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Determinants of adherence to recommendations on physical activity, red and processed meat intake, and body weight among lynch syndrome patients

Determinants of adherence to recommendations on physical activity, red and processed meat intake,... This study aimed to identify determinants of adherence to lifestyle and body weight recommendations for cancer preven- tion among Lynch Syndrome (LS) patients. Cross-sectional baseline data of LS patients participating in the Lifestyle & Lynch (LiLy) study was used to assess determinants of adherence to the World Cancer Research Fund cancer prevention recommendations on body weight, physical activity, and red and processed meat intake. Adherence and potential deter- minants of adherence were assessed using questionnaires. Multivariable logistic regression analyses were conducted to identify determinants of adherence. Of the 211 participants, 50.2% adhered to the body weight recommendation, 78.7% adhered to the physical activity recommendation, and 33.6% adhered to the red and processed meat recommendation. Being younger and having a higher level of education were associated with adherence to the recommendation on body weight. Having knowledge about the recommendation was associated with adherence to the recommendations on physi- cal activity and red and processed meat. Results confirm that knowledge about recommendations for cancer prevention is an important determinant for adherence and suggest that strategies to increase knowledge should be included in lifestyle promotion targeted at LS patients, along with behavior change techniques influencing other modifiable determinants. Keywords Lynch Syndrome · Cancer prevention · Physical activity · Body weight · Red and processed meat intake · Determinants Introduction Worldwide, approximately 28,600 cases of LS are newly (2) diagnosed each year . LS is caused by a germline muta- Lynch syndrome (LS) is an inherited cancer syndrome tion in one of the mismatch repair (MMR) genes [2, 3]. LS characterized by a high hereditary risk of various cancers, patients have a risk of developing colorectal cancer (CRC) primarily in the colorectum and the endometrium [1]. between 22 and 69% up to age 70, as opposed to 1–5% in the general Western population [4–6]. Significant differ - ences have been reported in cumulative cancer risk and risk of different cancer types according to MMR gene mutation M Hoedjes type (MLH1, MSH2, MSH6 and PMS2) [7, 8]. The clinical m.hoedjes@tilburguniversity.edu phenotype of LS has been shown to vary between families, 1 countries, and continents [8], suggesting the importance of Center of Research on Psychological and Somatic the role of environmental and non-genetic factors, such as disorders, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE Tilburg, The lifestyle-related factors [9], in the development of cancer Netherlands [10, 11]. In addition, low penetrance genetic risk factors Department for Health Evidence, Radboud university may be associated with the observed variety in cancer risk medical center, Nijmegen, The Netherlands among LS patients [12]. The influence of lifestyle-related Department of Clinical Genetics, Maastricht University factors on CRC among LS patients appears to be compa- Medical Center, Maastricht, The Netherlands rable or even stronger as compared with the general popula- Division of Human Nutrition and Health, Wageningen tion [11]. University, Wageningen, the Netherlands 1 3 M. Hoedjes et al. Studies investigating the association between lifestyle- patients. Data on non-changeable determinants associated related factors and the occurrence of sporadic cancer have with (non-)adherence (such as sociodemographic and cer- shown that lower levels of physical activity and higher body tain health-related determinants specific to LS, including fatness are associated with an increased risk of different cancer diagnosis in personal history and years since LS types of cancer, including CRC and endometrium cancer diagnosis) provides insight into which LS patients spe- [13]. Also, the intake of red and processed meat has been cifically should be targeted to improve adherence. Data on associated with an increased risk of sporadic CRC [13]. changeable determinants associated with (non-)adherence Among LS patients, lifestyle-related factors have also been provides insight into which modifiable determinants should associated with cancer risk. A recent systematic review be targeted for change and informs about what type of tech- has shown that early-adulthood overweight/obese weight niques or strategies can be used to positively influence these status and adulthood weight gain may be associated with changeable determinants. Such changeable determinants increased colorectal cancer risk in LS patients [14]. More- relevant for LS patients include psychological determi- over, a recent meta-analysis has shown that obesity has nants, such as cancer worry and symptoms of depression. been associated with an increased risk for colorectal can- These psychological determinants have been associated cer, but only in men with LS [15]. Furthermore, reviews of with unfavorable lifestyle behaviors in previous studies [23, the current literature among LS patients have shown that 24]. Besides, behavior change concepts that are frequently high fruit intake and physical activity have been associated included in theories and models of health behavior change with decreased colorectal cancer risk [14], whereas smok- are knowledge (about the recommendations) and aware- ing and alcohol consumption have been associated with an ness (of the influence of lifestyle-related factors on cancer increased colorectal cancer risk in LS patients [16]. risk) [25]. Knowledge and awareness have been shown to Based on a large body of scientific evidence for these be determinants of health behavior in other populations [26, observed associations, the World Cancer Research Fund 27]. (WCRF) has issued lifestyle and body weight recommen- The aim of this cross-sectional study was to explore dations for cancer prevention [13]. Cancer survivors (i.e. demographic, health-related, behavior change and psycho- those who have been diagnosed with cancer including logical determinants for adherence to body weight, physical those who have recovered) are also recommended to meet activity, and red and processed meat intake recommenda- these lifestyle and body weight recommendations for can- tions among LS patients, as these specific recommendations cer prevention. Meeting these recommendations has been are relevant for LS-related types of cancer (CRC, endome- associated with favorable health-outcomes, such as a higher trium) [13]. health-related quality of life, and a decreased risk for type II diabetes mellitus, cardiovascular disease, second primary cancers, cancer recurrences, and mortality [17–20]. Current Methods guidelines from the European Hereditary Tumour Group (EHTG) and European Society of Coloproctology (ESCP) Study design advise health care providers to inform LS patients about the observed associations between lifestyle, body weight and This study uses cross-sectional, baseline data (n = 218) from the risk of cancer [16]. the Lifestyle & Lynch (LiLy) study, a randomized con- We previously found that adherence to WCRF lifestyle trolled trial to test the effect of providing LS patients with and body weight recommendations in LS patients is low and WCRF-NL health promotion materials of the WCRF cancer that providing WCRF health promotion materials increased prevention recommendations [21]. awareness of and knowledge about WCRF recommenda- tions, without increasing psychological distress. However, Participants and procedure this did not affect adherence [ 21]. Little is known on how adherence to these recommendations can best be promoted. The LiLy study recruited participants between April and Insight into determinants of health behaviors among LS September 2015 at Radboud University Medical Center and patients is needed to be able to identify what techniques and Maastricht University Medical Centre. LS patients aged strategies can be used to achieve health behavior changes between 18 and 65 years were eligible for participation if LS in this specific patient population. Apart from our previous diagnoses was confirmed by a germline pathogenic variant qualitative study on determinants of adherence to lifestyle in one of the MMR-genes (MLH1, MSH2, MSH6 or PMS2). and body weight recommendations among LS patients [22], LS patients were excluded from participation if they had to our knowledge, no other study has examined determi- insufficient understanding of the Dutch language or if they nants of adherence or health behavior change among LS were participating in the GeoLynch study, a prospective 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… cohort study among LS patients, to prevent interference Red and processed meat between both studies [28]. Since only 4% of eligible LS patients participated in the GeoLynch study, this is unlikely Intake of red and processed meat was measured with an to have biased the results of this study. More information on adjusted version of a 40-item, validated Food Frequency the LiLy study can be found elsewhere [21]. Questionnaire (FFQ) specifically developed to assess adher - After informed consent was obtained, eligible LS patients ence to the Dutch Guidelines for a healthy diet [31]. Items were asked to fill in the baseline questionnaire, which took assessing red meat intake (grams per week) and processed approximately 45 min to complete. The medical ethical meat intake (grams per week) during the last month were research committees of the Radboud University Medical used to determine adherence to the recommendation on Center and Maastricht University Medical Centre granted red and processed meat intake. When red meat intake was permission to perform this study. < 500 g/w, of which processed meat was < 3 g/d, participants were considered to adhere to the recommendation on red Measures and processed meat intake. Adherence to the WCRF recommendations Demographic and health-related characteristics For this study, adherence to the WCRF recommendations Demographic characteristics were assessed using the base- on physical activity, body weight, and red and processed line questionnaire, which included items on age, gender, meat intake were included. These recommendations were marital status, and education. Clinical characteristics were included as these are relevant for LS-related types of cancer assessed using the same questionnaire by items on personal (CRC, endometrium) [13] and the smallest group of each of and family cancer history, colon surgery (colectomy, hemi- these dichotomous outcome variables (adherence vs. non- colectomy, colon resection), time since LS diagnosis, and adherence to these recommendations) was large enough to smoking behaviour. be able to be incorporated into the statistical analyses given the sample size (n = 211)[29]. Behavior change and psychological characteristics Body weight Awareness Awareness of the cancer risk factors as described in the WCRF/AICR recommendations for cancer preven- Self-reported body weight and height were used to calcu- tion (referred to as awareness of the WCRF/AICR recom- lated Body Mass Index (BMI) (kg/m ). Participants were mendations) was assessed using a question from the AICR categorised into the following BMI categories: <18.5; Cancer Risk Awareness Survey: “Do the following factors 25-<30;18.5-<25; and > 30 kg/m . The category 18.5– have a significant influence on whether or not the average 24.9 kg/m was considered as adherent to the body weight person develops cancer?”