Comprehensive Lifestyle Modification Intervention to Improve Chronic Disease Risk Factors and Quality of Life in Cancer Survivors

Abstract

Objectives:

Healthy lifestyle modifications, including weight management, regular physical activity, prudent diet, and stress relief, have been identified as key components of tertiary cancer prevention. In this study, we evaluate the effectiveness of a comprehensive, lifestyle medicine intervention, Lifestyle 180^®, on chronic disease risk factors and quality of life in cancer survivors.

Design:

Retrospective subgroup analysis of a clinical program.

Settings/Location:

An outpatient medical facility.

Subjects:

Lifestyle 180 participants with a diagnosis of past cancer.

Intervention:

Sixty-four hours of intensive nutrition, culinary medicine, physical activity, and stress relief practices over a 6-month period, with 9- and 12-month follow-up.

Outcome measures:

Pre–postanalysis (baseline vs. 12 months) included biometrics: weight, body mass index (BMI), waist circumference, and blood pressure; standard laboratory tests: lipids, C-reactive protein, fasting insulin/glucose, and insulin resistance; and empirically validated questionnaires: perceived stress, depression, and quality of life.

Results:

Fifty-eight cancer survivors participated in Lifestyle 180. Average age was 63 years, roughly 75% of participants were female, and the greatest majority had a diagnosis of breast, prostate, or skin cancer. Diagnosis of hyperlipidemia, hypertension, diabetes, and prediabetes presented in 47%, 57%, 22%, and 50% of patients, respectively. Forty-five percent of patients were obese, 24% were overweight, and 16% were depressed. At 12 months, participants lost an average of 14 pounds (−6.6%, p < 0.001) and 2.6 inches off their waist (−5.9%, p < 0.001). BMI decreased significantly by an average of 2.4 kg/m² (−6.8%, p < 0.001). Significant decreases from well-managed baseline levels also occurred in most measured biomarkers (average change: high-density lipoprotein +3.3 mg/dL, p < 0.05; triglycerides −23.0 mg/dL, p < 0.01; C-reactive protein −1.3 mg/L, p < 0.01; fasting insulin −4.2 μU/mL, p < 0.05; and homeostasis model assessment-insulin resistance −1.5, p < 0.01; n = 40). Changes in psychosocial variables included significant improvements in perceived stress (−20%, p < 0.01) and quality of life (+54%, p < 0.001). We were unable to detect a difference in depressive symptoms.

Conclusions:

Cancer survivors participating in a comprehensive intervention could employ the prescribed lifestyle modifications to produce clinically relevant health and quality-of-life benefits. These data support the American Cancer Society (ACS) and American Society of Clinical Oncology (ASCO) recommendations to incorporate healthy lifestyle modifications into long-term cancer survivorship care.

Introduction

In January 2016, it was estimated that there were nearly 16 million cancer survivors in the United States.^1,2 Over the next two decades, that number is projected to double due to advances in early detection and treatment as well as a growing and aging population.^3,4 These data along with the increased economic burden of cancer survivorship⁵ underscore the importance of expanding cancer care to include the promotion of long-term health. Data from Medicare beneficiaries in the United States indicate that 4 of 10 cancer patients have at least one other comorbid condition and 15% have two or more, the most common of which are cardiovascular disease, obesity, and mental illness.⁶

Over the last 15 years, the American Cancer Society and the American Society of Clinical Oncology have identified lifestyle modifications, including weight management, regular physical activity, and a healthy diet, as key components of tertiary cancer prevention.⁷ Diverse lines of evidence also support the role of stress relief practices to improve mood and sleep and to reduce fatigue in cancer survivors.⁸ In 2007, the Institute of Medicine published a report calling for these lifestyle recommendations to be included as a standard part of cancer survivorship care planning to optimize health and well-being following cancer treatment.⁹ With increased age, cancer survivors are more likely to have increased number of comorbid conditions.

