) have focused on short-term outcomes without evaluating longer-term outcomes and PA maintenance. This study examined the effects of an mHealth PA intervention at 12 months, after 6 months of tapered contacts, relative to a self-help group among 280 YACS.

METHODS

YACS participated in a 12-month randomized trial that compared self-help and intervention groups. All participants received an activity tracker, smart scale, individual videochat session, and access to a condition-specific Facebook group. Intervention participants also received lessons, tailored feedback, adaptive goal setting, text messages, and Facebook prompts for 6 months, followed by tapered contacts. Accelerometer-measured and self-reported PA (total [primary outcome], moderate-to-vigorous [MVPA], light, steps, sedentary behaviors) were collected at baseline, 6, and 12 months. Generalized estimating equation analyses evaluated group effects on outcomes from baseline to 12 months.

RESULTS

From baseline to 12 months, there were no between- or within-group differences in accelerometer-measured total PA min/week, while increases in self-reported total PA were greater in the intervention versus self-help group (mean difference = +55.8 min/week [95% CI, 6.0-105.6], p = 0.028). Over 12 months, both groups increased accelerometer-measured MVPA (intervention: +22.5 min/week [95% CI, 8.8-36.2] vs. self-help: +13.9 min/week [95% CI, 3.0-24.9]; p = 0.34), with no between-group differences. Both groups maintained accelerometer-measured and self-reported PA (total, MVPA) from 6 to 12 months. At 12 months, more intervention participants reported meeting national PA guidelines than self-help participants (47.9% vs. 33.1%, RR = 1.45, p = 0.02).

CONCLUSION

The intervention was not more effective than the self-help group at increasing accelerometer-measured total PA over 12 months. Both groups maintained PA from 6 to 12 months. Digital approaches have potential for promoting sustained PA participation in YACS, but additional research is needed to identify what strategies work for whom, and under what conditions.

Effectiveness of the perioperative encounter in promoting regular exercise and physical activity: a systematic review and meta-analysis

Background

Low levels of physical activity (PA) are associated with poorer health outcomes. The perioperative encounter (extending from initial contact in primary care to beyond discharge from hospital) is potentially a good time to intervene, but data regarding the effectiveness of interventions are scarce. To address this, we systematically reviewed existing literature to evaluate the effectiveness of interventions applied perioperatively to facilitate PA in the medium to long-term (at least six months after the intervention).

Methods

In this systematic review and meta-analysis, we searched Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, CINAHL, Embase, PsycInfo, and SPORTDiscus from database inception to October 22nd 2020, with an updated search done on August 4th 2022. We searched clinical trials registers, and conducted forward- and backward-citation searches. We included randomised controlled trials and quasi-randomised trials comparing PA interventions with usual care, or another PA intervention, in adults who were scheduled for, or had recently undergone, surgery. We included trials which reported our primary outcomes: amount of PA or whether participants were engaged in PA at least six months after the intervention. A random effects meta-analysis was used to pool data across studies as risk ratios (RR), or standardised mean differences (SMDs), which we interpreted using Cohen. We used the Cochrane risk of bias tool and used GRADE to assess the certainty of the evidence. This study is registered with PROSPERO, CRD42019139008.

Findings

We found 57 trials including 8548 adults and compared 71 interventions facilitating PA. Most interventions were started postoperatively and included multiple components. Compared with usual care, interventions may slightly increase the number of minutes of PA per day or week (SMD 0.17, 95% CI 0.09-0.26; 14 studies, 2172 participants; I2 = 0%), and people's engagement in PA at the study's end (RR 1.19, 95% CI 0.96-1.47; 9 studies, 882 participants; I2 = 25%); this was moderate-certainty evidence. Some studies compared two different types of interventions but it was often not feasible to combine data in analysis. The effect estimates generally indicated little difference between intervention designs and we judged all the evidence for these comparisons to be very low certainty. Thirty-six studies (63%) had low risk of selection bias for sequence generation, 27 studies (47%) had low risk of bias for allocation concealment, and 56 studies (98%) had a high risk of performance bias. For detection bias for PA outcomes, we judged 30 studies (53%) that used subjective measurement tools to have a high risk of detection bias.

Interpretation

Interventions delivered in the perioperative setting, aimed at enhancing PA in the medium to long-term, may have overall benefit. However, because of imprecision in some of the findings, we could not rule out the possibility of no change in PA.

Funding

National Institute for Health Research Health Services and Delivery Research programme (NIHR127879).

Healthy Eating Index Diet Quality in Randomized Weight Loss Trials: A Systematic Review

BACKGROUND

Weight loss interventions focus on dietary and physical activity changes to induce weight loss. Both through weight loss and independent of it, diet quality is important for reducing chronic disease risk. However, whether and how diet quality changes over the course of a behavioral intervention is unclear.

OBJECTIVE

To systematically review the evidence from randomized controlled trials on the effect of behavioral interventions on diet quality as defined by the Healthy Eating Index (HEI) among adults with overweight and obesity.

METHODS

PubMed, Ebscohost CINAHL, Embase, OVID APA PsycInfo, Scopus, and Web of Science were searched through May 2021. Inclusion criteria comprised randomized controlled trial design, a primary or secondary aim of weight loss, a sample of US adults with overweight or obesity, measurement using the HEI-2005, 2010, or 2015, and assessment of the time by treatment effect. Interventions must have included behavioral components and lasted at least 3 months. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The systematic review protocol was published on Open Science Framework.

RESULTS

Of 3,707 citations retrieved, 18 studies met inclusion criteria. A wide array of behavioral interventions were assessed, including in-person and mobile health interventions as well as those prescribing intake of specific foods. Risk of bias in the included studies primarily arose from the measurement of the outcome variable. Sample sizes ranged from 34 to 413 participants. Nine studies used multiple dietary recalls, with few using the recommended method of Healthy Eating Index calculation. Changes in diet quality ranged from no improvement to a 20-point improvement. More often, improvement was in the 4- to 7-point range.

CONCLUSIONS

The evidence for the efficacy of behavioral weight loss interventions for improving diet quality among adults with overweight and obesity is limited. Modest improvements in HEI scores were observed in the reviewed studies.

Harvest for Health, a Randomized Controlled Trial Testing a Home-Based, Vegetable Gardening Intervention Among Older Cancer Survivors Across Alabama: An Analysis of Accrual and Modifications Made in Intervention Delivery and Assessment During COVID-19

BACKGROUND

Accelerated functional decline is a concern among older cancer survivors that threatens independence and quality of life. Pilot studies suggest that vegetable gardening interventions ameliorate functional decline through improved diet and physical activity.

OBJECTIVE

The aim of this article was to describe the rationale, recruitment challenges, and enrollment for the Harvest for Health randomized controlled trial (RCT), which will test the impact of a home-based, vegetable gardening intervention on vegetable and fruit consumption, physical activity, and physical functioning among older cancer survivors. Modifications made to the intervention and assessments to assure safety and continuity of the RCT throughout the COVID-19 pandemic also are reported.

DESIGN

Harvest for Health is a 2-year, 2-arm, single-blinded, wait-list controlled RCT with cross-over.