. recommendation. The other categories were considered not From the exposures that were mentioned in the entire to be adherent to the body weight recommendation. Awareness questionnaire reflecting all recommendations, only the exposures related to the recommendations on body Physical activity weight, insufficient physical activity, and red and processed meat intake were included for the current study. For each Adherence to the physical activity recommendation was exposure, answer options were: “yes, a big influence”; “yes, assessed using the validated Short Questionnaire to Assess a small influence”; “no”; and “I do not know”. Participants Health Enhancing Physical Activity (SQUASH) question- with correct answers, indicating that the exposures were of naire, which contains questions about multiple activities influence, were considered to be aware of the specific can - referring to a normal week in the past month. Results were cer risk factors while participants with answers “no” and “I converted to time spent on light, moderate, and vigorous do not know“ were considered to be unaware. activities, which were then converted to activity scores [30]. Knowledge Knowledge of the WCRF recommendations on When the number of moderate and vigorous exercise activi- body weight, physical activity, and red and processed meat ties was at least 30 min a day, for a minimum of 5 days a intake was assessed using 3 multiple choice questions; 1 for week, patients were categorized as adherent to the physical each recommendation. These knowledge questions required activity recommendation. more detailed content-specific knowledge about the rec - ommendations. For example, the multiple choice question “What is the minimally recommended amount of time a day you should be spending on physical activity according to the 1 3 M. Hoedjes et al. recommendations for cancer prevention?”, assessed knowl- years. Time since LS diagnosis was categorized into the fol- edge about the physical activity recommendation. The 5 lowing categories: 0–2 years; 2–4 years; and 4–20 years. answer options included: “A recommendation regarding First, univariable logistic regression analyses were con- physical activity and cancer risk does not exist”; “A mini- ducted with adherence to one of the WCRF recommenda- mum of 30 minutes physical activity per day of moderate tions on body weight, physical activity, or red and processed intensity (meaning an increased breath and heart rate)”; “A meat intake as dependent dichotomous variable, and a single minimum of 60 minutes physical activity per day of moder- potential determinant as independent variable. The follow- ate intensity”; “A minimum of 90 minutes physical activity ing potential demographic determinants were included as per day of moderate intensity”; “I don’t know”. Participants independent variables: gender (male, female); age (21–43, with correct answers were considered to have knowledge 44–54, and 55–73 years), education level (low, medium, about the respective recommendation. high), and marital status (partner, no partner). The following Cancer risk perception Cancer risk perception was assessed potential health-related determinants were included: years by two standardized questions. Participants were asked to since LS diagnosis (0–2 years, 2–4 years, and 4–20 years), express their perceived cancer risk in a percentage between colon surgery (yes, no), personal cancer history (yes, no), 0 and 100. In addition they were asked to choose one out and smoking status (current, ex-, never smoker). The fol- of 5 categories: ranging from a very low to a very high per- lowing potential psychological determinants were included: ceived cancer risk [32]. awareness (yes, no) and knowledge of the recommenda- Symptoms of depression Symptoms of depression were tions (yes, no), symptoms of depression (continuous), can- measured by using the Dutch version of the Hospital Anxi- cer worry (continuous), and cancer risk perception (< 50%, ety and Depression Scale (HADS) [33]. The HADS consists 50%, > 50%). of 14 items assessing self-reported symptoms of anxiety (7 Subsequently, multivariable logistic regression analy- items) and depression (7 items) in the past week. Each item ses were conducted with adherence to each recommenda- is scored on a 4-point Likert scale, ranging from 0 to 3, with tion as dependent variable, and as independent variables all higher scores indicating more symptoms. For the current socio-demographic, health-related, and psychological char- study, only scores for symptoms of depression were used acteristics that were found to be statistically significantly (because of the conceptual overlap with cancer worry). A associated with adherence in the univariable logistic regres- total score can be calculated for symptoms of depression by sion analyses. adding up the scores on the 7 items. This total score ranges Statistical analyses were performed using IBM SPSS from 0 to 21, with higher scores indicating more symptoms Statistics for Windows, version 24. P-values < 0.05 were [33]. considered to be statistically significant. Cancer worry Cancer worry was assessed using the Can- cer Worry Scale (CWS), consisting of 8 items. The reli- ability and validity has shown to be good among breast and Results colorectal cancer survivors [34, 35]. The total score ranges between 8 and 32, with higher scores corresponding to more Of the 218 LS patients who agreed to participate in the cancer worry. study, seven participants with missing data on one or more of the variables were excluded and 211 were included in the Statistical analyses population for analysis. Participants were aged between 21 and 73 years (mean 48.2; SD 10.9), and 61.1% was female The population for analysis consisted of participants with (N = 129) (Table 1). The number of years since LS diagnosis complete baseline data. Participants with missing data on ranged between 0 and 20 years (mean 3.7; SD 2.7). 18% one or more of the variables included in the analyses were had had a type of colon surgery (colectomy n = 7, hemico- excluded from the analyses. lectomy n = 24, colon resection n = 7). Means with standard deviations (SD) and frequency The majority of participants were aware of the influence tables were used to describe potential socio-demographic, of or had knowledge about the recommendation on body health-related, and psychological determinants. Since the weight (73% and 64.5%, respectively) and physical activity variables ‘age’ and ‘time since LS diagnosis’ were not nor- (66.8% and 64.5%, respectively) in relation to cancer risk. mally distributed, these variables were incorporated in the Much less participants were aware of the influence of or had statistical analyses as categorical variables. Age was catego- knowledge about the recommendation on red and processed rized into the following categories based on the observed meat intake in relation to cancer risk (37.4% and 14,2%, data distribution: 21–43 years; 44–54 years; and 55–73 respectively). 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… Table 1 Demographic, health- Total Cancer in per- No cancer in related, behavior change and (n = 211) sonal history personal history psychological characteristics N (%)* (n = 75) (n = 136) in Lynch Syndrome patients N(%)* N(%)* (n = 211) Demographic characteristics Gender 129(61.1) 45(60.0) 84(61.8) Female 82(38.9) 30(40.0) 52(38.2) Male Age at measurement 72(34.1) 10(13.3) 62(45.6) 21–43 years 74(35.1) 34(45.3) 40(29.4) 44–54 years 65(30.8) 31(41.3) 34(25.0) 55–73 years Educational level Low 20(9.5) 7(9.3) 13(9.6) Medium 107(50.7) 43(57.3) 64(47.1) High 84(39.8) 25(33.3) 59(43.4) Partner 187(88.6) 9(12.0) 15(11.0) Yes 24(11.4) 66(88.0) 121(89.0) No Health-related characteristics Years since LS diagnosis 82(38.9) 27(36.0) 55(40.4) 0–2 years 63(29.9) 18(24.0) 45(33.1) 2–4 years 66(31.3) 30(40.0) 36(26.5) 4–20 years Colon surgery 173(82.0) 38(50.7) 135(99.3) No colon surgery 38(18.0) 37(49.3) 1(0.7) Colon surgery Smoking status 22(10.4) 8(10.7) 14(10.3) Current smoker 92(43.6) 40(53.3) 52(38.2) Ex-smoker 97(46.0) 27(36.0) 70(51.5) Never smoker Behavior change and psychological characteristics Knowledge Weight recommendation Yes 111(52.6) 41(54.7) 70(51.5) No 100(47.4) 34(45.3) 66(48.5) Physical activity recommendation 136(64.5) 50(66.7) 86(63.2) Yes 75(35.5) 25(33.3) 50(36.8) No Meat intake recommendation 30(14.2) 10(13.3) 20(14.7) Yes 181(85.8) 65(86.7) 116(85.3) No Awareness Influence of overweight on cancer risk Yes 154(73.0) 56(74.7) 98(72.1) No 57(27.0) 19(25.3) 38(27.9) Influence of physical activity on cancer risk 141(66.8) 52(69.3) 89(65.4) Yes 70(33.2) 23(30.7) 47(34.6) No Influence of meat intake on cancer risk 79(37.4) 35(46.7) 44(32.4) Yes 132(62.6) 40(53.3) 92(67.6) No Symptoms of depression [Mean(SD)] 2.78(3.13) 3.4(3.4) 2.4(3.0) Cancer worry [Mean(SD)] 13.8(4.22) 15.1(4.6) 13.1(3.8) Cancer risk perception 71(33.6) 24(32.0) 47(34.6) <50% 51(24.2) 16(21.3) 35(25.7) *Unless otherwise specified; 50% 89(42.2) 35(46.7) 54(39.7) M = mean; SD = standard devia- >50% tion; BMI = Body Mass Index Of the 211 participants, 35.5% had a cancer diagnosis in diagnosed with colorectal