obesity, exercise, and quality of lifeobesity, … exercise, and quality of lifeobesity, exercise,...
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Obesity, Exercise, and Quality of LifeObesity, Exercise, and Quality of Life in Endometrial Cancer Survivors
Karen Basen-Engquist, PhD, MPHProfessor and Research Center DirectorProfessor and Research Center Director
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Today’s Talky
Health issues and exercise Health issues and exercise Adherence to exercise
d irecommendations Motivating survivors to exerciseg
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Risk Factors for Endometrial Cancer(AICR/WCRF CUP, 2013)
• Being at a healthy weight and being physically active can prevent roughly 3 in 5 endometrial cancersg y
• 50% increased risk per 5 BMI units• PA includes recreational, occupational, and transportation activity• Sitting behavior emerging as a risk factor
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Physical Activity: Gynecologic Cancer S iSurvivors
35
25
30
35
15
20
25
5
10
0Endometrial,
MDAEndometrial,
CanadaOvarian, Canada Gyn, NHIS
M ti / di id liMeeting/exceeding guidelines
Basen-Engquist et al, AJOG, 2008 Courneya et al, Gyn Onc, 2005Stevinson et al, Intl J Gyn Onc, 2009 Bellizi et al, JCO, 2005
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Endometrial Cancer Survivors’ Physical Functioning Varies by Their Activity Levelg y y
(Basen-Engquist et al, AJOG, 2008)
80
100
40
60
Physical functioning, differencefrom normPhysical functioning scale
0
20Physical functioning scale
-40
-20
No exercise Exercise belowid li
Exercise meetingid liguidelines guidelines
Differences by PA level: Unadjusted – Physical functioning, p<.0001, Adjusted –Physical functioning, p<.0001
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Endometrial Cancer Survivors’ Fatigue and Pain Varies by Their Activity LevelVaries by Their Activity Level
(Basen-Engquist et al, AJOG, 2008)
6
5
6
3
4
0 ra
ting
Fatigue
2
3
0 - 1
0 Pain
0
1
No PA PA below guidelines PA meeting guidelines
Differences by PA level: Unadjusted -Fatigue, p=.018, Pain, p=.021 Adjusted – Fatigue, p=.069; Pain, p= .107
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Effects on Fitness and Body CompositionComposition
(Speck et al, J Ca Surv, 2009)
Fit B d C itiFitnessDuringTrtmnt
AfterTrtmnt
Body CompositionDuringTrtmnt
After Trtmnt
Physical activity level + +Aerobic fitness + +
Body weight + +Fat mass o o+ +
Upper body strength + +
Lean mass o oBody fat % + +
Lower body strength + + BMI o +
Waist I o+ = significant positive effects;circumference
I oArm volume I I
+ = significant positive effects;o= no significant effect-- = significant negative effectsI = insufficient evidence
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Effects on Quality of Life and P h i l V i blPsychosocial Variables
D i Aft I ffi i id /DuringTrtmnt
AfterTrtmnt
Overall QOL o +
• Insufficient evidence/ no significant effect– Mental, physical, social ,
general QOLo +Functional QOL + oBreast-cancer I +
g– life satisfaction– sexual attractiveness– weight concerns– physical condition
specific QOLI +
Fatigue o +C f i
physical condition– positive mood– mood disturbance– anger
vigor/vitalityConfusion I +Body image I +
– vigor/vitality• No significant effect, both
groups– depression
Anxiety + oSelf-esteem + I
p
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Exercise Guidelines, ACSM & ACSExercise Guidelines, ACSM & ACS
• AVOID INACTIVITY• Follow age appropriate guidelines for
general populationgeneral population– Aerobic: 150 minutes/week
moderate or greater intensitySt th 2 kl h j– Strength: 2x weekly, each major muscle group, 8-10 repetitions, 1-3 sets per exerciseFl ibilit t l t 2 d– Flexibility: at least 2 days per week for 10 min/day (older adults)
• Special precautions: metastases, di fi di l h d tcardiac findings, lymphedema, stem
cell transplant
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Adherence to ExerciseAdherence to ExerciseI usually do two hours of cardio and then four more of cardioI usually do two hours of cardio and then four more of cardio
and then two more of cardio…