Chronic conditions present at the time of cancer diagnosis, such as cardiovascular disease, obesity, and diabetes, may also have substantial influence on survival,^{10

–17} and studies indicate that the leading cause of death among Medicare breast cancer survivors is cardiovascular disease, not breast cancer.^10,18,19 Similarly, prostate cancer survivors have a higher risk of dying from chronic diseases other than prostate cancer.^11,12 It should be noted that both breast and prostate cancers are generally diagnosed at an early stage when the disease is less aggressive and therapies are more likely to be effective. Unfortunately, programs to guide patients in applying healthy lifestyle practices to reduce the risk factors for these chronic diseases as well as cancer prevention and recurrence are rarely implemented in the current fee-for-service healthcare model.

In 2011, we reported outcomes for over 400 patients with multiple chronic conditions who participated in a comprehensive, therapeutic, lifestyle intervention program, Lifestyle 180^®, for 6 months (a total of 64 h of intervention). Over those 6 months, participants experienced clinically significant improvements in biometric and laboratory outcomes as well as decreased use of prescription medications.²⁰ Patients also attended two 4-h interventions at 9 and 12 months after the start of the program, and these data have not yet been evaluated. In this study, we report 12-month biometric and psychosocial outcomes for the 58 Lifestyle 180 participants with a diagnosis of past cancer.

Materials and Methods

Intervention

Lifestyle 180 has been described in detail previously.²⁰ The comprehensive, healthy lifestyle, medicine intervention program ran from 2008 to 2013 and involved an intensive 6-week immersion course, including 8 h of group instructions per week, followed by three 4-h follow-up sessions over the course of 6 months and two 4-h follow-up visits during the next 6 months. Curricula included nutrition, culinary medicine, physical activity, and stress relief components.²⁰ The nutritional aspects of the program most closely aligned with a Mediterranean diet²¹ and promoted an increase in consumption of unrefined, whole plant foods,^22,23 a decrease in consumption of meats and animal fats,²⁴ and avoidance of red and processed meats.²⁵ Participants were actively engaged in the culinary medicine curriculum, not only receiving technique-driven demonstrations and education but also by physically preparing delicious and healthy meals with few ingredients. Culinary medicine education focused on how to achieve moisture without adding fat, sweetness without added sugars, flavor without added sodium, and savory density without meat. Participants prepared their meals in a professional teaching kitchen and ate them together in the adjoining conference room, practicing mindful eating. Physical activity curricula included both aerobic and resistance exercises with the goal of increasing participants' strength and endurance in a safe and effective way. The stress relief module included meditation and mindfulness practices such as guided imagery as well as seated and standing yoga.²⁰

Study population

Lifestyle 180 participants were largely selected by their employer to enroll in the program, while others were self-referred. They all paid out of pocket to participate. All participants had at least one of eight chronic conditions such as obesity, hyperlipidemia, diabetes, and cancer. This report focuses on the outcomes of Lifestyle 180 participants with a cancer diagnosis.

Outcomes

To measure the effectiveness of the Lifestyle 180 intervention, we collected biometric, metabolic, and psychosocial data at baseline, 6 weeks, 6 months, and 12 months. Body weight and height were measured to calculate body mass index (BMI; weight in kilograms divided by height in meters squared). Waist circumference was measured using a tape measure between the lowest costal margin and the iliac crest. Blood pressure was measured following the standard protocol using a sphygmomanometer. Laboratory measures included high-density lipoprotein (HDL) and low-density lipoprotein (LDL) cholesterol, triglycerides, ultrasensitive C-reactive protein, and fasting insulin. Insulin resistance was calculated using homeostasis model assessment (HOMA-insulin resistance; the product of fasting insulin and fasting glucose divided by 405).^26,27 All medications were managed by participants' primary care physicians as they deemed necessary, and data were self-reported to the study team. Psychosocial metrics included perceived stress, depression, and quality of life, which were measured using standard validated questionnaires. The 4-item Perceived Stress Scale (PSS-4) measures a person's perception of and response to daily hassles and stress, resulting in a total score of 0 (best) to 16 (worst).²⁸ The 10-item Center for Epidemiological Studies-Depression survey (CES-D 10) asks respondents to rate how often over the past week they experienced symptoms associated with depression such as sleep difficulties and feeling lonely. Scores range from 0 to 30 with higher scores indicating more symptomatology.²⁹ The 12-item Veterans RAND Health Survey (VR-12) measures health-related quality of life. Scores range from 0 (worst) to 100 (best) and can be subdivided into a physical health score, a mental health score, and a health change score, which asks participants to assess how much their physical and emotional health has changed over the past year.³⁰