cancer, 17 with endometrium can- their personal medical history (n = 75), of which 37 had been cer, 4 with both colorectal and endometrium cancer, and 17 1 3 M. Hoedjes et al. with other types of cancer. Compared with LS patients with- Discussion out a cancer diagnosis in their personal history, LS patients with a cancer diagnosis were older (p < .000), had more This first quantitative explorative study on determinants of often had a type of colon surgery (p < .000), were more fre- adherence to WCRF lifestyle and body weight recommen- quently aware of the influence of meat intake on cancer risk dations for cancer prevention in LS patients showed that (p = .04), and had a higher mean score of depressive symp- knowledge about the recommendations was a statistically toms (p = .037) and cancer worry (p = .001). See Table 1. significant determinant of adherence to the lifestyle recom - mendations on physical activity and red and processed meat Adherence to the recommendations intake. Being younger and having a higher level of educa- tion were associated with adherence to the recommendation Out of the 211 LS patients, 50.2% adhered to the body on body weight. weight recommendation, 78.7% adhered to the physical Adherence to the body weight recommendation among activity recommendation, and 33.6% adhered to the red and LS patients in the current study was comparable to adher- processed meat intake recommendation. ence in the general Dutch population in which 50% of those aged 18 and older adhered to the body weight recommenda- Determinants of adherence tion [36]. As compared to an observational study in Dutch colorectal cancer survivors, adherence to the recommen- Body weight recommendation dations on body weight (50% vs. 34%), physical activity (78.7% vs. 73%), and red and processed meat (33.6% vs. The univariable logistic regression analyses showed that age 8%) was higher in the LS patients participating in the cur- 44–54 vs. <44 years, medium and high vs. low educational rent study [37]. level, and symptoms of depression were associated with To our knowledge, no other studies have quantitatively adherence to the body weight recommendation (Table 2). investigated determinants of adherence to lifestyle and In the multivariable analyses, only age 44–54 vs. <44 body weight recommendations in LS patients. The results years (OR 0.48, 95% CI: 0.24–0.94) and medium (OR of this first quantitative exploration of determinants of 4.55, 95% CI: 1.34–15.5) and high (OR 6.41, 95% CI: adherence are in accordance with our previous qualita- 1.83–22.5) vs. low educational level remained statistically tive findings showing that having knowledge about the significantly associated with adherence to the body weight recommendations serves as a cue to action for adherence recommendation. to lifestyle recommendations in LS patients [22]. Knowl- edge is incorporated as a determinant in multiple frequently Physical activity recommendation used theories and models of health behavior change (e.g., the theory of planned behavior, the Health Belief Model, The univariable logistic regression analyses showed that Social Cognitive Theory) [25]. In this study, knowledge was age 55–73 vs. <44 years, ex-smoking vs. current smoking, found to be a determinant of adherence to the recommen- and having vs. not having knowledge about the physical dations on health behaviors (physical activity and red and activity recommendation were associated with adherence to processed meat intake), but not of adherence to the body the physical activity recommendation (Table 3). weight recommendation. These findings may be explained In the multivariable analyses, only having knowledge by the theoretical proximity of the determinant knowledge about the physical activity recommendation remained sta- to a certain health behavior (such as physical activity or tistically significantly associated with adherence to this rec - red and processed meat intake) as opposed to an outcome ommendation (OR 2.04, 95% CI: 1.04; 3.98). of multiple lifestyle behaviors (body weight). Considering that adherence to the body weight recommendation is sub- Red and processed meat intake recommendation ject to adherence to recommendations on energy balancing behaviors (physical activity, sedentary behavior, and dietary The univariable logistic regression analyses showed that intake), it seems plausible that knowledge is a more proxi- only having vs. not having knowledge about the red and mal determinant of health behaviors and a more distal deter- processed meat intake recommendation was associated with minant of adherence to the body weight recommendation adherence to the red and processed meat recommendation (outcome of the health behaviors physical activity and diet (Table 4; OR 2.62, 95% CI: 1.19; 5.74). quality). In other words, it makes sense that it’s more dif- ficult to influence (the result of) multiple lifestyle behaviors just by increasing knowledge than it is to influence a single lifestyle behavior. Hence, this could explain our finding that 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… Table 2 Demographic, health-related, behavior change and psychological characteristics of Lynch Syndrome patients (n = 211) and associations with adherence to the WCRF recommendation on body weight [1] [[2]] [[3]] Non- Adherent Univariable Multivariable adherent N = 106 N = 105 N(%) N(%) OR(95%CI) OR(95%CI) Demographic characteristics Gender 59(56.2) 70(66.0) 1.52(0.87–2.65) Female 46(43.8) 36(34.0) 1 Male Age at measurement 28(26.7) 44(41.5) 1 1 21–43 years 43(41.0) 31(29.2) 0.46(0.24– 0.48(0.24–0.94)* 44–54 years 34(32.4) 31(29.2) 0.89)* 0.86(0.41–1.79) 55–73 years 0.58(0.29–1.14) Education level Low 16(15.2) 4(3.8) 1 1 Medium 56(53.3) 51(48.1) 3.64(1.14– 4.55(1.34–15.5)* High 33(31.4) 51(48.1) 11.6)* 6.41(1.83– 6.18(1.90– 22.5)** 20.1)** Partner 97(92.4) 90(84.9) 0.46(0.19–1.14) Yes 8(7.6) 16(15.1) 1 No Health-related characteristics Years since LS diagnosis 35(33.3) 47(44.3) 1 0–2 years 33(31.4) 30(28.3) 0.68 2–4 years 37(35.2) 29(27.4) (0.35–1.31) 4–20 years 0.58(0.30–1.12) Colon surgery 81(77.1) 92(86.8) 1 No surgery 24(22.9) 14(13.2) 1.95(0.94–4.02) Surgery Cancer in personal history Yes 44(41.9) 31(29.2) 0.57(0.32–1.01) No 61(58.1) 75(70.8) 1 Smoking status 12(11.4) 10(9.4) 1 Current smoker 54(51.4) 38(35.8) 0.84(0.33–2.15) Ex-smoker 39(37.1) 58(54.7) 1.79(0.70–4.53) Never smoker Behavior change and psychological characteristics Knowledge Yes 55(52.4) 50(47.2) 1.02(0.59–1.75) No 50(47.6) 56(52.8) 1 Awareness Yes 76(72.4) 78(73.6) 1.06(0.58–1.95) No 29(27.6) 28(26.4) 1 Symptoms of depression[Mean(SD)] [4] 3.25(3.22) 2.32(2.98) 0.91(0.83– 0.94(0.85–1.03) 0.99)* Cancer worry [Mean(SD)] [5] 14.4(4.42) 13.3(3.95) 0.94(0.88-1.00) Cancer risk perception 39(37.1) 32(30.2) 1 <50% 27(25.7) 24(22.6) 1.08(0.53–2.23) 50% 39(37.1) 50(47.2) 1.56(0.83–2.93) >50% * ** *** p < .05, p < .01, p < .001 1 2 Body weight recommendation: Body Mass Index 18.5–24.9 kg/m Odds ratios are derived from univariable logistic regression analyses with adherence to the weight recommendation (yes vs. no) as dependent variable and one sociodemographic, health-related or psychological characteristic as independent variable Odds ratios are derived from a multivariable logistic regression analysis with adherence to the weight recommendation (yes vs. no) as depen- dent variable and all statistically significant (p < .05) sociodemographic, cancer-related, and health-related characteristics in the univariable logistic regression analyses as independent variables Odds ratio per 1 unit increase in the depressive symptoms subscale of the Hospital Anxiety and Depression Scale Odds ratio per 1 unit increase in the Cancer Worry Scale 1 3 M. Hoedjes et al. Table 3 Demographic, health-related, behavior change and psychological characteristics of Lynch Syndrome patients (n = 211) and associations with adherence to the WCRF recommendation on physical activity [1] [[2]] [[3]] Non- Adherent Univariable Multivariable adherent N = 166 N = 45 N(%) N(%) OR(95%CI) OR(95%CI) Demographic characteristics Gender 23(51.1) 106(63.9) 1.69(0.87–3.29) Female 22(48.9) 60(36.1) 1 Male Age at measurement 16(35.6) 56(33.7) 1 1 21–43 years 23(51.1) 51(30.7) 0.63(0.30–1.33) 0.54(0.25–1.19) 44–54 years 6(13.3) 59(35.5) 2.81(1.03– 2.44(0.85–6.97) 55–73 years 7.69)* Education level Low 3(6.7) 17(10.2) 1 Medium 22(48.9) 85(51.2) 0.68(0.18–2.54) High 20(44.4) 64(38.6) 0.57(0.15–2.13) Partner 42(93.3) 145(87.3) 0.49(0.14–1.73) Yes 3(6.7) 21(12.7) 1 No Health-related characteristics Years since LS diagnosis 22(48.9) 60(36.1) 1 0–2 years 12(26.7) 51(30.7) 1.56(0.70–3.46) 2–4 years 11(24.4) 55(33.1) 1.83(0.82–4.13) 4–20 years Colon surgery 33(73.3) 140(84.3) 1 No surgery 12(26.7) 26(15.7) 1.96(0.90–4.28) Surgery Cancer in personal history Yes 20(44.4) 55(33.1) 0.62(0.32–1.21) No 25(55.6) 111(66.9) 1 Smoking status 8(17.8) 14(8.4) 1 1 Current smoker 14(31.1) 78(47.0) 3.18(1.13-9.00)* 2.59(0.87–7.74) Ex-smoker 23(51.1) 74(44.6) 1.84(0.69–4.93) 1.72(0.60–4.95) Never smoker Behavior change and psychological characteristics Knowledge Yes 23(51.1) 113(68.1) 2.04(1.04– 2.22(1.09–4.52)* No 22(48.9) 53(31.9) 3.98)* 1 Awareness Yes 27(60.0) 114(68.7) 1.46(0.74–2.89) No 18(40.0) 52(31.3) 1 Symptoms of depression [Mean(SD)] [4] 3.42(2.86) 2.61(3.19) 0.93(0.84–1.02) Cancer worry [Mean(SD)] [5] 13.9 (4.68) 13.8(4.09) 0.99(0.92–1.07) Cancer risk perception 14(31.1) 57(34.3) 1 <50% 13(28.9) 38(22.9) 0.72(0.30–1.70) 50% 18(40.0) 71(42.8) 0.97(0.44–2.12) >50% * ** *** p < .05, p < .01, p < .001 Physical activity recommendation: moderate to vigorous activities for at least 30 min a day, for a minimum of 5 days a week Odds ratios are derived from univariable logistic regression analyses with adherence to the physical activity recommendation as dependent variable and one sociodemographic, health-related or psychological characteristic as independent variable Odds ratios are derived from a multivariable logistic regression analysis with adherence to the physical activity recommendation (yes vs. no) as dependent variable and all statistically significant (p < .05) sociodemographic, health-related, and psychological characteristics in the univariable logistic regression analyses as independent variables Odds ratio per 1 unit increase in the depressive symptoms subscale of the Hospital Anxiety and Depression Scale Odds ratio per 1 unit increase in the Cancer Worry Scale 