PARTICIPANTS/SETTING

Medicare-eligible survivors of cancers with ≥60% 5-year survival were recruited across Alabama from October 1, 2016 to February 8, 2021.

INTERVENTION

Participants were randomly assigned to a wait-list control or a 1-year home-based gardening intervention and individually mentored by extension-certified master gardeners to cultivate spring, summer, and fall vegetable gardens.

MAIN OUTCOME MEASURES

Although the RCT's primary end point was a composite measure of vegetable and fruit consumption, physical activity, and physical functioning, this article focuses on recruitment and modifications made to the intervention and assessments during COVID-19.

STATISTICAL ANALYSES PERFORMED

χ2 and t tests (α < .05) were used to compare enrolled vs unenrolled populations.

RESULTS

Older cancer survivors (n = 9,708) were contacted via mail and telephone; 1,460 indicated interest (15% response rate), 473 were screened eligible and consented, and 381 completed baseline assessments and were randomized. Enrollees did not differ from nonrespondents/refusals by race and ethnicity, or rural-urban status, but comprised significantly higher numbers of comparatively younger survivors, those who were female, and survivors of breast cancer (P < .001). Although COVID-19 delayed trial completion, protocol modifications overcame this barrier and study completion is anticipated by June 2022.

CONCLUSIONS

This RCT will provide evidence on the effects of a mentored vegetable gardening program among older cancer survivors. If efficacious, Harvest for Health represents a novel, multifaceted approach to improve lifestyle behaviors and health outcomes among cancer survivors-one with capacity for sustainability and widespread dissemination.

Adapting MultiPLe behavior Interventions that eFfectively Improve (AMPLIFI) cancer survivor health: program project protocols for remote lifestyle intervention and assessment in 3 inter-related randomized controlled trials among survivors of obesity-related cancers

BACKGROUND

Scalable, multiple behavior change interventions are needed to address poor diet, inactivity, and excess adiposity among the rising number of cancer survivors. Efficacy-tested diet (RENEW) and exercise (BEAT Cancer) programs were adapted for web delivery among middle-aged and older cancer survivors for the AMPLIFI study, a National Cancer Institute-funded, multi-site, program project.

METHODS

Throughout the continental U.S., survivors of several obesity-related cancers are being recruited for three interconnected randomized controlled trials (RCTs). Projects 1 and 2 test 6-month diet or exercise interventions versus a wait-list control condition. Upon completion of the 6-month study period, the intervention participants receive the next behavior change sequence (i.e., diet receives exercise, exercise receives diet) and the wait-list control arm initiates a 12-month combined diet and exercise intervention. Project 3 tests the efficacy of the sequential versus simultaneous interventions. Assessments occur at baseline and semi-annually for up to 2-years and include: body mass index, health behaviors (diet quality, accelerometry-assessed physical activity/sleep), waist circumference, D3 creatine-assessed muscle mass, physical performance, potential mediators/moderators of treatment efficacy, biomarkers of inflammation and metabolic regulation, health care utilization, cost, and overall health. Four shared resources support AMPLIFI RCTs: 1) Administrative; 2) Adaptation, Dissemination and Implementation; 3) Recruitment and Retention; and 4) Assessment and Analysis.

DISCUSSION

Representing a new generation of RCTs, AMPLIFI will exclusively use remote technologies to recruit, intervene and assess the efficacy of the newly-adapted, web-based diet and exercise interventions and determine whether sequential or combined delivery works best for at-risk (older, rural, racial minority) cancer survivors.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04000880 . Registered 27 June 2019.

Do people change their eating habits after a diagnosis of cancer? A systematic review

INTRODUCTION

People who live with and beyond cancer are thought to be motivated to change their diet. However, there is a lack of reviews conducted on what specific dietary changes people make and further evaluation may inform future interventional studies. Hence, we aim to summarise the evidence on dietary changes in observational studies before and after a cancer diagnosis.

METHODS

This systematic review followed the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Electronic searches were conducted in four databases to identify cohort and cross-sectional studies on dietary changes before and after a cancer diagnosis, excluding studies that evaluated an intervention. Quality assessment was undertaken, and meta-analyses were conducted where suitable.

RESULTS

We identified 14 studies with 16,443 participants diagnosed with cancer, age range 18-75 years. Dietary change was assessed <1-5 years before diagnosis and up to 12-years post-diagnosis. Meta-analyses showed that the standard mean difference (SMD) for energy (SMD-0.32, 95% CI -0.46 to -0.17) and carbohydrate consumption (SMD 0.20, 95% CI -0.27 to -0.14). Studies showed inconsistent findings for fat, protein, and fibre, most food groups, and supplement intake. A small decrease in red and processed meat consumption was consistently reported.

CONCLUSION

All studies reported some positive changes in dietary intake and supplement consumption after receiving a cancer diagnosis without any intervention. However, differences for food groups and nutrients were mainly small and not necessarily clinically meaningful. Evidence demonstrates that a cancer diagnosis alone is insufficient to motivate people to change their dietary intake, indicating that most people would benefit from a dietary intervention to facilitate change. This article is protected by copyright. All rights reserved.

Physical Activity and Cancer Status Among Middle-Aged and Older Chinese: A Population-Based, Cross-Sectional Study

Background

The relative contributions of demographic and lifestyle behaviors to the association between physical activity (PA) and cancer are poorly understood. This study assesses the relationship between PA level and cancer status considering the full activity spectrum within a large and representative Chinese population.

Methods

Data were derived from the Chinese Health and Retirement Longitudinal Study (using four-stage stratified probability-proportional-to-size sampling), including 416 cancer survivors and 14,574 individuals without cancer from 28 provinces in China. Cancer status and sites were self-reported, and PA, other health behaviors (e.g., smoking, drinking) and comorbidities (e.g., hypertension, diabetes) were assessed by a questionnaire. The total PA score was calculated using metabolic equivalent (MET) multipliers. Multivariable logistic regression was used to estimate differences in PA levels between cancer survivors and those without a cancer diagnosis, adjusting for age, sex, and other potential confounding factors.

Results

Cancer survivors (416, 2.8%) were more likely to be women than men (65.4 vs. 34.6%). They were older (age ≥65 years, 43.8 vs. 38.9%) and more likely to be overweight (18.3 vs. 13.3%), be depressed (49.5 vs. 37.6%), have quit smoking (17.8 vs. 14.4%), drink less (17.5 vs. 26.6%), sleep less (65.9 vs. 56.8%) and have more chronic comorbidities (≥2 comorbidities, 26.0 vs. 19.2%) than those without cancer. There was a significant associations between cancer status and participation in vigorous-intensity activity for at least 10 min every week, when compared with the inactivity [odds ratio (OR) = 0.56, 95% CI = 0.39–0.80], while no differences were observed in the moderate and light activity groups. Individuals who spent more than half an hour performing moderate or vigorous intensity activity every day were significantly less likely to report a cancer diagnosis than inactive individuals (moderate OR = 0.64, 95% CI = 0.48–0.86; vigorous OR = 0.50, 95% CI = 0.37–0.68). Participants who spent more than 2 h performing light, moderate or vigorous intensity activity reported fewer cancer cases than their inactive counterparts. In addition, there was an inverse dose-response relationship between the total PA score and cancer status (P_–trend < 0.001).