Statistical analyses

Only participants who had both baseline and 12-month follow-up data were included in the statistical analysis. All data were analyzed using paired two-sample t-tests. Continuous variables are presented as mean ± standard deviation and categorical variables as n (%). Analyses were performed in R, version 3.3.2, and GraphPad Prism 5 software.

Results

Of the 694 Lifestyle 180 participants, 58 had a diagnosis of past cancer (13.5%). Table 1 shows the baseline characteristics of these 58 cancer survivors. Average age was 63 years, and 75% were female. Breast cancer was the most common type of cancer among participants (53.5%), followed by prostate cancer (8.6%). Other cancer types included skin, testicular, and uterine cancers, among others. In addition to the diagnosis of cancer, other comorbidities in this study population included hypertension (56.9%), prediabetes (50%), hyperlipidemia (46.6%), obesity (44.8%), and type 2 diabetes (22.4%). Most participants suffered from a high burden of chronic disease, with over 86% having anywhere from 2 to 4 of the aforementioned comorbid diagnoses. The Lifestyle 180 program was very well attended with only one participant lost to follow-up at week 6. At 12 months, 35 participants attended and had biometric measurements taken, and 40 participants fulfilled their clinical laboratory orders.

Table 1.

Baseline Characteristics of 58 Cancer Patients Participating in Lifestyle 180^®

	Mean	SD
Age, years	63.6	8.7
	N	%
Gender
Male	14	24.1
Female	44	75.9
Type of cancer
Breast	31	53.5
Prostate	6	10.3
Skin	5	8.6
Kidney	4	6.9
Testicular	3	5.2
Uterine	3	5.2
Other^a	6	10.3
Other comorbidities
Prediabetes	29	50.0
Type 2 diabetes	13	22.4
Hypertension	33	56.9
Hyperlipidemia	27	46.6
Overweight (BMI 25–30)	14	24.1
Obesity (BMI >30)	26	44.8
Cardiovascular disease	4	6.9
Depression	9	15.5
Number of comorbidities
0	1	1.7
1	5	8.6
2	14	24.1
3	21	36.2
4	15	25.9
5	2	3.5

Other cancer types include endometrial, cervical, thyroid, oropharyngeal, and nasopharyngeal cancers.

BMI, body mass index; SD, standard deviation.

Tables 2 –4 summarize the biometric, metabolic, and psychosocial outcomes, respectively, for all cancer survivors for whom we have baseline and 12-month follow-up data. At 12 months, participants lost an average of 14 pounds (−6.6%, p < 0.001) and 2.6 inches (5.9%, p < 0.001) off their waist (Table 2). Changes in systolic and diastolic blood pressure did not reach statistical significance; however, participants reported an overall decrease in their use of blood pressure medications: 18 stopped, decreased, or avoided blood pressure medication and 6 started or increased medication.

Table 2.

Biometric Outcomes for 35 Cancer Patients Participating in Lifestyle 180

	Baseline		12 Months
	Mean	SD	Mean	SD	p
Weight (lbs)	216.8	49.2	202.5	46.7	<0.001
Waist circumference (inches)	43.5	5.1	41.0	4.9	<0.001
Body mass index (kg/m²)	35.4	7.5	33.0	7.3	<0.001
Systolic blood pressure (mmHg)	128.5	19.6	129.3	24.6	0.81
Diastolic blood pressure (mmHg)	80.6	8.4	77.5	10.1	0.07

SD, standard deviation.

