Effects of exercise on quality of life in patients with cancer: an individual patient data meta-analysis

In a paper just published in Cancer Treatment Reviews -with Dr. Laurien Buffart as first author, as part of the POLARIS study, and together with a large international consortium -, we present the methods and results of a large individual patient data (IPD) meta-analysis to evaluate the effects of exercise on quality of life (QoL) and physical function (PF) in patients with cancer, and to identify moderator effects of demographic (age, sex, marital status, education), clinical (body mass index, cancer type, presence of metastasis), intervention-related (intervention timing, delivery mode and duration, and type of control group), and exercise-related (exercise frequency, intensity, type, time) characteristics.  IPD from 34 randomised controlled trials (n=4,519 patients) that evaluated the effects of exercise compared to a usual care, wait-list or attention control group on QoL and PF in adult patients with cancer were retrieved and pooled. Linear mixed-effect models were used to evaluate the effects of the exercise on post-intervention outcome values (z-score) adjusting for baseline values. Moderator effects were studies by testing interactions. Exercise significantly improved QoL. These effects were not moderated by demographic, clinical or exercise characteristics. Effects on QoL were significantly larger for supervised than unsupervised interventions. In conclusion, exercise, and particularly supervised exercise, effectively improves QoL and PF in patients with cancer with different demographic and clinical characteristics during and following treatment. Although effect sizes are small, there is consistent empirical evidence to support implementation of exercise as part of cancer care.

New edition of Dutch handbook on health education

This week the new edition of our book 'Gezondheidsvoorlichting en gedragsverandering' (Health education and behavior change) was published. Dr. Patricia van Assema of Maastricht University and Prof. Lilian Lechner of the Dutch Open University were my co-editors. The book provides a comprehensive overview for planning, preparing, conducting and evaluation of health education and health behavior change interventions. The book is structured according to a planning model that includes analyses of health and quality of life, the underlying health behaviors and the determinants of engaging in these behaviors, as well as behavior change strategies tailored to these determinants. The Intervention Mapping approach is presented as a means
to translate the information from these analyses into actual interventions. The book has further chapters on different settings for health education, implementation and dissemination of interventions, and on evaluation of health education interventions. The second part of the book presents real-life examples of intervention development and evaluations.

Lifestyle correlates of overweight in adults: a hierarchical approach

Obesity-related lifestyle behaviors usually co-exist but few studies have examined their simultaneous relation with body weight. In a study just published in the International Journal of Behavioral Nutrition & Physical Activity as part of the Sustainable prevention of obesity through integrated strategies (SPOTLIGHT) project, we aimed to identify the hierarchy of lifestyle-related behaviors associated with being overweight in adults, and to examine subgroups so identified.
Data were obtained from a cross-sectional survey conducted across 60 urban neighborhoods in 5 European urban regions between February and September 2014. Data on socio-demographics, physical activity, sedentary behaviors, eating habits, smoking, alcohol consumption, and sleep duration were collected by questionnaire. Participants also reported their weight and height. A recursive partitioning tree approach (CART) was applied to identify both main correlates of overweight and lifestyle subgroups.
Among the 5295 adults that participated, the mean body mass index was 25.2 kg/m2, and 46.0 % were overweight as indicated by a BMI ≥25 kg/m2. CART analysis showed that among all lifestyle-related behaviors examined, the first identified correlate was sitting time while watching television, followed by smoking status. Different combinations of lifestyle-related behaviors (prolonged daily television viewing, former smoking, short sleep, lower vegetable consumption, and lower physical activity) were associated with a higher likelihood of being overweight, revealing 10 subgroups. Members of four subgroups with overweight prevalence >50 % were mainly males, older adults, with lower education, and living in greener neighborhoods with low residential density.
Sedentary behavior while watching television was identified as the most important correlate of being overweight. Delineating the hierarchy of correlates provides a better understanding of lifestyle-related behavior combinations which may assist in targeting preventative strategies aimed at tackling obesity.

Psychosocial variables moderate the relationship between leisure time physical activity and mortality among myocardial infarction survivors

Leisure time physical activity (LTPA) is inversely related to mortality risk among patients with a history of myocardial infarction (MI). In a paper just published in BMC Cardiovascular Disorders -with Dr. Rony Oosterom-Calo as first author- we explored if heart failure (HF) status and psychosocial variables moderate this association in a prospective cohort study among MI survivors.
LTPA was inversely associated with mortality. HF did not, but psychosocial variables did, moderate the association. Among the higher active patients, patients with a high level of depression had a lower mortality risk in comparison to those with a low level, and patients with a low level of social support had a lower mortality risk in comparison to those with a high level of social support.