Conclusion

Associations between PA and cancer status were independent of demographics, lifestyle confounders, and comorbidities. Cancer survivors are less physically active than those without cancer.

¡Mi Vida Saludable! A randomized, controlled, 2 × 2 factorial trial of a diet and physical activity intervention among Latina breast cancer survivors: Study design and methods

BACKGROUND

Most Latina breast cancer survivors do not meet diet and physical activity (PA) guidelines for cancer survivors and effective lifestyle interventions to adopt and maintain these recommendations are limited, especially among underserved populations. Here we describe the design, methods and enrollment of a 2 × 2 factorial-designed trial testing the separate effects of the ¡Mi Vida Saludable! (My Healthy Life!) intervention program on changes in diet and PA behaviors among Latina breast cancer survivors.

METHODS

Latinas with a history of stage 0-III breast cancer, no evidence of recurrent/metastatic disease, and > 90 days post-treatment were primarily identified via cancer registries and physician referral. Participants were randomized to four arms: 1) 4 weeks of in-person group sessions plus 11 months of eHealth communication, 2) in-person group sessions alone, 3) eHealth alone, or 4) control. All participants received a Fitbit to self-monitor PA. Assessments at baseline, 6 and 12 months include diet, PA, anthropometrics, predictors and mediators of behavior change, psychosocial and quality of life outcomes, and blood draw.

RESULTS

Of 884 women screened between January 2016 and September 2018, 27% were eligible. Primary reasons for ineligibility included not being willing/able to participate due to work/life responsibilities, health reasons, or transportation. Of 241 eligible women, 167 completed baseline assessment and enrolled.

CONCLUSIONS

We successfully enrolled a diverse group of breast cancer survivors representing more than 15 Latin American nationalities to a diet and physical activity trial. If effective, the ¡Mi Vida Saludable! program can be implemented by community groups and medical centers.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02780271, registered May 2016.

Rationale and Methods for a Randomized Controlled Trial of a Dyadic, Web-Based, Weight Loss Intervention among Cancer Survivors and Partners: The DUET Study

Scalable, effective interventions are needed to address poor diet, insufficient physical activity, and obesity amongst rising numbers of cancer survivors. Interventions targeting survivors and their friends and family may promote both tertiary and primary prevention. The design, rationale, and enrollment of an ongoing randomized controlled trial (RCT) (NCT04132219) to test a web-based lifestyle intervention for cancer survivors and their supportive partners are described, along with the characteristics of the sample recruited. This two-arm, single-blinded RCT randomly assigns 56 dyads (cancer survivor and partner, both with obesity, poor diets, and physical inactivity) to the six-month DUET intervention vs. wait-list control. Intervention delivery and assessment are remotely performed with 0-6 month, between-arm tests comparing body weight status (primary outcome), and secondary outcomes (waist circumference, health indices, and biomarkers of glucose homeostasis, lipid regulation and inflammation). Despite COVID-19, targeted accrual was achieved within 9 months. Not having Internet access was a rare exclusion (<2%). Inability to identify a support partner precluded enrollment of 42% of interested/eligible survivors. The enrolled sample is diverse: ages 23-81 and 38% racial/ethnic minorities. Results support the accessibility and appeal of web-based lifestyle interventions for cancer survivors, though some cancer survivors struggled to enlist support partners and may require alternative strategies.

Mobile Health Applications, Cancer Survivors, and Lifestyle Modification: An Integrative Review

Cancer survivors' well-being is threatened by the risk of cancer recurrence and the increased risk of chronic diseases resulting from cancer treatments. Improving lifestyle behaviors attenuates these risks. Traditional approaches to lifestyle modification (ie, counseling) are expensive, require significant human resources, and are difficult to scale. Mobile health interventions offer a novel alternative to traditional approaches. However, to date, systematic reviews have yet to examine the use of mobile health interventions for lifestyle behavior improvement among cancer survivors. The objectives of this integrative review were to synthesize research findings, critically appraise the scientific literature, examine the use of theory in intervention design, and identify survivors' preferences in using mobile health interventions for lifestyle improvement. Nineteen articles met eligibility requirements. Only two studies used quantitative methods. Study quality was low, and only one study reported the use of theory in app design. Unfortunately, the evidence has not yet sufficiently matured, in quality or in rigor, to make recommendations on how to improve health behaviors or outcomes. However, six themes emerged as important considerations for intervention development for cancer survivors (app features/functionality, social relationships/support, provider relationships/support, app content, app acceptability, and barriers to use). These findings underscored the need for rigorous, efficacy studies before the use of mobile health interventions can be safely recommended for cancer survivors.

Increasing physical activity in Cancer Survivors through a Text-messaging Exercise motivation Program (ICanSTEP)

PURPOSE

Cancer survivors are often sedentary. Self-monitoring may promote physical activity through self-activation. We conducted a pilot trial to evaluate whether wearable activity tracker with personalized text message feedback would increase physical activity.

METHODS

We enrolled 30 patients with solid tumor cancers into a non-randomized prospective intervention trial (NCT02627079): 15 had completed treatment in the past year and 15 under active treatment. Each participant received an activity tracker and daily text messages personalized to their activity level. We assessed patient-reported outcomes and 6-min walk (6 MW) at baseline and 3 months.

RESULTS

Twenty-six participants completed the study. There was substantial variation in baseline activity. Overall, 39% of participants increased their steps taken by at least 20%, and 23% increased their 6 MW distance by 20% or more. More participants who had completed treatment strongly agreed (73%) that the intervention increased their exercise levels than those receiving active treatment (47%). At 3 months, there was a significant improvement in median Beck Depression Inventory-II and Godin Leisure Index composite scores. At 6 months, 72% still wore their activity tracker at least 4 days per week.

CONCLUSION

We found that the intervention was well-accepted with a high completion rate at 3 months and continued self-use at 6 months. In this pilot study of combined activity tracker and motivational messaging, we found a signal for increased physical activity over a 3-month period. Future research is needed to study this technique for its impact on activity and other physical and psychological measures of well-being.

IMPLICATION FOR CANCER SURVIVORS

Activity tracker with personalized motivational messaging may be useful in promoting physical activity in cancer survivors.

Systematic Review of Behaviour Change Theories Implementation in Dietary Interventions for People Who Have Survived Cancer

Background: An increasing number of dietary interventions for cancer survivors have been based on the behaviour change theory framework. The purpose of this study is to review the use and implementation of behaviour change theories in dietary interventions for people after cancer and assess their effects on the reported outcomes. Methods: The search strategy from a Cochrane review on dietary interventions for cancer survivors was expanded to incorporate an additional criterion on the use of behaviour change theory and updated to September 2020. Randomised controlled trials (RCT) testing a dietary intervention compared to the control were included. Standard Cochrane methodological procedures were used. Results: Nineteen RCTs, with 6261 participants (age range 44.6 to 73.1 years), were included in the review. The Social Cognitive Theory was the most frequently used theory (15 studies, 79%). Studies included between 4 to 17 behaviour change techniques. Due to limited information on the mediators of intervention and large heterogeneity between studies, no meta-analyses was conducted to assess which theoretical components of the interventions are effective. Conclusions: Whilst researchers have incorporated behaviour change theories into dietary interventions for cancer survivors, due to inconsistencies in design, evaluation and reporting, the effect of theories on survivors’ outcomes remains unclear.