Table 3.

Biomarker Outcomes for 40 Cancer Patients Participating in Lifestyle 180

	Baseline	12 Months
	Mean	SD	Mean	SD	p
HDL cholesterol (mg/dL)	52.4	12.5	55.7	13.9	<0.05
LDL cholesterol (mg/dL)	108.3	31.6	102.2	28.6	0.06
Triglycerides (mg/dL)	134.7	60.2	110.7	54.2	<0.01
Us-C-reactive protein^a (mg/L)	6.0	6.5	4.7	5.6	<0.01
Fasting insulin^b (μU/mL)	15.5	10.7	11.3	7.3	<0.05
Fasting glucose (mg/dL)	107.4	39.4	98.6	27.7	0.17
HOMA-insulin resistance^b	4.5	4.3	3.0	3.2	<0.01

N = 29.

N = 27.

HDL, high-density lipoprotein; HOMA, homeostasis model assessment; LDL, low-density lipoprotein; SD, standard deviation.

Table 4.

Psychosocial Outcomes for Cancer Patients Participating in Lifestyle 180

		Baseline		12 Months
	N	Mean	SD	Mean	SD	p
Perceived stress (PSS-4)^a	32	6.6	3.1	5.3	3.2	<0.01
Depression (CES-D 10)^b	25	8.5	4.8	8.5	6.6	0.97
Veterans RAND 12 (VR-12)^c
Physical	21	73.0	19.4	83.3	16.7	<0.01
Mental	26	71.0	18.4	77.1	18.8	<0.05
Health change	27	53.0	17.7	81.5	21.2	<0.001

Scores range from 0 to 16, with higher scores indicating more perceived stress.

Scores range from 0 to 30, with higher scores indicating more depressive symptoms.

Scores range from 0 to 100, with higher scores indicating greater quality of life.

CES-D 10, 10-item Center for Epidemiological Studies-Depression survey; PSS-4, 4-item Perceived Stress Scale; SD, standard deviation.

Several metabolic risk factors also significantly improved (Table 3), including an increase in HDL cholesterol (+6%, p < 0.05) and a decrease in triglycerides (−18%, p < 0.01), ultrasensitive C-reactive protein (−23%, p < 0.01), fasting insulin (−27%, p < 0.05), and HOMA-insulin resistance (−33%, p < 0.01). In addition, participants reported an overall decrease in lipid-lowering medication use: seven stopped, decreased, or avoided lipid-lowering medication, and two started medication. LDL cholesterol and fasting glucose levels also decreased, but did not quite reach statistical significance (LDL −6%, p = 0.06; fasting glucose −9%, p = 0.17).

Regarding psychosocial outcomes (Table 4), participants reported significant improvements in their perceived stress as well as their physical and mental quality of life. PSS-4 scores decreased by an average of 19% (p < 0.05). VR-12 physical component scores increased by 12% on average (p < 0.01), and mental component scores increased by an average of 9% (p < 0.05). Participants also reported vastly significant improvement in their physical and emotional health over the past year (+54%, p < 0.001). No changes were observed in depression scores (−0.5%, p = 0.97).

Discussion

Poor lifestyle choices are key factors in the development and progression of preventable chronic diseases, including cancer. Individual chronic disease risk factors may be successfully addressed through cholesterol-lowering medication or gastric bypass surgery, for example; however, these interventions do not address the behavioral and lifestyle factors that contributed to the chronic conditions in the first place. In this study, we report findings that a comprehensive, lifestyle modification intervention consisting of healthy diet, physical activity, and stress relief practices improves chronic disease risk factors and quality of life in cancer survivors. Baseline biomarker data include relatively healthy values, suggesting that participants were well managed with medications at the start of the program. Even still, significant decreases from these well-managed levels preintervention were observed at 12 months, and many participants reported lowered or discontinued medication use during the intervention. In addition, nearly all measured biometric and behavioral variables were also significantly improved at the 12-month follow-up.