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… Table 4 Demographic, health-related, behavior change and psychological characteristics of Lynch Syndrome patients (n = 211) and associations with adherence to the WCRF recommendation on red and processed meat intake [1] [[2]] [[3]] Non- Adherent Univariable Multivariable adherent N = 71 N = 140 N(%) N(%) OR(95%CI) OR(95%CI) Demographic characteristics Gender 82(58.6) 47(66.2) 1.39(0.76–2.51) Female 58(41.4) 24(33.8) 1 Male Age at measurement 48(34.3) 24(33.8) 1 21–43 years 49(35.0) 25(35.2) 1.02(0.51–2.03) 44–54 years 43(30.7) 22(31.0) 1.02(0.50–2.08) 55–73 years Education level Low 14(10.0) 6(8.5) 1 Medium 75(53.6) 32(45.1) 0.99(0.35–2.82) High 51(36.4) 33(46.5) 1.51(0.53–4.32) Partner 121(86.4) 66(93.0) 2.07(0.74–5.81) Yes 19(13.6) 5(7.0) 1 No Health-related characteristics Years since LS diagnosis 58(41.4) 24(33.8) 1 0–2 years 38(27.1) 25(35.2) 1.59(0.80–3.18) 2–4 years 44(31.4) 22(31.0) 1.21(0.60–2.43) 4–20 years Colon surgery 111(79.3) 62(87.3) 1 No surgery 29(20.7) 9(12.7) 1.80(0.80–4.04) Surgery Cancer in personal history Yes 55(39.3) 20(28.2) 0.61(0.33–1.13) No 85(60.7) 51(71.8) 1 Smoking status 19(13.6) 3(4.2) 1 Current smoker 59(42.1) 33(46.5) 3.54(0.98–12.9) Ex-smoker 62(44.3) 35(49.3) 3.58(0.99–12.9) Never smoker Behavior change and psychological characteristics Knowledge Yes 14(10.0) 16(22.5) 2.62(1.19– 2.62(1.19–5.74)* No 126(90.0) 55(77.5) 5.74)* 1 Awareness Yes 50(35.7) 29(40.8) 1.24(0.69–2.23) No 90(64.3) 42(59.2) 1 Symptoms of depression [Mean(SD)] [4] 2.87(3.13) 2.61(3.16) 0.97(0.89–1.07) Cancer worry [Mean(SD)] [5] 14.1(4.52) 13.2(3.48) 0.94(0.88–1.01) Cancer risk perception 46(32.9) 25(35.5) 1 <50% 32(22.9) 19(26.8) 1.09(0.52–2.31) 50% 62(44.3) 27(38.0) 0.80(0.41–1.56) >50% * ** *** p < .05, p < .01, p < .001 Meat intake recommendation: <500 g/w red meat, < 3 g/d processed meat Odds ratios are derived from univariable logistic regression analyses with adherence to the WCRF red and processed meat intake recomme- n dation (yes vs. no) as dependent variable and one sociodemographic, health-related or psychological characteristic as independent variable The independent variable Knowledge is the only variable that was statistically significantly (p < .05) associated with adherence to the WCRF red and processed meat intake recommendation (yes vs. no) in the univariable logistic regression analyses Odds ratio per 1 unit increase in the depressive symptoms subscale of the Hospital Anxiety and Depression Scale Odds ratio per 1 unit increase in the Cancer Worry Scale 1 3 M. Hoedjes et al. knowledge was found to be a statistically significant deter - of body weight, particularly among individuals with over- minant of the health behaviors physical activity and red and weight or obesity [42, 43]. Additionally, the sample size processed meat intake, but not for the outcome of health (n = 211) was too small to be able to enter all independent behaviors (body weight). variables into one multivariable logistic regression analyses The observed association between adherence to the body as the validated rule of thumb of a minimum of 10 partici- weight recommendation and educational level is in line with pants per independent categorical variable in the smallest previous research. A large Canadian cross-sectional study group would have been violated [44]. Therefore, only the examining determinants of adherence to WCRF recom- independent variables that were statistically significantly mendations in the general population, also found that higher associated with adherence were entered into the multivari- education attainment was associated with higher odds of able logistic regression analyses. It should also be noted adhering to the recommendation for body weight [38]. that we did not distinguish between different MMR genes It should be noted that most of the potential determi- in our statistical analyses, while the cumulative cancer risk nants of adherence included in this study did not show a and the risk of different cancer types differs according to statistically significant association with adherence to recom - MMR gene mutation type [7]. Since we found that having mendations on body weight, physical activity, and red and been diagnosed with (any type of) cancer was not associated processed meat intake. Contrary to our expectations, having with adherence this is not expected to influence our results. a cancer diagnosis in one’s personal medical history was not Finally, it should be noted that there are many more pos- found to be statistically significantly associated with adher - sible determinants of health behavior change that we did not ence. This seems to be in disagreement with the presumed incorporate in this study that may have influenced adher - window of opportunity for lifestyle change after a cancer ence. Such possible determinants include for example social diagnosis that has been described in the scientific literature and environmental factors, which should be incorporated in on health behavior change after a cancer diagnosis [39]. In future studies to provide a more comprehensive picture of addition, time after LS diagnosis also was not found to be the determinants of adherence to lifestyle recommendations statistically significantly associated with adherence. in LS patients. The results of this study confirm the importance of hav - Strengths and limitations ing knowledge about lifestyle recommendations and sug- gest that such knowledge should be promoted to achieve A strength of this first quantitative study on determinants of adherence. Our previous publication about the LiLy study adherence to WCRF lifestyle recommendations for cancer has shown that knowledge about lifestyle recommendations prevention in LS patients is the relatively large sample size can be increased by providing LS patients with WCRF- (n = 211) in relation to the number of LS patients (estimated NL health promotion materials [21]. Health care providers 10-year prevalence of 3.316 in the Netherlands) [40, 41]. involved in (follow-up) care for LS patients (such as genetic Other strengths include the extensive assessment of adher- counsellors, clinical geneticists, gastro-enterologists, gyn- ence to the recommendations and potential determinants aecologists) could easily incorporate providing WCRF-NL and the use of widely-used validated questionnaires. health promotion materials during counselling or surveil- Several limitations should be considered when interpret- lance visits with LS patients. Informing LS patients about ing the results of this study. Our study sample consisted lifestyle-related factors (including the preventive use of aspi- of LS patients who agreed to participate in a study about rin [45]) and cancer risk is in line with current guidelines for lifestyle and cancer risk (response rate 53%). LS patients LS patients [16]. Increasing knowledge, by providing health who participated were more likely to be older, female, and promotion materials or referring to online health education to have had a previous diagnosis of cancer compared with material (e.g., via the international and national websites of those who did not participate. Therefore, our study sample the WCRF such as www.wcrf.org), is an important first step may not be a representative sample of LS patients. In addi- to achieve adherence. When health care professionals pro- tion, our sample consisted of a relatively high proportion of vide these materials, this is in itself an additional behavior highly educated individuals, which may limit the generaliz- change technique (credible source) [46]. However, as our ability of our findings and may reflect an overestimation of previous study and many others have shown, health behav- the proportion of LS patients having knowledge about the ior change is not likely to be achieved by solely providing recommendations. Furthermore, while interpreting our find - information [21, 47]. Although information provision is an ings, it should be taken into account that adherence to life- important first step towards health behavior change, typi - style and body weight recommendations was assessed using cally, a combination of multiple behavior change techniques self-report questionnaires, which may have led to over- and strategies targeting a multitude of health behavior deter- reporting of healthy lifestyle behavior and under-reporting minants is needed to achieve and maintain health behavior 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… 3. Steinke V, Engel C, Büttner R, Schackert HK, Schmiegel WH, changes. Therefore, health care professionals treating LS Propping P (2013) Hereditary nonpolyposis colorectal cancer patients could refer to other health care professionals spe- (HNPCC)/Lynch syndrome. Deutsches Ärzteblatt International 110(3):32 cialized in health behavior change (such as a dietician, 4. Barrow E, Alduaij W, Robinson L et al (2008) Colorectal can- physical therapist, or a lifestyle coach). They could provide cer in HNPCC: cumulative lifetime incidence, survival and these additional behavior change techniques to achieve tumour distribution. A report of 121 families with proven health behavior changes and to improve health outcomes in mutations. Clin Genet Sep 74(3):233–242. doi:https://doi. org/10.1111/j.1399-0004.2008.01035.x LS patients. 