Promoting physical activity in young adult cancer survivors using mHealth and adaptive tailored feedback strategies: Design of the Improving Physical Activity after Cancer Treatment (IMPACT) randomized controlled trial

INTRODUCTION

Despite the health benefits of physical activity for cancer survivors, nearly 60% of young adult cancer survivors (YACS) are physically inactive. Few physical activity interventions have been designed specifically for YACS.

PURPOSE

To describe the rationale and design of the IMPACT (IMproving Physical Activity after Cancer Treatment) trial, which tests the efficacy of a theory-based, mobile physical activity intervention for YACS.

METHODS

A total of 280 physically inactive YACS (diagnosed at ages 18-39) will be randomized to a self-help control or intervention condition. All participants will receive an activity tracker and companion mobile app, cellular-enabled scale, individual videochat session, and access to a Facebook group. Intervention participants will also receive a 6-month mobile intervention based on social cognitive theory, which targets improvements in behavioral capability, self-regulation, self-efficacy, and social support, and incorporates self-regulation strategies and behavior change techniques. The program includes: behavioral lessons; adaptive goal-setting in response to individuals' changing activity patterns; tailored feedback based on objective data and self-report measures; tailored text messages; and Facebook prompts encouraging peer support. Assessments occur at baseline, 3, 6, and 12 months. The primary outcome is total physical activity min/week at 6 months (assessed via accelerometry); secondary outcomes include total physical activity at 12 months, sedentary behavior, weight, and psychosocial measures.

CONCLUSIONS

IMPACT uniquely focuses on physical activity in YACS using an automated tailored mHealth program. Study findings could result in a high-reach, physical activity intervention for YACS that has potential to be adopted on a larger scale and reduce cancer-related morbidity. ClinicalTrials.gov Identifier: NCT03569605.

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.

Healthy Eating and Active Lifestyle After Bowel Cancer (HEAL ABC): feasibility randomised controlled trial protocol

Background

Targeting modifiable lifestyle factors including diet and physical activity represents a potentially cost-effective strategy that could support a growing population of colorectal cancer survivors and improve their health outcomes. Currently, effective, evidence-based interventions and resources helping people after bowel cancer to adopt new lifestyle habits are lacking. The aim of this trial is to test the Healthy Eating and Active Lifestyle After Bowel Cancer (HEAL-ABC) intervention to inform a future definitive randomised controlled trial.

Methods/design

This is a feasibility randomised controlled trial. A total of 72 survivors who have completed surgery and all anticancer treatments will be recruited. The intervention group will receive HEAL-ABC resources based on behaviour change theory combined with supportive telephone calls informed by motivational interviewing every 2 weeks during the 3-month intervention, and once a month for 6 months to follow-up. Participants in the control group will follow usual care and have access to resources available in the public domain. The study is testing feasibility of the intervention including adherence and ability to collect data on anthropometry, body composition, diet, physical activity, behaviour change, quality of life, blood markers, contact with healthcare services, morbidities and overall survival.

Discussion

The proposed study will add to the evidence base by addressing an area where there is a paucity of data. This study on lifestyle interventions for people after colorectal cancer follows the Medical Research Council guidance on evaluating complex interventions in clinical practice. It focuses on people living after treatment for colorectal cancer and targets an important research area identified by cancer survivors as a research priority reported by the National Cancer Institute and James Lind Alliance UK.

Trial registration

ClinicalTrials.gov NCT04227353 approved on the 13th of January 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-020-00721-y.

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.

Translating research into practice: outcomes from the Healthy Living after Cancer partnership project

BACKGROUND

Healthy Living after Cancer (HLaC) was a national dissemination and implementation study of an evidence-based lifestyle intervention for cancer survivors. The program was imbedded into existing telephone cancer information and support services delivered by Australian state-based Cancer Councils (CC). We report here the reach, effectiveness, adoption, implementation, and maintenance of the program.

METHODS

In this phase IV study (single-group, pre-post design) participants - survivors of any type of cancer, following treatment with curative intent - received up to 12 nurse/allied health professional-led telephone health coaching calls over 6 months. Intervention delivery was grounded in motivational interviewing, with emphasis on evidence-based behaviour change strategies. Using the RE-AIM evaluation framework, primary outcomes were reach, indicators of program adoption, implementation, costs and maintenance. Secondary (effectiveness) outcomes were participant-reported anthropometric, behavioural and psychosocial variables including: weight; physical activity; dietary intake; quality-of-life; treatment side-effects; distress; and fear of cancer recurrence and participant satisfaction. Changes were evaluated using linear mixed models, including terms for timepoint (0/6 months), strata (Cancer Council), and timepoint x strata.

RESULTS

Four of 5 CCs approached participated in the study. In total, 1183 cancer survivors were referred (mostly via calls to the Cancer Council telephone information service). Of these, 90.4% were eligible and 88.7% (n = 791) of those eligible consented to participate. Retention rate was 63.4%. Participants were mostly female (88%), aged 57 years and were overweight (BMI = 28.8 ± 6.5 kg/m2). Improvements in all participant-reported outcomes (standardised effect sizes of 0.1 to 0.6) were observed (p < 0.001). The program delivery costs were on average AU$427 (US$296) per referred cancer survivor.

CONCLUSIONS

This telephone-delivered lifestyle intervention, which was feasibly implemented by Cancer Councils, led to meaningful and statistically significant improvements in cancer survivors' health and quality-of-life at a relatively low cost.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12615000882527 (registered on 24/08/2015).

Physical Activity for Oncological Patients in COVID-19 Era: No Time to Relax

Whereas the coronavirus disease 2019 (COVID-19) storm is relentlessly progressing worldwide, a great effort from scientific societies has been made to give recommendations for safely continuing oncological care, prioritizing the interventions according to patients' condition and type and stage of tumor. Nevertheless, to date no specific suggestions regarding physical activity and exercise in cancer patients during the COVID-19 era have been released, neglecting the potential deleterious effects of quarantine and sedentary behaviour (imposed as containment measures against COVID-19), particularly in these subjects. Moreover, literature is constantly consolidating the crucial impact of regular physical activity in cancer in reducing recurrence and mortality risk. In this commentary, we discuss possible adaptations of the recently published exercise guidelines to the current pandemic emergency, proposing various modalities to prevent or mitigate the physical inactivity risk in cancer patients.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, 56,675 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 17% (risk ratio (RR) 0.83; 95% confidence interval (CI) 0.70 to 0.98, 12 trials, 53,758 participants of whom 8% had a cardiovascular event, I² = 67%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 53. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Improving Physical and Mental Health in Patients with Prostate Cancer Undergoing Androgen Deprivation Therapy: Strategies to Promote and Improve Physical Activity Quality and Quantity

OBJECTIVE

Prostate cancer continues to be one of the highest-incident cancers among men. Reducing serum testosterone with androgen deprivation therapy (ADT) is a common effective treatment. While well-demonstrated for cancer suppression, there are numerous adverse effects caused by ADT that can contribute to short- and long-term prognosis. Increased levels of physical activity (PA) during treatment may reduce these side effects. However, uptake of PA is low. The purpose of this review is to identify and evaluate the current literature on strategies to promote and increase the levels of PA in patients with prostate cancer undergoing ADT.