Biometric improvements included a loss of almost 7% body weight within 1 year, with similar reductions in BMI. This is of great clinical importance because it reduces patients' risk of cancer recurrence and it reduces cardiovascular risk as well. A meta-analysis of more than 40 studies showed a statistically significant and clinically relevant increase in all-cause and breast cancer-specific mortality in obese versus nonobese women,³¹ and emerging evidence suggests that the adverse effects of obesity on cancer outcomes persist long term.^7,32 A large prospectively studied population of almost 1 million adults showed that increased body weight was associated with increased death rates for all cancers combined and for cancers at multiple specific sites.³³ In addition, the Women's Intervention Nutrition Study (WINS) showed that breast cancer survivors in a low-fat intervention group lost an average of 6 pounds and had better relapse-free survival at 5 years.²⁴ With the two most comorbid conditions among cancer patients being obesity and cardiovascular disease,⁷ it is imperative that interventions for cancer survivors address the factors that put them at increased cardiovascular risk.

There are many pathways by which obesity may promote cancer development and progression. Adipose inflammation is one important link between obesity and cancer risk, and it occurs in the setting of the metabolic syndrome, including insulin resistance and dyslipidemia, which interact with local proinflammatory mechanisms that may promote cancer progression.^34,35 For cancer survivors in this study, average HOMA-insulin resistance decreased by 33% along with a significantly improved lipid profile (increased HDL cholesterol and decreased triglyceride levels and use of cholesterol-lowering medications) and a 6% decrease in waist circumference. These changes, particularly the dramatic decrease in HOMA-insulin resistance, are similar to others reported in the literature, including a recent study on the impact of a behavior-based weight loss intervention in breast cancer survivors, which showed a 29% decrease in HOMA-insulin resistance,³⁶ and our results exceed the 17% decrease identified with the use of metformin.³⁷ Although long-term follow-up of cancer survivors in our cohort would be needed to demonstrate potential survival benefits, our comprehensive lifestyle intervention achieved improvements in several key metabolic factors that may result in better survival outcomes.

Increased physical activity has also been associated with decreased risk of many cancer types, and strong associations between postdiagnosis exercise and decreased cancer-specific mortality have been reported.³⁸ Unfortunately, recent surveys show that only a small fraction of patients recalled being instructed to exercise by their physicians, and only one of nine surveyed practitioners documented the discussion of exercise in patient charts.^39,40 In Lifestyle 180, cancer survivors received 18 h of physical activity during group visits and were instructed to exercise on their own to achieve the goals of the American College of Sports Medicine (30 min of moderate-intensity physical activity 5 days per week).⁴¹

Highlighting the importance of a healthy diet in cancer patients, survival studies consistently demonstrate lower mortality risk among cancer survivors who consume a prudent guideline-based diet, with decreases ranging from 15% to 43%.^42
–44 While cancer survivors may receive nutrition advice from their oncologist, primary care physician, or dietitian, hands-on education regarding how to prepare healthy meals is not provided in the current practice. Lifestyle 180 included 18 h of culinary medicine education as well as practical experience cooking healthy meals in our professional teaching kitchen. This hands-on experience in the teaching kitchen provides participants with skills that allow them to cook more at home, which has long been associated with consumption of a healthier diet.⁴⁵ Support is also growing to evaluate the effectiveness of teaching kitchens to create sustainable dietary change,⁴⁶ including the formation of the Teaching Kitchen Collaborative (TKC), a national network of 31 thought-leading organizations with existing teaching kitchens focused on assessing their potential to impact behaviors, health outcomes, quality of life, and total costs of care across varying populations.