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Social Cognitive Theory and Physical Activity after Endometrial Cancer y
(R01 CA109919)
Karen Basen-Engquist, PhD, MPH - Principal InvestigatorCindy Carmack, PhD - Co-Principal Investigator
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PopulationPopulation
St I II III d t i l Stage I, II, or IIIa endometrial cancer diagnosed in past 5 years
Completed treatment at least 6 months ago
Not currently meeting public healthNot currently meeting public health guidelines for physical activity
Obtain physician clearance for exercise; no Obtain physician clearance for exercise; no contraindications for cardiorespiratoryfitness testingg
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ExerciseLab ExerciseHome-based
Design: Assessment and Intervention ScheduleHome-basedExercise
prescriptionLab Exercise
and assessmentHome basedAssessment
Weekly Telephone
Home basedAssessmentT0: Baseline
Weekly Telephone Counseling for Exercise Adherence
Lab Exercise Home-basedHome-basedT1: 2 months
T1
and assessment
Semi-Weekly Telephone Counseling for Exercise Adherence
AssessmentAssessmentT1: 2 months
Counseling for Exercise Adherence
Lab Exercise and assessment
Home-basedAssessment
Home-basedAssessment
T2: 4 months
Monthly Telephone Counseling for Exercise Adherence
Lab Exercise and assessment
Home-basedAssessment
Home-basedAssessmentT3: 6 months
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Intervention Componentsp
• Exercise Recommendation– Main modality moderate intensity walks– Goal – 30 minutes of accumulated activity on most
days of the weekdays of the week• Telephone Counseling
– Weekly in months 1 & 2, every two weeks on months 3 & 4, monthly in months 5 & 6
– 15-20 minute session– Provide individualized feedback, problem solving, and
motivational factors• Print Materials• Print Materials
– Self-regulatory skills using cognitive-behavioral techniques
– Role model stories• Pedometers
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Sample Demographics, n=100p g p ,
R / th i it Ed tiRace/ethnicity 75% White, non-Hispanic 12% White, Hispanic
Education• 2% < high school• 13% HS diploma/GED
7% Black, non-Hispanic 6% Other
• 8% Technical/vocational degree• 36% Some college/2 yr degree• 24% 4 year degree
%Age, M=57.1 (11.1), range=25-78 8%, <40
• 17% Advanced degree
8%, 40 12%, 40 – 49 34%, 50 – 59 35%, 60 – 6935%, 60 69 11%, 70+
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Medical Issues
Disease/treatment On average, 26.1 (14.4) months
from diagnosis59% had s rger onl 40% had
Number of co-morbidities, M=3.2, SD=2.0, range=0-11
• 53%, Hypertension 59% had surgery only; 40% had
surgery and radiation; 1% had radiation only
Stage I, 80%; Stage II, 16%; 4%, Stage III
• 41%, Anemia• 37%, Peripheral neuropathy• 31%, Thyroid problems
27% O t th itiStage III 15% had another cancer diagnosis
BMI, M=34.3 (9.4), 19 69 3
• 27%, Osteoarthritis• 18%, Lung problems• 21%, Diabetes• 13% mental health diagnosisrange=19-69.3
15%, <25 21%, 25 – 29.9
25% 30 34 9
13%, mental health diagnosis• 10%, heart condition (angina or
arrhythmia)
25%, 30 – 34.9 11%, 35 – 39.9 28%, 40+
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Minutes of ExerciseSteps to HealthSteps to Health
(Basen-Engquist et al, 2014)
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Changes in Quality of LifeSteps to HealthSteps to Health
(Basen-Engquist et al, 2014)
Physical F ti iFunctioningTime, p<.001Obesity, p<.001
GeneralGeneral HealthTime, p<.001Obesity, p=.001
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Changes in Quality of LifeSteps to HealthSteps to Health
(Basen-Engquist et al, 2014)
VitalityTime p< 001Time, p<.001
MentalMental HealthTime, p<.029, p
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Changes in Quality of LifeSteps to HealthSteps to Health
(Basen-Engquist et al, 2014)
Distress -RRecurrenceTime, p=.032Obesity, p=0.01
NegativeNegative AffectTime, p<.001Time, p .001
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Changes in Quality of LifeSt t H lthSteps to Health
Cognitive P blProblemsTime, p=.005
StressStressTime, p<.001
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Does obesity make a difference i i ?in exercise program outcomes?