DATA SOURCES

Electronic databases including CINAHL, MEDLINE, PsychINFO, Scopus, and grey literature were searched using Google Scholar up until April 2020.

CONCLUSION

At present the most appropriate modes and dosages of PA for specific ADT toxicities is not known. It is established that some PA in the form of exercise, whether aerobic or resistance, is better than being sedentary for improvements in physical health, but beyond this prescription specifics have not been established. Further research is required to understand the impact of PA on the mental and physical health of men with prostate cancer undergoing ADT.

IMPLICATIONS FOR NURSING PRACTICE

Being physically active and avoiding sedentary behaviour is important for men with prostate cancer undergoing ADT, especially the implementation of strength training. PA in the form of exercise can assist in reducing the adverse physical side effects in the short- and long-term, with limited understanding of the effects on mental health. PA improves mental health outcomes across populations, which may also translate to men with prostate cancer, although further research is required. An important strategy to improve PA within the prostate cancer population is to provide an early referral to an exercise professional, such as an accredited exercise physiologist/clinical exercise physiologist or physical therapist/physiotherapist, and is supported by research as best practice for people affected by cancer undergoing active treatment.

Leveraging Fitness Tracker and Personalized Exercise Prescription to Promote Breast Cancer Survivors' Health Outcomes: A Feasibility Study

PURPOSE

This feasibility study investigated whether a year-long combined fitness wristband-based and personalized exercise prescription intervention improves Chinese breast cancer survivors' (BCSs) health outcomes.

METHODS

Ninety-five BCSs (X̅age = 44.81 ± 7.94; X̅BMI = 22.18 ± 3.48) were recruited from Southern region of China and were delivered the exercise intervention across 12 months, using a single group pretest-posttest design. Participants' lipid profile (e.g., total cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides), blood glucose, breast cancer biomarkers (e.g., carcinoembryonic antigen and cancer antigen 15-3), and functional fitness (e.g., strength in arms and legs, endurance, balance, agility, and flexibility) were assessed at baseline and 12-month post-intervention.

RESULTS

Thirty-three BCSs successfully completed the intervention. A significant change in blood glucose (mean difference (MD): -0.22, 95% confidence interval (CI): -0.41--0.03, t = -2.25, p = 0.028) was observed, with participants demonstrating lower levels of blood glucose at the 12-month post-intervention versus the baseline assessment. Notable changes in functional fitness were also discerned, including agility and balance (MD: -0.47, 95% CI: -0.68--0.26, t = -4.336, p < 0.001), aerobic endurance (MD: 89.25, 95% CI: 73.82-104.68, t = 11.336, p < 0.001), lower-body flexibility (left) (MD: 4.58, 95% CI: -4.4-13.56, t = 4.653, p < 0.001), and lower-body flexibility (right) (MD: 4.84, 95% CI: -4.65-14.33, t = 4.092, p < 0.001).

CONCLUSION

The observations suggested that our behavioral change program might promote certain health outcomes in Chinese BCSs, yet we are unable to recommend such a program given existing limitations. Future randomized control trials with diverse samples are warranted to confirm our findings.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, ~59,000 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 21% (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.66 to 0.93, 11 trials, 53,300 participants of whom 8% had a cardiovascular event, I² = 65%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 32. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Personal decision support for survivor engagement: formulation and feasibility evaluation of a conceptual framework for implementing online cancer survivorship care plans

BACKGROUND

Although cancer survivorship care plans have been in use for several years, they have been shown to not be effective in meeting the long-term needs of cancer survivors, in addition being generic and passive in nature. Interactive survivorship care plans in the form of a personal decision support aid could provide an opportunity to not only engage survivors in their health care, but also capture meaningful treatment-related outcomes to use as a rich data source as the basis for making informed decisions. The objective of this research is to formulate an evidence-based model framework for implementing breast cancer survivorship guidelines via an online breast cancer survivorship care plan (SCP).

METHODS

The study was completed in three steps. In the first step, or the requirements gathering phase, we conducted personal interviews of breast cancer survivors to determine their use of the survivorship care plan (SCP) and related needs to determine core SCP functions and formulate an implementation framework for an online SCP. In the second step, we used the framework as a guide to design and develop the online SCP tool. Finally, in the third step, we conducted preliminary testing to determine the feasibility of the developed tool among online users.

RESULTS

Fifteen breast cancer survivors were consulted, who reported several issues from their use of the traditional paper-based SCP. Four themes were identified that represent the SCP's core desired functions. Eight features were matched to implement these core functions. Using a personal decision approach, an online SCP tool called ACESO that incorporates these features and functions was developed. Preliminary feasibility testing yielded overall positive responses from breast cancer survivors (n = 51).

CONCLUSION

Our study demonstrated that survivors face challenges from their use of a traditional paper-based SCP. The online SCP we developed is technically feasible and has the potential to effectively engage breast cancer survivors in self-management and shared decision-making with their clinicians and caregivers. Further testing is required to assess its usability and long-term impact.

Assessing the nutritional needs of men with prostate cancer

BACKGROUND

Nutrition is important for prostate cancer (PC) survivorship care to help achieve a healthy weight, reduce treatment side effects and reduce the risk of developing other chronic diseases. We aimed to advance the understanding of the nutritional needs of men with PC and services that could be potentially implemented to address them.

METHODS

We conducted a needs assessment of nutrition services for men with PC drawing on four perspectives; 1) patient evaluation of a nutrition education session in British Columbia (BC), 2) survey of BC health professionals, 3) an environmental scan of existing nutrition services across Canada and 4) a scoping literature review.

RESULTS

Patients expressed a need for more nutrition information and a desire for additional nutrition services. More than 60% of health professionals believed there is a need for more nutrition services for men with PC, and reported the focus should be on weight management or management of PC progression. The environmental scan revealed few existing services for men with PC across Canada, most were inclusive of multiple cancers and not tailored for men with PC. Eighteen completed studies were identified in the scoping literature review. The majority provided combined diet and exercise programs with various formats of delivery such as individual, group and home-based. Overall, 78% of studies reported improvements in one or more of the following measures: dietary intake/ diet quality, body composition, self-efficacy, quality of life, fatigue, practicing health behavior goals and physical function/ exercise. Four studies assessed feasibility, adherence or satisfaction with all reporting positive findings.

CONCLUSION

Despite the high prevalence of PC in Canada, and the perceived need for more support by patients and health professionals, there are limited nutrition services for men with PC. Evidence from the literature suggests nutrition services are effective and well-accepted by men with PC. Our findings define a need for standardized nutrition services for men with PC that assess and meet long term nutritional needs. Our findings also provide insight into the type and delivery of nutrition services that may help close the gap in care for men with PC.