5. Jenkins MA, Baglietto L, Dowty JG et al (2006) Cancer risks for mismatch repair gene mutation carriers: a population-based early onset case-family study. Clin Gastroenterol Hepatol Apr Conclusion 4(4):489–498. doi:https://doi.org/10.1016/j.cgh.2006.01.002 6. Quehenberger F, Vasen HF, van Houwelingen HC (2005) Risk of colorectal and endometrial cancer for carriers of mutations The results of this first quantitative study on determinants of of the hMLH1 and hMSH2 gene: correction for ascertainment. adherence to WCRF lifestyle and body weight recommen- J Med Genet Jun 42(6):491–496. doi:https://doi.org/10.1136/ dations among LS patients confirm that knowledge about jmg.2004.024299 7. Dominguez-Valentin M, Sampson JR, Seppala TT et al (Jan 2020) the recommendation is an important determinant for adher- Cancer risks by gene, age, and gender in 6350 carriers of patho- ence to the recommendations on physical activity and red genic mismatch repair variants: findings from the Prospective and processed meat intake. Results suggest that strategies to Lynch Syndrome Database. Genet Med 22(1):15–25. doi:https:// increase knowledge (e.g., providing health education mate- doi.org/10.1038/s41436-019-0596-9 8. International Mismatch Repair C (2021) Variation in the risk of rials) should be included in lifestyle promotion targeted at colorectal cancer in families with Lynch syndrome: a retrospec- LS patients, along with behavior change techniques influ - tive cohort study. lancet Oncol Jul 22(7):1014–1022. doi:https:// encing other modifiable determinants of adherence. doi.org/10.1016/S1470-2045(21)00189-3 9. Wiseman M, The Second World Cancer Research Fund/American Acknowledgements The World Cancer Research Fund (WCRF) Institute for Cancer Research Expert Report (2008). Food, Nutri- financially supported this study (grant number: SG2013/1019): http:// tion, Physical Activity, and the Prevention of Cancer: A Global www.wcrf.org. The funder had no role in study design, data collection Perspective: Nutrition Society and BAPEN Medical Symposium and analysis, decision to publish, or preparation of the manuscript. on ‘Nutrition support in cancer therapy’. Proceedings of the Nutrition Society. ;67(3):253–256 Data Availability Data is available upon request from the correspond- 10. Park JG, Park YJ, Wijnen JT, Vasen HF (1999) Gene-environ- ing author. ment interaction in hereditary nonpolyposis colorectal cancer with implications for diagnosis and genetic testing. Int J Cancer 82(4):516–519 Declarations 11. van Duijnhoven FJ, Botma A, Winkels R, Nagengast FM, Vasen HF, Kampman E (2013) Do lifestyle factors influence colorectal Competing interests The authors have declared no conflicting inter - cancer risk in Lynch syndrome? Fam Cancer 12(2):285–293 ests. 12. 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Determinants of adherence to recommendations on physical activity, red and processed meat intake, and body weight among lynch syndrome patients

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Abstract

This study aimed to identify determinants of adherence to lifestyle and body weight recommendations for cancer preven- tion among Lynch Syndrome (LS) patients. Cross-sectional baseline data of LS patients participating in the Lifestyle & Lynch (LiLy) study was used to assess determinants of adherence to the World Cancer Research Fund cancer prevention recommendations on body weight, physical activity, and red and processed meat intake. Adherence and potential deter- minants of adherence were assessed using questionnaires. Multivariable logistic regression analyses were conducted to identify determinants of adherence. Of the 211 participants, 50.2% adhered to the body weight recommendation, 78.7% adhered to the physical activity recommendation, and 33.6% adhered to the red and processed meat recommendation. Being younger and having a higher level of education were associated with adherence to the recommendation on body weight. Having knowledge about the recommendation was associated with adherence to the recommendations on physi- cal activity and red and processed meat. Results confirm that knowledge about recommendations for cancer prevention is an important determinant for adherence and suggest that strategies to increase knowledge should be included in lifestyle promotion targeted at LS patients, along with behavior change techniques influencing other modifiable determinants. Keywords Lynch Syndrome · Cancer prevention · Physical activity · Body weight · Red and processed meat intake · Determinants Introduction Worldwide, approximately 28,600 cases of LS are newly (2) diagnosed each year . LS is caused by a germline muta- Lynch syndrome (LS) is an inherited cancer syndrome tion in one of the mismatch repair (MMR) genes [2, 3]. LS characterized by a high hereditary risk of various cancers, patients have a risk of developing colorectal cancer (CRC) primarily in the colorectum and the endometrium [1]. between 22 and 69% up to age 70, as opposed to 1–5% in the general Western population [4–6]. Significant differ - ences have been reported in cumulative cancer risk and risk of different cancer types according to MMR gene mutation M Hoedjes type (MLH1, MSH2, MSH6 and PMS2) [7, 8]. The clinical m.hoedjes@tilburguniversity.edu phenotype of LS has been shown to vary between families, 1 countries, and continents [8], suggesting the importance of Center of Research on Psychological and Somatic the role of environmental and non-genetic factors, such as disorders, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000 LE Tilburg, The lifestyle-related factors [9], in the development of cancer Netherlands [10, 11]. In addition, low penetrance genetic risk factors Department for Health Evidence, Radboud university may be associated with the observed variety in cancer risk medical center, Nijmegen, The Netherlands among LS patients [12]. The influence of lifestyle-related Department of Clinical Genetics, Maastricht University factors on CRC among LS patients appears to be compa- Medical Center, Maastricht, The Netherlands rable or even stronger as compared with the general popula- Division of Human Nutrition and Health, Wageningen tion [11]. University, Wageningen, the Netherlands 1 3 M. Hoedjes et al. Studies investigating the association between lifestyle- patients. Data on non-changeable determinants associated related factors and the occurrence of sporadic cancer have with (non-)adherence (such as sociodemographic and cer- shown that lower levels of physical activity and higher body tain health-related determinants specific to LS, including fatness are associated with an increased risk of different cancer diagnosis in personal history and years since LS types of cancer, including CRC and endometrium cancer diagnosis) provides insight into which LS patients spe- [13]. Also, the intake of red and processed meat has been cifically should be targeted to improve adherence. Data on associated with an increased risk of sporadic CRC [13]. changeable determinants associated with (non-)adherence Among LS patients, lifestyle-related factors have also been provides insight into which modifiable determinants should associated with cancer risk. A recent systematic review be targeted for change and informs about what type of tech- has shown that early-adulthood overweight/obese weight niques or strategies can be used to positively influence these status and adulthood weight gain may be associated with changeable determinants. Such changeable determinants increased colorectal cancer risk in LS patients [14]. More- relevant for LS patients include psychological determi- over, a recent meta-analysis has shown that obesity has nants, such as cancer worry and symptoms of depression. been associated with an increased risk for colorectal can- These psychological determinants have been associated cer, but only in men with LS [15]. Furthermore, reviews of with unfavorable lifestyle behaviors in previous studies [23, the current literature among LS patients have shown that 24]. Besides, behavior change concepts that are frequently high fruit intake and physical activity have been associated included in theories and models of health behavior change with decreased colorectal cancer risk [14], whereas smok- are knowledge (about the recommendations) and aware- ing and alcohol consumption have been associated with an ness (of the influence of lifestyle-related factors on cancer increased colorectal cancer risk in LS patients [16]. risk) [25]. Knowledge and awareness have been shown to Based on a large body of scientific evidence for these be determinants of health behavior in other populations [26, observed associations, the World Cancer Research Fund 27]. (WCRF) has issued lifestyle and body weight recommen- The aim of this cross-sectional study was to explore dations for cancer prevention [13]. Cancer survivors (i.e. demographic, health-related, behavior change and psycho- those who have been diagnosed with cancer including logical determinants for adherence to body weight, physical those who have recovered) are also recommended to meet activity, and red and processed meat intake recommenda- these lifestyle and body weight recommendations for can- tions among LS patients, as these specific recommendations cer prevention. Meeting these recommendations has been are relevant for LS-related types of cancer (CRC, endome- associated with favorable health-outcomes, such as a higher trium) [13]. health-related quality of life, and a decreased risk for type II diabetes mellitus, cardiovascular disease, second primary cancers, cancer recurrences, and mortality [17–20]. Current Methods guidelines from the European Hereditary Tumour Group (EHTG) and European Society of Coloproctology (ESCP) Study design advise health care providers to inform LS patients about the observed associations between lifestyle, body weight and This study uses cross-sectional, baseline data (n = 218) from the risk of cancer [16]. the Lifestyle & Lynch (LiLy) study, a randomized con- We previously found that adherence to WCRF lifestyle trolled trial to test the effect of providing LS patients with and body weight recommendations in LS patients is low and WCRF-NL health promotion materials of the WCRF cancer that providing WCRF health promotion materials increased prevention recommendations [21]. awareness of and knowledge about WCRF recommenda- tions, without increasing psychological distress. However, Participants and procedure this did not affect adherence [ 21]. Little is known on how adherence to these recommendations can best be promoted. The LiLy study recruited participants between April and Insight into determinants of health behaviors among LS September 2015 at Radboud University Medical Center and patients is needed to be able to identify what techniques and Maastricht University Medical Centre. LS patients aged strategies can be used to achieve health behavior changes between 18 and 65 years were eligible for participation if LS in this specific patient population. Apart from our previous diagnoses was confirmed by a germline pathogenic variant qualitative study on determinants of adherence to lifestyle in one of the MMR-genes (MLH1, MSH2, MSH6 or PMS2). and body weight recommendations among LS patients [22], LS patients were excluded from participation if they had to our knowledge, no other study has examined determi- insufficient understanding of the Dutch language or if they nants of adherence or health behavior change among LS were participating in the GeoLynch study, a prospective 