No significant Time by Obesity status interactions
Similar improvements in both obese and pnon-obese endometrial cancer survivors
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Model of Social Cognitive TheoryAdoption of Exercise Behavior
SomaticSensations/
AffectComorbidities
Mastery Experiences
CardiorespiratoryFitness
And obesity
Self-efficacy
Short term outcomes
Social support
Long-termOutcomes
Exercise History
ExerciseModeling
ExerciseAdherence
for activityOutcome
Expectations
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Assessment MethodologyAssessment MethodologyRetrospective questionnaires
AnthropometricsAnthropometricsCardiorespiratory fitness test
Implicit tasks
Home-based Home-basedLaboratoryAssessment5 days
Assessment5 days
Laboratory Assessment
Ecological Momentary AssessmentScheduled AM assessment: Self-efficacy & outcome expectations
Random assessments: somatic sensationsU i iti t d E i i t d i t itUser initiated: Exercise minutes and intensity
Scheduled PM assessment: ExerciseAccelerometers
Worn daily during waking hours on EMA assessment days
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Relationship Between SCT Variables d E i Mi tand Exercise Minutes
MorningA 1-point increase in positive outcome
+
Morningassessment
positive outcome expectations was associated with an increase of 3.9 minutes of exercise (t=3.62,
Self
outcome expect.
p=0.0003)
Negative outcome expectations not
Minutes of
Self-efficacy
expectations not associated with exercise minutes (t=-1.01, p=0.31)
exerciseA 1-point increase in self-efficacy was associated with an increase of 6 minutes of exercise (t =14 7exercise (t =14.7, p<0.0001)
Basen-Engquist et al, Health Psychology, 2013
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Self-efficacy Association with Exercise Mi tMinutes
• With self-efficacy and outcome expectations in the same model, self-efficacy remains significant (estimate = 6.09, Self Efficacy Individual Slopes significant (estimate 6.09, SEE=0.43, t=14.26; p<0.0001), but positive outcome expectations is notSelf efficacy remains significant
8
10
12
ues
y p
• Self-efficacy remains significant when– Accelerometer minutes are
used as DV2
4
6
Slop
e Va
l– Exercise is dichomized– Only those with >0 minutes of
exercise included– SE from day before is included
0
2
Subjects25% 50% 75%
SE from day before is included in model
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Longitudinal Prediction of Exercise Mi tMinutes
• Do SCT variables measured at earlier time points predict exercise minutes at subsequent
Baseline exercise minutes (covariate)
Baseline SCT variables (predictors)
time points?
• Lab measures of exercise self-efficacy barriers self-efficacy
2 month exercise minutes (outcome)
2 month SCT variables (predictors)efficacy, barriers self-efficacy, positive & negative outcome expectations 4 month exercise minutes (outcome)
4 month SCT variables (predictors)• Only exercise self-efficacy
predicted minutes of exercise at the next time point (controlling f b li i i t
4 month SCT variables (predictors)
6 month exercise minutes (outcome)for baseline exercise minutes (p=0.0021)
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Model of Social Cognitive TheoryAdoption of Exercise Behavior
SomaticSensations/
AffectComorbidities
Mastery Experiences
CardiorespiratoryFitness
And obesity
Self-efficacy
Short term outcomes
Social support
Long-termOutcomes
Exercise History
ExerciseModeling
ExerciseAdherence
for activityOutcome
Expectations
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Self-efficacy before an after exercise t t i d t ltest: survivors and controls
3 43.63.8
4• Effect of exercise test on SE
– Survivors: significant increaseControls: no change
2.83
3.23.4 – Controls: no change
• Predictors of post-exercise SE– Survivors: Pre-exercise SE, pre-exercise
somatic sensations post exercise
22.22.42.6
somatic sensations, post exercise somatic sensations (inverse)
– Controls: pre-exercise SE, post-exercise somatic sensations, estimated VO2 max
2Before
exercise testAfter exercise
test
Survivors Controls
• Change in self-efficacy positively associated with number of minutes of exercise in following
Survivors Controlsg
weekHughes et al, JPAH, 2010
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Conclusions and ImplicationsConclusions and Implications
Exercise is beneficial to endometrial cancer survivors
Obese survivors realize similar benefits from exercise as non-obese survivors, even if they are not exercising as much
Self-efficacy – confidence in their ability to exercise is key to exercise adherence Varies day-to day and affects whether exercise is done, and how long a es day to day a d a ects et e e e c se s do e, a d o o g
survivor exercises
Indicates that a real-time intervention – “ecological momentary intervention” - may be useful in increasing exercise behavior in this populationthis population
Preliminary data indicates that how people feel during exercise, physically and emotionally
Providers can provide support and recommendations normalizeProviders can provide support and recommendations, normalize feelings experienced during exercise
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Thank youThank you