In addition to the importance of a healthy diet and increased physical activity, long-term care of cancer survivors should also include a stress relief component.⁹ Cancer survivors consistently report unwanted physical and emotional side effects persisting long after treatment ends. Fatigue, insomnia, depression, and reduced quality of life are common difficulties, in addition to the relentless fear of cancer recurrence.⁴⁷ These patients often use complementary and alternative therapies to alleviate these symptoms, including relaxation and mindfulness training,⁴⁸ meditation,^49
–51 and yoga.^52
–54 A recent randomized controlled trial of Hatha yoga intervention versus wait-list control in 200 breast cancer survivors demonstrated an increase in vitality and a decrease in fatigue as well as in proinflammatory blood markers, interleukin-6 and tumor necrosis factor-alpha.⁵⁵ A study of the long-term psychological benefits of stress management in cancer survivors showed a significant decrease in depressive symptoms and improved quality of life within the intervention group that continued up to 15 years later,⁴⁷ supporting the importance of incorporating stress relief practices into long-term cancer survivorship care. Lifestyle 180 included 18 h of yoga and 18 h of behavioral health coaching in a group setting, and participants reported significant reductions in perceived stress, improved mental and physical quality of life, and dramatic improvement in perceived health change. We were unable to detect differences in depression; however, baseline and 12-month scores on the CES-D 10 were below the threshold for significant depressive symptoms, indicating a low risk for clinical depression at both time points.

This study has several limitations. Because it was not a randomized, controlled clinical trial, we are unable to establish causality or to assess how much the observed changes are specifically due to the Lifestyle 180 program. Seventy-five percent of participants completed the program through their employer at their employer's expense and the other 25% paid out of pocket to participate in Lifestyle 180. This may represent a biased sample of relatively local participants with sufficient resources or economic advantages based on employment, limiting the generalizability of our findings and the potential to disseminate the program more broadly. We also did not measure program adherence, and therefore we are unable to correlate the degree of adherence to the program with changes in chronic disease risk factors or to identify lifestyle changes that are most important for positive health outcomes. We did not formally evaluate whether or not participants exercised as instructed, but it is likely that they did based on the improved biometric and laboratory biomarkers. We also did not collect sufficient information to know if participants reduced their intake of dietary fat, especially saturated fats, as prescribed. One-day food recall diaries were completed by Lifestyle 180 participants at baseline, but they were largely incomplete and were therefore discontinued. Block food frequency surveys⁵⁶ were incorporated into the intervention about a year after Lifestyle 180 began, and data were collected at baseline and 6 weeks. With complete data sets for only 10% of participating cancer survivors, we still saw a statistically significant decrease in patient-reported weekly dietary fat consumption (average decrease of 50.5%, n = 6, p = 0.007) and a near-significant increase in weekly servings of dietary fruit, vegetable, and fiber (average increase of 36.0%, n = 5, p = 0.13). In addition to these limited dietary intake data, biometric and biomarker outcomes as well as medication use data also suggest program adherence; however, this was not systematically evaluated.

Conclusions

Retrospective analysis of patients with a past diagnosis of cancer who participated in Lifestyle 180 indicates that cancer survivors could incorporate the prescribed comprehensive lifestyle modifications into their lives to a degree that produced clinically relevant health and quality-of-life benefits. This program was consistent with the clinical practice guidelines put forth by the American Cancer Society, the American Society of Clinical Oncology, and the Institute of Medicine, and the effects were of such magnitude that even with the small number of patients, most evaluated outcomes reached statistical significance. As a result, it is prudent for comprehensive lifestyle interventions aimed at addressing weight management, increased physical activity, improvement in diet quality, and reductions in perceived stress to be incorporated into long-term cancer survivorship care.

Footnotes

Acknowledgments

This study was internally funded by the Cleveland Clinic. All work was performed at the Cleveland Clinic.

Author Disclosure Statement

No competing financial interests exist.

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