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.

Phase II randomised control feasibility trial of a nutrition and physical activity intervention after radical prostatectomy for prostate cancer

OBJECTIVE

Dietary factors and physical activity may alter prostate cancer progression. We explored the feasibility of lifestyle interventions following radical prostatectomy for localised prostate cancer.

DESIGN

Patients were recruited into a presurgical observational cohort; following radical prostatectomy, they were offered randomisation into a 2×3 factorial randomised controlled trial (RCT).

SETTING

A single National Health Service trust in the South West of England, UK.

PARTICIPANTS

Those with localised prostate cancer and listed for radical prostatectomy were invited to participate.

RANDOMISATION

Random allocation was performed by the Bristol Randomised Trial Collaboration via an online system.

INTERVENTIONS

Men were randomised into both a modified nutrition group (either increased vegetable and fruit, and reduced dairy milk; or lycopene supplementation; or control) and a physical activity group (brisk walking or control) for 6 months.

BLINDING

Only the trial statistician was blind to allocations.

PRIMARY OUTCOME MEASURES

Primary outcomes were measures of feasibility: randomisation rates and intervention adherence at 6 months. Collected at trial baseline, three and six months, with daily adherence reported throughout. Our intended adherence rate was 75% or above, the threshold for acceptable adherence was 90%.

RESULTS

108 men entered the presurgical cohort, and 81 were randomised into the postsurgical RCT (randomisation rate: 93.1%) and 75 completed the trial. Of 25 men in the nutrition intervention, 10 (40.0%; 95% CI 23.4% to 59.3%) adhered to the fruit and vegetable recommendations and 18 (72.0%; 95% CI 52.4% to 85.7%) to reduced dairy intake. Adherence to lycopene (n=28), was 78.6% (95% CI 60.5% to 89.8%), while 21/39 adhered to the walking intervention (53.8%; 95% CI 38.6% to 68.4%). Most men were followed up at 6 months (75/81; 92.6%). Three 'possibly related' adverse events were indigestion, abdominal bloating and knee pain.

CONCLUSIONS

Interventions were deemed feasible, with high randomisation rates and generally good adherence. A definitive RCT is proposed.

TRIAL REGISTRATION NUMBER

ISRCTN 99048944.

Exploring Views of Healthcare Professionals, Researchers, and People Living with and beyond Colorectal Cancer on a Healthy-Eating and Active Lifestyle Resource

BACKGROUND

People after bowel cancer are at high risk of cancer recurrences and co-morbidities, and therefore strategies are needed to reduce these risks. One promising strategy targets modifiable lifestyle factors including diet and physical activity. However, effective, evidence-based resources in adopting new lifestyle habits are currently lacking.

METHODS

The Healthy-Eating and Active Lifestyle After Bowel Cancer (HEAL ABC) resource was developed incorporating behavior change theory and World Cancer Research Fund and American Institute of Cancer Research guidelines. Focus groups and telephone interviews were conducted with professionals and survivors (age ≥18 years) to obtain feedback on the resource layout, structure, and content. Recorded data were transcribed verbatim and analyzed using framework analysis.

RESULTS

Thirty participants evaluated the resource-19 cancer survivors and 11 professionals. Survivors' mean age was 62 years (SD 11.5), 11 (58%) were females and 8 (42%) were male. Professionals were all females and mean age was 40 years (SD 6.06). Both survivors and professionals evaluated the resource as useful and provided suggestions for improvements.

CONCLUSIONS

HEAL ABC is an evidence-based resource designed to aid cancer survivors in translating their motivation into action. It was valued positively by both survivors and healthcare professionals and viewed as filling a gap in post-treatment advice.

Food Label Literacy and Use among US Adults Diagnosed with Cancer: Results from a National Representative Study

For those diagnosed with cancer, lifestyle factors including diet can be more important than ever. However, lack of nutrition-related knowledge can pose a significant barrier to healthy eating. Food labels guide consumers in selecting appropriate portion sizes-that is, caloric content-and ensuring adequate intake of nutrients. Data from the 2013-2014 HINTS were used to examine (a) differences in food label use and food label literacy between respondents ever had a cancer diagnosis and those never had a diagnosis; (b) sociodemographic correlates and health-related correlates of food label use and literacy, in a context of cancer diagnosis; and (c) potential association between food label use/literacy and each of two dietary choices, eating vegetables and fruits and limiting intake of sugary drinks, again, in a context of cancer diagnosis. Data was analyzed via SPSS version 24.0, and cross tabulations using Pearson's Chi-square test and logistic regressions. Income, gender and non-participation in support groups were associated with food label literacy (p<.05). Confidence to take care of self was associated with food label use (p<.05). Relationships were observed between using food labels and curtailing soda intake (b = -.368, p<.05), eating relatively more fruits (b = .558, p<.05), and eating relatively more vegetables (b = .558, p<.05). The overall models predicting consumption of soda [x2 (2) = 13.70, p = .001, Nagelkerke R-square = .059], of fruits [x2 (2) = 33.87, p < .001, Nagelkerke R-square = .136], and of vegetables [x2 (2) = 36.08, p < .001, Nagelkerke R-square = .144] was statistically significant. Implications for research and practice can be found in results linking food label use to better quality diets. They include the usefulness of nutrition education interventions targeting lower-income men with cancer diagnoses; one lesson should be the use of food labels.

Helping Patients Eat Better During and Beyond Cancer Treatment: Continued Nutrition Management Throughout Care to Address Diet, Malnutrition, and Obesity in Cancer

Cancer patients and survivors are at risk of poor clinical outcomes due to poor nutritional intake following cancer diagnosis. During cancer treatment, treatment toxicities can affect eating patterns and can lead to malnutrition resulting in loss of lean body mass and excessive weight loss. Following treatment and throughout survivorship, patients are at risk of not meeting national nutrition guidelines for cancer survivors, which can affect recurrence and survival. Obesity, which is highly prevalent in cancer patients and survivors, can affect clinical outcomes during treatment by masking malnutrition and is also a risk factor for cancer recurrence and poorer survival in some cancers. Appropriate and effective nutritional education and guidance by trained clinicians are needed throughout the cancer continuum. This article presents an overview of recommendations and guidelines for nutrition and weight management and provides recent examples of behavioral theory-based targeted lifestyle interventions designed to increase adherence to recommendation by cancer patients and survivors.

Changes in dietary intake, plasma carotenoids and erythrocyte membrane fatty acids in breast cancer survivors after a lifestyle intervention: results from a single-arm trial

BACKGROUND

The influence of nutrition on breast cancer prognosis is still inconclusive and therefore dietary interventions incorporating dietary biomarkers are needed to confirm compliance with dietary goals and clarify biological mechanisms. The present study assessed whether a lifestyle intervention in breast cancer survivors could affect dietary biomarkers of fruit and vegetables and fatty acids.