Social capital, neighborhood income and overweight across Europe

People with lower socio-economic status -lower levels of education, income and/or job status- in general have poorer health and engage more in unhealthy life style behaviors such as unhealthy diets and lack of physical activity. They also tend to have higher body weight and are more likely to be overweight or obese. Neighbourhood income inequality may contribute to such differences in body weight. In a paper just published in the European Journal of Public Health -with Joreintje Mackenbach as first author- we explored whether neighbourhood social capital mediated the association of neighbourhood income inequality with individual body mass index (BMI). For this study data from the SPOTLIGHT project -a study in different urban regions across Europe to explore neighbourhood contextual determinants of overweight and obesity-were used. A total of 4126 adult participants from 48 neighbourhoods in France, Hungary, the Netherlands and the UK provided information on their levels of income, perceptions of neighbourhood social capital and BMI. Higher neighbourhood income inequality was associated with elevated levels of BMI a
nd lower levels of neighbourhood social networks and neighbourhood social cohesion. High levels of neighbourhood social networks were associated with lower BMI. Results stratified by country demonstrated that social networks fully explained the association between income inequality and BMI in France and the Netherlands. Social cohesion was only a significant mediating variable for Dutch participants. In conclusion our results suggest that in some European urban regions, neighbourhood social capital plays a large role in the association between neighbourhood income inequality and individual BMI.

Correlates of adherence to a physical exercise program after cancer treatment

In a paper just published in the International Journal of Behavioral Nutrition and Physical Activity we studied demographic, clinical, psychosocial, physical and environmental factors associated with participation in and adherence to a combined resistance and endurance exercise program among cancer survivors, shortly after completion of primary cancer treatment. Data from the randomized controlled Resistance and Endurance exercise After ChemoTherapy (REACT) study were used for this study.
Participants were randomly allocated to either a high intensity (HI) or low-to-moderate intensity (LMI) exercise program. Patients’ participation rate was defined as their decision to participate in the REACT study. Exercise adherence reflected participants’ attendance to the scheduled exercise sessions and their compliance to the prescribed exercises. High session attendance rates were defined as attending at least 80 % of the sessions. High compliance rates were defined as performing at least of 90 % of the prescribed exercise across all sessions. Correlates of exercise adherence were studied separately for HI and LMI exercise. Demographic, clinical, and physical factors were assessed using self-reported questionnaires. Relevant clinical information was extracted from medical records.

Cancer survivors who participated in the exercise program were more likely to have higher education, be non-smokers, have lower psychological distress, higher outcome expectations, and perceive more exercise barriers than non-participants. In HI exercise, higher self-efficacy was significantly associated with high session attendance and high compliance with endurance exercises, and lower psychological distress was significantly associated with high compliance with resistance exercises. In LMI exercise, being a non-smoker was significantly associated with high compliance with resistance exercises and higher BMI was significantly associated with high compliance with resistance and endurance exercises. Furthermore, breast cancer survivors were less likely to report high compliance with resistance and endurance exercises in LMI exercise compared to survivors of other types of cancer.

In conclusion, several demographic, clinical and psychosocial factors were associated with participation in and adherence to exercise among cancer survivors. Psychosocial factors were more strongly associated with adherence in HI than LMI exercise.

lack of association of health behaviors and psychosocial characteristics with preterm birth

Preterm birth is the leading pregnancy outcome associated with perinatal morbidity and mortality and remains difficult to prevent. There is evidence that some modifiable maternal health characteristics may influence the risk of preterm birth. The aim of our study just published in Maternal and Child Health Journal was to investigate the relationships of self-reported maternal health behaviour and psychological characteristics in nulliparous women with spontaneous preterm birth in prenatal primary care. We used data from the nationwide DELIVER multicentre cohort study, which was designed to examine perinatal primary care in the Netherlands. In our study, consisting of 2768 nulliparous women, we estimated the relationships of various self-reported health behaviours (smoking, alcohol consumption, folic acid supplementation, daily fruit, daily fresh vegetables, daily hot meal and daily breakfast consumption) and psychological characteristics (anxious/depressed mood and health control beliefs) with spontaneous preterm birth.
Of all variables investigated, low health control beliefs was the sole characteristic significantly associated with spontaneous preterm birth.