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… cohort study among LS patients, to prevent interference Red and processed meat between both studies [28]. Since only 4% of eligible LS patients participated in the GeoLynch study, this is unlikely Intake of red and processed meat was measured with an to have biased the results of this study. More information on adjusted version of a 40-item, validated Food Frequency the LiLy study can be found elsewhere [21]. Questionnaire (FFQ) specifically developed to assess adher - After informed consent was obtained, eligible LS patients ence to the Dutch Guidelines for a healthy diet [31]. Items were asked to fill in the baseline questionnaire, which took assessing red meat intake (grams per week) and processed approximately 45 min to complete. The medical ethical meat intake (grams per week) during the last month were research committees of the Radboud University Medical used to determine adherence to the recommendation on Center and Maastricht University Medical Centre granted red and processed meat intake. When red meat intake was permission to perform this study. < 500 g/w, of which processed meat was < 3 g/d, participants were considered to adhere to the recommendation on red Measures and processed meat intake. Adherence to the WCRF recommendations Demographic and health-related characteristics For this study, adherence to the WCRF recommendations Demographic characteristics were assessed using the base- on physical activity, body weight, and red and processed line questionnaire, which included items on age, gender, meat intake were included. These recommendations were marital status, and education. Clinical characteristics were included as these are relevant for LS-related types of cancer assessed using the same questionnaire by items on personal (CRC, endometrium) [13] and the smallest group of each of and family cancer history, colon surgery (colectomy, hemi- these dichotomous outcome variables (adherence vs. non- colectomy, colon resection), time since LS diagnosis, and adherence to these recommendations) was large enough to smoking behaviour. be able to be incorporated into the statistical analyses given the sample size (n = 211)[29]. Behavior change and psychological characteristics Body weight Awareness Awareness of the cancer risk factors as described in the WCRF/AICR recommendations for cancer preven- Self-reported body weight and height were used to calcu- tion (referred to as awareness of the WCRF/AICR recom- lated Body Mass Index (BMI) (kg/m ). Participants were mendations) was assessed using a question from the AICR categorised into the following BMI categories: <18.5; Cancer Risk Awareness Survey: “Do the following factors 25-<30;18.5-<25; and > 30 kg/m . The category 18.5– have a significant influence on whether or not the average 24.9 kg/m was considered as adherent to the body weight person develops cancer?”. recommendation. The other categories were considered not From the exposures that were mentioned in the entire to be adherent to the body weight recommendation. Awareness questionnaire reflecting all recommendations, only the exposures related to the recommendations on body Physical activity weight, insufficient physical activity, and red and processed meat intake were included for the current study. For each Adherence to the physical activity recommendation was exposure, answer options were: “yes, a big influence”; “yes, assessed using the validated Short Questionnaire to Assess a small influence”; “no”; and “I do not know”. Participants Health Enhancing Physical Activity (SQUASH) question- with correct answers, indicating that the exposures were of naire, which contains questions about multiple activities influence, were considered to be aware of the specific can - referring to a normal week in the past month. Results were cer risk factors while participants with answers “no” and “I converted to time spent on light, moderate, and vigorous do not know“ were considered to be unaware. activities, which were then converted to activity scores [30]. Knowledge Knowledge of the WCRF recommendations on When the number of moderate and vigorous exercise activi- body weight, physical activity, and red and processed meat ties was at least 30 min a day, for a minimum of 5 days a intake was assessed using 3 multiple choice questions; 1 for week, patients were categorized as adherent to the physical each recommendation. These knowledge questions required activity recommendation. more detailed content-specific knowledge about the rec - ommendations. For example, the multiple choice question “What is the minimally recommended amount of time a day you should be spending on physical activity according to the 1 3 M. Hoedjes et al. recommendations for cancer prevention?”, assessed knowl- years. Time since LS diagnosis was categorized into the fol- edge about the physical activity recommendation. The 5 lowing categories: 0–2 years; 2–4 years; and 4–20 years. answer options included: “A recommendation regarding First, univariable logistic regression analyses were con- physical activity and cancer risk does not exist”; “A mini- ducted with adherence to one of the WCRF recommenda- mum of 30 minutes physical activity per day of moderate tions on body weight, physical activity, or red and processed intensity (meaning an increased breath and heart rate)”; “A meat intake as dependent dichotomous variable, and a single minimum of 60 minutes physical activity per day of moder- potential determinant as independent variable. The follow- ate intensity”; “A minimum of 90 minutes physical activity ing potential demographic determinants were included as per day of moderate intensity”; “I don’t know”. Participants independent variables: gender (male, female); age (21–43, with correct answers were considered to have knowledge 44–54, and 55–73 years), education level (low, medium, about the respective recommendation. high), and marital status (partner, no partner). The following Cancer risk perception Cancer risk perception was assessed potential health-related determinants were included: years by two standardized questions. Participants were asked to since LS diagnosis (0–2 years, 2–4 years, and 4–20 years), express their perceived cancer risk in a percentage between colon surgery (yes, no), personal cancer history (yes, no), 0 and 100. In addition they were asked to choose one out and smoking status (current, ex-, never smoker). The fol- of 5 categories: ranging from a very low to a very high per- lowing potential psychological determinants were included: ceived cancer risk [32]. awareness (yes, no) and knowledge of the recommenda- Symptoms of depression Symptoms of depression were tions (yes, no), symptoms of depression (continuous), can- measured by using the Dutch version of the Hospital Anxi- cer worry (continuous), and cancer risk perception (< 50%, ety and Depression Scale (HADS) [33]. The HADS consists 50%, > 50%). of 14 items assessing self-reported symptoms of anxiety (7 Subsequently, multivariable logistic regression analy- items) and depression (7 items) in the past week. Each item ses were conducted with adherence to each recommenda- is scored on a 4-point Likert scale, ranging from 0 to 3, with tion as dependent variable, and as independent variables all higher scores indicating more symptoms. For the current socio-demographic, health-related, and psychological char- study, only scores for symptoms of depression were used acteristics that were found to be statistically significantly (because of the conceptual overlap with cancer worry). A associated with adherence in the univariable logistic regres- total score can be calculated for symptoms of depression by sion analyses. adding up the scores on the 7 items. This total score ranges Statistical analyses were performed using IBM SPSS from 0 to 21, with higher scores indicating more symptoms Statistics for Windows, version 24. P-values < 0.05 were [33]. considered to be statistically significant. Cancer worry Cancer worry was assessed using the Can- cer Worry Scale (CWS), consisting of 8 items. The reli- ability and validity has shown to be good among breast and Results colorectal cancer survivors [34, 35]. The total score ranges between 8 and 32, with higher scores corresponding to more Of the 218 LS patients who agreed to participate in the cancer worry. study, seven participants with missing data on one or more of the variables were excluded and 211 were included in the Statistical analyses population for analysis. Participants were aged between 21 and 73 years (mean 48.2; SD 10.9), and 61.1% was female The population for analysis consisted of participants with (N = 129) (Table 1). The number of years since LS diagnosis complete baseline data. Participants with missing data on ranged between 0 and 20 years (mean 3.7; SD 2.7). 18% one or more of the variables included in the analyses were had had a type of colon surgery (colectomy n = 7, hemico- excluded from the analyses. lectomy n = 24, colon resection n = 7). Means with standard deviations (SD) and frequency The majority of participants were aware of the influence tables were used to describe potential socio-demographic, of or had knowledge about the recommendation on body health-related, and psychological determinants. Since the weight (73% and 64.5%, respectively) and physical activity variables ‘age’ and ‘time since LS diagnosis’ were not nor- (66.8% and 64.5%, respectively) in relation to cancer risk. mally distributed, these variables were incorporated in the Much less participants were aware of the influence of or had statistical analyses as categorical variables. Age was catego- knowledge about the recommendation on red and processed rized into the following categories based on the observed meat intake in relation to cancer risk (37.4% and 14,2%, data distribution: 21–43 years; 44–54 years; and 55–73 respectively). 