METHODS

In this phase II single-arm trial, 37 overweight/obese early stage breast cancer patients completed a 12-week diet and exercise intervention. The intervention involved 1-h weekly diet sessions delivered by a dietician and 75-min bi-weekly physical activity sessions of moderate-to-high intensity led by trained monitors. Before and after the intervention, three 24-h dietary recalls were carried out to calculate nutrient intakes and, in addition, blood samples were taken to measure plasma carotenoids, vitamin E and retinol concentrations and erythrocyte membrane fatty acid (EFA) composition. Wilcoxon signed rank tests were used to assess changes in dietary and biomarkers measurements over the intervention period.

RESULTS

After the intervention, there was a significant increase in the intake of dietary carotenoids (+15.1% compared to baseline) but not plasma carotenoids levels (+6.3%). Regarding the EFA levels, we observed a significant decrease in percentage of saturated fatty acids (-1.4%) and n-6 polyunsaturated fatty acids (-2.9%) and an increase in monounsaturated fatty acids (1.7%) and total and long-chain n-3 polyunsaturated fatty acids (by 13.1% and 13.7%, respectively). A favourable decrease in the ratio of long-chain n-6 to n-3 polyunsaturated fatty acids (-9.1%) was also observed.

CONCLUSIONS

After a short-term diet and exercise intervention in overweight/obese breast cancer survivors, we observed significant changes in dietary nutrients and fatty acid biomarkers, suggesting positive dietary changes that could be relevant for breast cancer prognosis.

A mixed methods process evaluation of a print-based intervention supported by internet tools to improve physical activity in UK cancer survivors

OBJECTIVE

A waiting list randomised control trial has shown the Move More Pack, a print-based intervention supported by Internet tools, to improve physical activity levels in cancer survivors; however, one-third of them do not improve from the intervention. The objective of this process evaluation is to understand intervention use, the mechanisms of impact, the perceived benefits and the contextual factors influencing these, identifying for whom it is a useful resource.

METHODS

The process evaluation used mixed methods, based on guidance from the UK Medical Research Council, including 181 questionnaire responses on intervention use and physical activity improvement over 12 weeks, 56 open-text responses and 17 semistructured interviews.

RESULTS

The Move More Pack was suggested to be most useful when delivered towards the start of the cancer journey to those with a positive attitude to fight cancer but with a low level of physical activity, capitalising on a teachable moment. It was suggested that healthcare professionals could support the effective distribution of the Move More Pack. The intervention's printed components were more popular and well used than the Internet tools. Use of the printed intervention components was positively correlated with physical activity improvement but use of the Internet tools was not. Women were more likely to use the intervention's printed components than men. Cancer survivors using the intervention reflected that they had increased confidence and motivation for physical activity and other lifestyle behaviours.

CONCLUSION

The Move More Pack should be offered by healthcare professionals, during cancer treatment, when health is salient, to those with a positive attitude to fight cancer but with low levels of physical activity. Use of the intervention's printed components is more likely to improve physical activity than the Internet tools, and the components are more likely to be used by women. The use of Internet tools to support physical activity improvement in cancer survivors requires further investigation.

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).

Dietary interventions for cancer survivors

This review evaluates evidence on dietary interventions for cancer survivors giving an overview of people's views and preferences for service attributes and provides a narrative review. After cancer, people often want to change their diet and there is a plethora of evidence why dietary optimisation would be beneficial. However, cancer survivors have different preferences about attributes of services including: place, person and communication mode. Randomised control trials have been reviewed to provide a narrative summary of evidence of dietary interventions. Most studies were on survivors of breast cancer, with a few on colorectal, prostate and gynaecological survivors. Telephone interventions were the most frequently reported means of providing advice and dietitians were most likely to communicate advice. Dietary assessment methods used were FFQ, food diaries and 24-h recalls. Dietary interventions were shown to increase intake of fruit and vegetables, dietary fibre, and improve diet quality in some studies but with contradictory findings in others. Telephone advice increased fruit and vegetable intake primarily in women with breast cancer and at some time points in people after colorectal cancer, but findings were inconsistent. Findings from mail interventions were contradictory, although diet quality improved in some studies. Web-based and group sessions had limited benefits. There is some evidence that dietary interventions improve diet quality and some aspects of nutritional intake in cancer survivors. However, due to contradictory findings between studies and cancer sites, short term follow-up and surrogate endpoints it is difficult to decipher the evidence base.

Behavior change techniques for increasing physical activity in cancer survivors: a systematic review and meta-analysis of randomized controlled trials

Purpose

The purpose of this systematic review and meta-analysis is to investigate how physical activity (PA) can be effectively promoted in cancer survivors. The effect of PA-promoting interventions in general, behavior change techniques (BCTs), and further variables as moderators in particular are evaluated.

Methods

This study included randomized controlled trials of lifestyle interventions aiming at an increase in PA that can be carried out independently at home, published by December 2016, for adults diagnosed with cancer after completion of the main treatment. Primary outcomes were subjective and objective measures of PA prior to and immediately after the intervention. Meta-analysis and meta-regression were used to estimate effect sizes (ES) in terms of standardized mean differences, variation between ES in terms of heterogeneity indices (I²), and moderator effects in terms of regression coefficients.

Results

This study included 30 studies containing 45 ES with an overall significant small positive effect size of 0.28 (95% confidence interval=0.18–0.37) on PA, and I²=54.29%. The BCTs Prompts, Reduce prompts, Graded tasks, Non-specific reward, and Social reward were significantly related to larger effects, while Information about health consequences and Information about emotional consequences, as well as Social comparison were related to smaller ES. The number of BCTs per intervention did not predict PA effects. Interventions based on the Theory of Planned Behavior were associated with smaller ES, and interventions with a home-based setting component were associated with larger ES. Neither the duration of the intervention nor the methodological quality explained differences in ES.

Conclusion

Certain BCTs were associated with an increase of PA in cancer survivors. Interventions relying on BCTs congruent with (social) learning theory such as using prompts and rewards could be especially successful in this target group. However, large parts of between-study heterogeneity in ES remained unexplained. Further primary studies should directly compare specific BCTs and their combinations.

Protocol for a phase III RCT and economic analysis of two exercise delivery methods in men with PC on ADT

BACKGROUND

Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer. However, side effects of ADT often lead to reduced quality of life and physical function. Existing evidence demonstrates that exercise can ameliorate multiple treatment-related side effects for men on ADT, yet adherence rates are often low. The method of exercise delivery (e.g., supervised group in-centre vs. individual home-based) may be important from clinical and economic perspectives; however, few studies have compared different delivery models. Additionally, long-term exercise adherence and an understanding of predictors of adherence are critical to achieving sustained benefits, but such data are lacking. The primary aim of this multi-centre phase III non-inferiority randomized controlled trial is to determine whether a home-based delivery model is non-inferior to a group-based delivery model in terms of benefits in fatigue and fitness in this population. Two other key aims include examining cost-effectiveness and long-term adherence.