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… Table 1 Demographic, health- Total Cancer in per- No cancer in related, behavior change and (n = 211) sonal history personal history psychological characteristics N (%)* (n = 75) (n = 136) in Lynch Syndrome patients N(%)* N(%)* (n = 211) Demographic characteristics Gender 129(61.1) 45(60.0) 84(61.8) Female 82(38.9) 30(40.0) 52(38.2) Male Age at measurement 72(34.1) 10(13.3) 62(45.6) 21–43 years 74(35.1) 34(45.3) 40(29.4) 44–54 years 65(30.8) 31(41.3) 34(25.0) 55–73 years Educational level Low 20(9.5) 7(9.3) 13(9.6) Medium 107(50.7) 43(57.3) 64(47.1) High 84(39.8) 25(33.3) 59(43.4) Partner 187(88.6) 9(12.0) 15(11.0) Yes 24(11.4) 66(88.0) 121(89.0) No Health-related characteristics Years since LS diagnosis 82(38.9) 27(36.0) 55(40.4) 0–2 years 63(29.9) 18(24.0) 45(33.1) 2–4 years 66(31.3) 30(40.0) 36(26.5) 4–20 years Colon surgery 173(82.0) 38(50.7) 135(99.3) No colon surgery 38(18.0) 37(49.3) 1(0.7) Colon surgery Smoking status 22(10.4) 8(10.7) 14(10.3) Current smoker 92(43.6) 40(53.3) 52(38.2) Ex-smoker 97(46.0) 27(36.0) 70(51.5) Never smoker Behavior change and psychological characteristics Knowledge Weight recommendation Yes 111(52.6) 41(54.7) 70(51.5) No 100(47.4) 34(45.3) 66(48.5) Physical activity recommendation 136(64.5) 50(66.7) 86(63.2) Yes 75(35.5) 25(33.3) 50(36.8) No Meat intake recommendation 30(14.2) 10(13.3) 20(14.7) Yes 181(85.8) 65(86.7) 116(85.3) No Awareness Influence of overweight on cancer risk Yes 154(73.0) 56(74.7) 98(72.1) No 57(27.0) 19(25.3) 38(27.9) Influence of physical activity on cancer risk 141(66.8) 52(69.3) 89(65.4) Yes 70(33.2) 23(30.7) 47(34.6) No Influence of meat intake on cancer risk 79(37.4) 35(46.7) 44(32.4) Yes 132(62.6) 40(53.3) 92(67.6) No Symptoms of depression [Mean(SD)] 2.78(3.13) 3.4(3.4) 2.4(3.0) Cancer worry [Mean(SD)] 13.8(4.22) 15.1(4.6) 13.1(3.8) Cancer risk perception 71(33.6) 24(32.0) 47(34.6) <50% 51(24.2) 16(21.3) 35(25.7) *Unless otherwise specified; 50% 89(42.2) 35(46.7) 54(39.7) M = mean; SD = standard devia- >50% tion; BMI = Body Mass Index Of the 211 participants, 35.5% had a cancer diagnosis in diagnosed with colorectal cancer, 17 with endometrium can- their personal medical history (n = 75), of which 37 had been cer, 4 with both colorectal and endometrium cancer, and 17 1 3 M. Hoedjes et al. with other types of cancer. Compared with LS patients with- Discussion out a cancer diagnosis in their personal history, LS patients with a cancer diagnosis were older (p < .000), had more This first quantitative explorative study on determinants of often had a type of colon surgery (p < .000), were more fre- adherence to WCRF lifestyle and body weight recommen- quently aware of the influence of meat intake on cancer risk dations for cancer prevention in LS patients showed that (p = .04), and had a higher mean score of depressive symp- knowledge about the recommendations was a statistically toms (p = .037) and cancer worry (p = .001). See Table 1. significant determinant of adherence to the lifestyle recom - mendations on physical activity and red and processed meat Adherence to the recommendations intake. Being younger and having a higher level of educa- tion were associated with adherence to the recommendation Out of the 211 LS patients, 50.2% adhered to the body on body weight. weight recommendation, 78.7% adhered to the physical Adherence to the body weight recommendation among activity recommendation, and 33.6% adhered to the red and LS patients in the current study was comparable to adher- processed meat intake recommendation. ence in the general Dutch population in which 50% of those aged 18 and older adhered to the body weight recommenda- Determinants of adherence tion [36]. As compared to an observational study in Dutch colorectal cancer survivors, adherence to the recommen- Body weight recommendation dations on body weight (50% vs. 34%), physical activity (78.7% vs. 73%), and red and processed meat (33.6% vs. The univariable logistic regression analyses showed that age 8%) was higher in the LS patients participating in the cur- 44–54 vs. <44 years, medium and high vs. low educational rent study [37]. level, and symptoms of depression were associated with To our knowledge, no other studies have quantitatively adherence to the body weight recommendation (Table 2). investigated determinants of adherence to lifestyle and In the multivariable analyses, only age 44–54 vs. <44 body weight recommendations in LS patients. The results years (OR 0.48, 95% CI: 0.24–0.94) and medium (OR of this first quantitative exploration of determinants of 4.55, 95% CI: 1.34–15.5) and high (OR 6.41, 95% CI: adherence are in accordance with our previous qualita- 1.83–22.5) vs. low educational level remained statistically tive findings showing that having knowledge about the significantly associated with adherence to the body weight recommendations serves as a cue to action for adherence recommendation. to lifestyle recommendations in LS patients [22]. Knowl- edge is incorporated as a determinant in multiple frequently Physical activity recommendation used theories and models of health behavior change (e.g., the theory of planned behavior, the Health Belief Model, The univariable logistic regression analyses showed that Social Cognitive Theory) [25]. In this study, knowledge was age 55–73 vs. <44 years, ex-smoking vs. current smoking, found to be a determinant of adherence to the recommen- and having vs. not having knowledge about the physical dations on health behaviors (physical activity and red and activity recommendation were associated with adherence to processed meat intake), but not of adherence to the body the physical activity recommendation (Table 3). weight recommendation. These findings may be explained In the multivariable analyses, only having knowledge by the theoretical proximity of the determinant knowledge about the physical activity recommendation remained sta- to a certain health behavior (such as physical activity or tistically significantly associated with adherence to this rec - red and processed meat intake) as opposed to an outcome ommendation (OR 2.04, 95% CI: 1.04; 3.98). of multiple lifestyle behaviors (body weight). Considering that adherence to the body weight recommendation is sub- Red and processed meat intake recommendation ject to adherence to recommendations on energy balancing behaviors (physical activity, sedentary behavior, and dietary The univariable logistic regression analyses showed that intake), it seems plausible that knowledge is a more proxi- only having vs. not having knowledge about the red and mal determinant of health behaviors and a more distal deter- processed meat intake recommendation was associated with minant of adherence to the body weight recommendation adherence to the red and processed meat recommendation (outcome of the health behaviors physical activity and diet (Table 4; OR 2.62, 95% CI: 1.19; 5.74). quality). In other words, it makes sense that it’s more dif- ficult to influence (the result of) multiple lifestyle behaviors just by increasing knowledge than it is to influence a single lifestyle behavior. Hence, this could explain our finding that 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… Table 2 Demographic, health-related, behavior change and psychological characteristics of Lynch Syndrome patients (n = 211) and associations with adherence to the WCRF recommendation on body weight [1] [[2]] [[3]] Non- Adherent Univariable Multivariable adherent N = 106 N = 105 N(%) N(%) OR(95%CI) OR(95%CI) Demographic characteristics Gender 59(56.2) 70(66.0) 1.52(0.87–2.65) Female 46(43.8) 36(34.0) 1 Male Age at measurement 28(26.7) 44(41.5) 1 1 21–43 years 43(41.0) 31(29.2) 0.46(0.24– 0.48(0.24–0.94)* 44–54 years 34(32.4) 31(29.2) 0.89)* 0.86(0.41–1.79) 55–73 years 0.58(0.29–1.14) Education level Low 16(15.2) 4(3.8) 1 1 Medium 56(53.3) 51(48.1) 3.64(1.14– 4.55(1.34–15.5)* High 33(31.4) 51(48.1) 11.6)* 6.41(1.83– 6.18(1.90– 22.5)** 20.1)** Partner 97(92.4) 90(84.9) 0.46(0.19–1.14) Yes 8(7.6) 16(15.1) 1 No Health-related characteristics Years since LS diagnosis 35(33.3) 47(44.3) 1 0–2 years 33(31.4) 30(28.3) 0.68 2–4 years 37(35.2) 29(27.4) (0.35–1.31) 4–20 years 0.58(0.30–1.12) Colon surgery 81(77.1) 92(86.8) 1 No surgery 24(22.9) 14(13.2) 1.95(0.94–4.02) Surgery Cancer in personal history Yes 44(41.9) 31(29.2) 0.57(0.32–1.01) No 61(58.1) 75(70.8) 1 Smoking status 12(11.4) 10(9.4) 1 Current smoker 54(51.4) 38(35.8) 0.84(0.33–2.15) Ex-smoker 39(37.1) 58(54.7) 1.79(0.70–4.53) Never smoker Behavior change and psychological characteristics Knowledge Yes 55(52.4) 50(47.2) 1.02(0.59–1.75) No 50(47.6) 56(52.8) 1 Awareness Yes 76(72.4) 78(73.6) 1.06(0.58–1.95) No 29(27.6) 28(26.4) 1 Symptoms of depression[Mean(SD)] [4] 3.25(3.22) 2.32(2.98) 0.91(0.83– 0.94(0.85–1.03) 0.99)* Cancer worry [Mean(SD)] [5] 14.4(4.42) 13.3(3.95) 0.94(0.88-1.00) Cancer risk perception 39(37.1) 32(30.2) 1 <50% 27(25.7) 24(22.6) 1.08(0.53–2.23) 50% 39(37.1) 50(47.2) 1.56(0.83–2.93) >50% * ** *** p < .05, p < .01, p < .001 1 2 Body weight recommendation: Body Mass Index 18.5–24.9 kg/m Odds ratios are derived from univariable logistic regression analyses with adherence to the weight recommendation (yes vs. no) as dependent variable and one sociodemographic, health-related or psychological characteristic as independent variable Odds ratios are derived from a multivariable logistic regression analysis with adherence to the weight recommendation (yes vs. no) as depen- dent variable and all statistically significant (p < .05) sociodemographic, cancer-related, and health-related characteristics in the univariable logistic regression analyses as independent variables Odds ratio per 1 unit increase in the depressive symptoms subscale of the Hospital Anxiety and Depression Scale Odds ratio per 1 unit increase in the Cancer Worry Scale 1 3 M. Hoedjes et al. Table 3 Demographic, health-related, behavior change and psychological characteristics of Lynch Syndrome patients (n = 211) and associations with adherence to the WCRF recommendation on physical activity [1] [[2]] [[3]] Non- Adherent Univariable Multivariable adherent N = 166 N = 45 N(%) N(%) OR(95%CI) OR(95%CI) Demographic characteristics Gender 23(51.1) 106(63.9) 1.69(0.87–3.29) Female 22(48.9) 60(36.1) 1 Male Age at measurement 16(35.6) 56(33.7) 1 1 21–43 years 23(51.1) 51(30.7) 0.63(0.30–1.33) 0.54(0.25–1.19) 44–54 years 6(13.3) 59(35.5) 2.81(1.03– 2.44(0.85–6.97) 55–73 years 7.69)* Education level Low 3(6.7) 17(10.2) 1 Medium 22(48.9) 85(51.2) 0.68(0.18–2.54) High 20(44.4) 64(38.6) 0.57(0.15–2.13) Partner 42(93.3) 145(87.3) 0.49(0.14–1.73) Yes 3(6.7) 21(12.7) 1 No Health-related characteristics Years since LS diagnosis 22(48.9) 60(36.1) 1 0–2 years 12(26.7) 51(30.7) 1.56(0.70–3.46) 2–4 years 11(24.4) 55(33.1) 1.83(0.82–4.13) 4–20 years Colon surgery 33(73.3) 140(84.3) 1 No surgery 12(26.7) 26(15.7) 1.96(0.90–4.28) Surgery Cancer in personal history Yes 20(44.4) 55(33.1) 0.62(0.32–1.21) No 25(55.6) 111(66.9) 1 Smoking status 8(17.8) 14(8.4) 1 1 Current smoker 14(31.1) 78(47.0) 3.18(1.13-9.00)* 2.59(0.87–7.74) Ex-smoker 23(51.1) 74(44.6) 1.84(0.69–4.93) 1.72(0.60–4.95) Never smoker Behavior change and psychological characteristics Knowledge Yes 23(51.1) 113(68.1) 2.04(1.04– 2.22(1.09–4.52)* No 22(48.9) 53(31.9) 3.98)* 1 Awareness Yes 27(60.0) 114(68.7) 1.46(0.74–2.89) No 18(40.0) 52(31.3) 1 Symptoms of depression [Mean(SD)] [4] 3.42(2.86) 2.61(3.19) 0.93(0.84–1.02) Cancer worry [Mean(SD)] [5] 13.9 (4.68) 13.8(4.09) 0.99(0.92–1.07) Cancer risk perception 14(31.1) 57(34.3) 1 <50% 13(28.9) 38(22.9) 0.72(0.30–1.70) 50% 18(40.0) 71(42.8) 0.97(0.44–2.12) >50% * ** *** p < .05, p < .01, p < .001 Physical activity recommendation: moderate to vigorous activities for at least 30 min a day, for a minimum of 5 days a week Odds ratios are derived from univariable logistic regression analyses with adherence to the physical activity recommendation as dependent variable and one sociodemographic, health-related or psychological characteristic as independent variable Odds ratios are derived from a multivariable logistic regression analysis with adherence to the physical activity recommendation (yes vs. no) as dependent variable and all statistically significant (p < .05) sociodemographic, health-related, and psychological characteristics in the univariable logistic regression analyses as independent variables Odds ratio per 1 unit increase in the depressive symptoms subscale of the Hospital Anxiety and Depression Scale Odds ratio per 1 unit increase in the Cancer Worry Scale 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… Table 4 Demographic, health-related, behavior change and psychological characteristics of Lynch Syndrome patients (n = 211) and associations with adherence to the WCRF recommendation on red and processed meat intake [1] [[2]] [[3]] Non- Adherent Univariable Multivariable adherent N = 71 N = 140 N(%) N(%) OR(95%CI) OR(95%CI) Demographic characteristics Gender 82(58.6) 47(66.2) 1.39(0.76–2.51) Female 58(41.4) 24(33.8) 1 Male Age at measurement 48(34.3) 24(33.8) 1 21–43 years 49(35.0) 25(35.2) 1.02(0.51–2.03) 44–54 years 43(30.7) 22(31.0) 1.02(0.50–2.08) 55–73 years Education level Low 14(10.0) 6(8.5) 1 Medium 75(53.6) 32(45.1) 0.99(0.35–2.82) High 51(36.4) 33(46.5) 1.51(0.53–4.32) Partner 121(86.4) 66(93.0) 2.07(0.74–5.81) Yes 19(13.6) 5(7.0) 1 No Health-related characteristics Years since LS diagnosis 58(41.4) 24(33.8) 1 0–2 years 38(27.1) 25(35.2) 1.59(0.80–3.18) 2–4 years 44(31.4) 22(31.0) 1.21(0.60–2.43) 4–20 years Colon surgery 111(79.3) 62(87.3) 1 No surgery 29(20.7) 9(12.7) 1.80(0.80–4.04) Surgery Cancer in personal history Yes 55(39.3) 20(28.2) 0.61(0.33–1.13) No 85(60.7) 51(71.8) 1 Smoking status 19(13.6) 3(4.2) 1 Current smoker 59(42.1) 33(46.5) 3.54(0.98–12.9) Ex-smoker 62(44.3) 35(49.3) 3.58(0.99–12.9) Never smoker Behavior change and psychological characteristics Knowledge Yes 14(10.0) 16(22.5) 2.62(1.19– 2.62(1.19–5.74)* No 126(90.0) 55(77.5) 5.74)* 1 Awareness Yes 50(35.7) 29(40.8) 1.24(0.69–2.23) No 90(64.3) 42(59.2) 1 Symptoms of depression [Mean(SD)] [4] 2.87(3.13) 2.61(3.16) 0.97(0.89–1.07) Cancer worry [Mean(SD)] [5] 14.1(4.52) 13.2(3.48) 0.94(0.88–1.01) Cancer risk perception 46(32.9) 25(35.5) 1 <50% 32(22.9) 19(26.8) 1.09(0.52–2.31) 50% 62(44.3) 27(38.0) 0.80(0.41–1.56) >50% * ** *** p < .05, p < .01, p < .001 Meat intake recommendation: <500 g/w red meat, < 3 g/d processed meat Odds ratios are derived from univariable logistic regression analyses with adherence to the WCRF red and processed meat intake recomme- n dation (yes vs. no) as dependent variable and one sociodemographic, health-related or psychological characteristic as independent variable The independent variable Knowledge is the only variable that was statistically significantly (p < .05) associated with adherence to the WCRF red and processed meat intake recommendation (yes vs. no) in the univariable logistic regression analyses Odds ratio per 1 unit increase in the depressive symptoms subscale of the Hospital Anxiety and Depression Scale Odds ratio per 1 unit increase in the Cancer Worry Scale 1 3 M. Hoedjes et al. knowledge was found to be a statistically significant deter - of body weight, particularly among individuals with over- minant of the health behaviors physical activity and red and weight or obesity [42, 43]. Additionally, the sample size processed meat intake, but not for the outcome of health (n = 211) was too small to be able to enter all independent behaviors (body weight). variables into one multivariable logistic regression analyses The observed association between adherence to the body as the validated rule of thumb of a minimum of 10 partici- weight recommendation and educational level is in line with pants per independent categorical variable in the smallest previous research. A large Canadian cross-sectional study group would have been violated [44]. Therefore, only the examining determinants of adherence to WCRF recom- independent variables that were statistically significantly mendations in the general population, also found that higher associated with adherence were entered into the multivari- education attainment was associated with higher odds of able logistic regression analyses. It should also be noted adhering to the recommendation for body weight [38]. that we did not distinguish between different MMR genes It should be noted that most of the potential determi- in our statistical analyses, while the cumulative cancer risk nants of adherence included in this study did not show a and the risk of different cancer types differs according to statistically significant association with adherence to recom - MMR gene mutation type [7]. Since we found that having mendations on body weight, physical activity, and red and been diagnosed with (any type of) cancer was not associated processed meat intake. Contrary to our expectations, having with adherence this is not expected to influence our results. a cancer diagnosis in one’s personal medical history was not Finally, it should be noted that there are many more pos- found to be statistically significantly associated with adher - sible determinants of health behavior change that we did not ence. This seems to be in disagreement with the presumed incorporate in this study that may have influenced adher - window of opportunity for lifestyle change after a cancer ence. Such possible determinants include for example social diagnosis that has been described in the scientific literature and environmental factors, which should be incorporated in on health behavior change after a cancer diagnosis [39]. In future studies to provide a more comprehensive picture of addition, time after LS diagnosis also was not found to be the determinants of adherence to lifestyle recommendations statistically significantly associated with adherence. in LS patients. The results of this study confirm the importance of hav - Strengths and limitations ing knowledge about lifestyle recommendations and sug- gest that such knowledge should be promoted to achieve A strength of this first quantitative study on determinants of adherence. Our previous publication about the LiLy study adherence to WCRF lifestyle recommendations for cancer has shown that knowledge about lifestyle recommendations prevention in LS patients is the relatively large sample size can be increased by providing LS patients with WCRF- (n = 211) in relation to the number of LS patients (estimated NL health promotion materials [21]. Health care providers 10-year prevalence of 3.316 in the Netherlands) [40, 41]. involved in (follow-up) care for LS patients (such as genetic Other strengths include the extensive assessment of adher- counsellors, clinical geneticists, gastro-enterologists, gyn- ence to the recommendations and potential determinants aecologists) could easily incorporate providing WCRF-NL and the use of widely-used validated questionnaires. health promotion materials during counselling or surveil- Several limitations should be considered when interpret- lance visits with LS patients. Informing LS patients about ing the results of this study. Our study sample consisted lifestyle-related factors (including the preventive use of aspi- of LS patients who agreed to participate in a study about rin [45]) and cancer risk is in line with current guidelines for lifestyle and cancer risk (response rate 53%). LS patients LS patients [16]. Increasing knowledge, by providing health who participated were more likely to be older, female, and promotion materials or referring to online health education to have had a previous diagnosis of cancer compared with material (e.g., via the international and national websites of those who did not participate. Therefore, our study sample the WCRF such as www.wcrf.org), is an important first step may not be a representative sample of LS patients. In addi- to achieve adherence. When health care professionals pro- tion, our sample consisted of a relatively high proportion of vide these materials, this is in itself an additional behavior highly educated individuals, which may limit the generaliz- change technique (credible source) [46]. However, as our ability of our findings and may reflect an overestimation of previous study and many others have shown, health behav- the proportion of LS patients having knowledge about the ior change is not likely to be achieved by solely providing recommendations. Furthermore, while interpreting our find - information [21, 47]. Although information provision is an ings, it should be taken into account that adherence to life- important first step towards health behavior change, typi - style and body weight recommendations was assessed using cally, a combination of multiple behavior change techniques self-report questionnaires, which may have led to over- and strategies targeting a multitude of health behavior deter- reporting of healthy lifestyle behavior and under-reporting minants is needed to achieve and maintain health behavior 1 3 Determinants of adherence to recommendations on physical activity, red and processed meat intake, and… 3. 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Journal

Familial Cancer – Springer Journals

Published: Apr 1, 2023

Keywords: Lynch Syndrome; Cancer prevention; Physical activity; Body weight; Red and processed meat intake; Determinants

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