METHODS

Men diagnosed with prostate cancer of any stage, starting or continuing on ADT for at least 6 months, fluent in English, and living close to a study centre are eligible. Participants complete five assessments over 12 months (baseline and every 3 months during the 6-month intervention and 6-month follow-up phases), including a fitness assessment and self-report questionnaires. Biological outcomes are collected at baseline, 6, and 12 months. A total of 200 participants will be randomized in a 1:1 fashion to supervised group training or home-based training supported by smartphones, health coaches, and Fitbit technology. Participants are asked to complete 4 to 5 exercise sessions per week, incorporating aerobic, resistance and flexibility training. Outcomes include fatigue, quality of life, fitness measures, body composition, biological outcomes, and program adherence. Cost information will be obtained using patient diary-based self-report and utilities via the EQ-5D.

DISCUSSION

To disseminate publicly funded exercise programs widely, clinical efficacy and cost-effectiveness have to be demonstrated. The goals of this trial are to provide these data along with an increased understanding of adherence to exercise among men with prostate cancer receiving ADT.

TRIAL REGISTRATION

The trial has been registered at clinicaltrials.gov (Registration # NCT02834416 ). Registration date was June 2, 2016.

Dietary intervention among breast cancer survivors increased adherence to a Mediterranean-style, anti-inflammatory dietary pattern: the Rx for Better Breast Health Randomized Controlled Trial

PURPOSE

The goal of this education and culinary-based dietary intervention was to increase adherence to a Mediterranean-style, anti-inflammatory dietary pattern in breast cancer survivors (BCS) by promoting the consumption of anti-inflammatory foods, herbs, and spices.

METHODS

Overweight and obese, early-stage, BCS were randomized to the Intervention (n = 76) or Control (n = 77). The 6-month intervention included monthly nutrition and cooking workshops, Motivational Interviewing telephone calls, and individualized newsletters. Control participants received monthly informational brochures and no navigational services. Dietary intakes were collected via questionnaire and 3-day food records at baseline and 6 months.

RESULTS

One hundred twenty-five BCS (n = 60 I; n = 65 C) completed post-testing (81.7%) and were included in analyses. Adherence to Mediterranean diet guidelines significantly increased in the intervention group, but not in the control group (+ 22.5% vs. + 2.7%, P < 0.001). Upon further analysis of adherence to individual dietary guidelines, the intervention group significantly improved adherence to only three guidelines: consuming ≥ 3 servings of fish or shellfish/week, reducing red meat intake to < 1 serving/day, and limiting consumption of commercial sweets and baked goods to < 3 times/week. The intervention arm increased the use of spices and herbs compared to control (+ 146.2% vs. +33.3%, P < 0.001), including significantly more frequent consumption of cinnamon, turmeric, garlic, ginger, black pepper, and rosemary.

CONCLUSION

An education and culinary-based intervention in BCS successfully increased adherence to a more Mediterranean-style, anti-inflammatory dietary pattern by increasing the consumption of anti-inflammatory foods, spices, and herbs and decreasing the consumption of pro-inflammatory foods.

Lifestyle Modifications and Policy Implications for Primary and Secondary Cancer Prevention: Diet, Exercise, Sun Safety, and Alcohol Reduction

Improved cancer treatments and cancer detection methods are not likely to completely eradicate the burden of cancer. Primary prevention of cancer is a logical strategy to use to control cancer while also seeking novel treatments and earlier detection. Lifestyle modification strategies to improve primary prevention and risk reduction for the development of cancer include choosing a healthy diet with an emphasis on plant sources, maintaining a healthy weight throughout life, being physically active, regularly using sunscreen and wearing protective clothing, limiting sun exposure during the hours of 10 AM to 2 PM, avoiding indoor tanning, and reducing or eliminating alcohol use. In addition to continued use of ongoing education of the public, health care providers, and cancer support communities, other policy and public health efforts should be pursued as well. Examples of supported and successful policy approaches are included in this article, including efforts to limit indoor tanning and improve community-wide interventions to reduce ultraviolet radiation exposure as well as to formally support various alcohol policy strategies including increasing alcohol taxes, reducing alcohol outlet density, improving clinical screening for alcohol use disorders, and limiting youth exposure to alcohol marketing and advertising. These prevention strategies are expected to have the largest impact on the development of melanoma as well as breast, colorectal, head and neck, liver, and esophageal cancers. The impact of these strategies as secondary prevention is less well understood. Areas of additional needed research and implementation are also highlighted. Future areas of needed research are the effects of these modifications after the diagnosis of cancer (as secondary prevention).

A systematic review of physical activity-based behaviour change interventions reaching men with prostate cancer

PURPOSE

Men who are survivors of prostate cancer report a variety of psychological and physical factors contributing to a lower quality of life, and physical activity can assist to mitigate these issues. This review aims to provide a summary of physical activity behaviour change trials targeting prostate cancer survivors, assess the feasibility of these interventions and, if possible, identify intervention and study characteristics associated with significant intervention effects.

METHOD

Four databases (PubMed, CINAHL, PsycINFO and EMBASE) were systematically searched for randomised controlled trials containing at least one behavioural outcome relating to physical activity published up until July 2016. Forward and backwards, hand, key author citation searching and known research were also considered.

RESULTS

From a total of 13, 828 titles, the search resulted in 12 studies (6 prostate cancer only and 6 mixed cancer interventions), eight of which found positive results most often related immediately to post-intervention aerobic activity. Factors relating to efficacy were not conclusive due to the heterogeneity of studies and lack of cancer-specific data in mixed cancer trials. Future research focusing on intervention reach, maintenance of intervention effects and resistance training outcomes is needed.

CONCLUSION

There is preliminary evidence to suggest that a variety of physical activity behaviour change interventions targeting men with a history of prostate cancer can be efficacious, at least in the short term. Experimental studies are required to identify key intervention features.

IMPLICATIONS FOR CANCER SURVIVORS

Physical activity interventions can assist prostate cancer survivors in relation to short-term lifestyle change, though more evidence is required to improve the clarity of factors related to efficacy.

Promoting Healthy Eating and Physical Activity Behaviors: A Systematic Review of Multiple Health Behavior Change Interventions Among Cancer Survivors

Multiple health behavior change (MHBC) interventions have great potential for enhancing health and well-being following cancer diagnosis and treatment. However, the characteristics and effects of MHBC interventions remain elusive for cancer survivors. The main purpose of this study was to evaluate the effectiveness of MHBC interventions on healthy eating and physical activity behaviors among cancer survivors. A secondary aim was to examine the effect of using a simultaneous and sequential design approach to MHBC (ie, changing both behaviors at the same time or one after the other). Randomized controlled trials reporting the impact of a MHBC intervention on both healthy eating and physical activity behaviors among cancer survivors were retrieved from MEDLINE, Cochrane Library, and PsycINFO. A total of 27 MHBC interventions were identified; most (92.6%) were designed to promote simultaneous change in both behaviors and assessed end-of-treatment effect among breast cancer survivors. MHBC interventions led by nurses or multidisciplinary teams showed the most compelling evidence for small to moderate improvement in both behaviors, with interventions that lasted ≥17 weeks more likely to improve both behaviors. This study identifies research priorities and provides preliminary evidence for clinical decision making and advancements in MHBC intervention design and delivery for clinical oncology.