J Cancer Surviv DOI 10.1007/s11764-014-0409-8
Accelerometer-assessed physical activity and sedentary time among colon cancer survivors: associations with psychological health outcomes Jeff K. Vallance & Terry Boyle & Kerry S. Courneya & Brigid M. Lynch
Received: 19 May 2014 / Accepted: 24 October 2014 # Springer Science+Business Media New York 2015
Abstract Purpose The purpose of this study was to determine associations of objectively assessed moderate-to-vigorous intensity physical activity (MVPA) and sedentary time with psychological health outcomes including depression symptoms, anxiety symptoms, and overall satisfaction with life in colon cancer survivors. Methods Colon cancer survivors (N=180) from Alberta, Canada (n=91), and Western Australia (n=89) completed a mailed survey that assessed depression symptom severity, state anxiety, and satisfaction with life (SWL). Sedentary time and MVPA were assessed using the Actigraph® GT3X+ accelerometer (60-s epochs) via a 7-day monitoring protocol. MVPA and sedentary time were corrected for wear time and then examined as quartiles (Q). Multivariate analysis of variance was used to examine associations of MVPA and sedentary time with psychological health. Results There was a significant association between psychological health outcomes and objectively assessed MVPA J. K. Vallance (*) Faculty of Health Disciplines, Athabasca University, 1 University Drive, AB, Athabasca T9S 3A3, Canada e-mail: [email protected] T. Boyle Epidemiology Group, Harry Perkins Institute for Medical Research, The University of Western Australia, Perth, Australia K. S. Courneya Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada B. M. Lynch Physical Activity Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia B. M. Lynch Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
[Wilks’ λ=0.886, F(3382.2)=2.156, p=0.024] that suggested a small and significant association between MVPA and SWL (p=0.032). A significant multivariate analysis of variance (MANOVA) [Wilks’ λ=0.945, F(3159)=3.1, p=0.028] suggested participants meeting guidelines reported significantly fewer anxiety symptoms (Mdiff =−1.23, p=0.027) and higher perceptions of SWL (Mdiff =3.0, p=0.008). No significant associations emerged for sedentary time [Wilks’ λ=0.956, F(9382.3)=0.788, p=0.628]. Conclusions Contrary to previously published research using self-reports, objectively assessed MVPA and sedentary time were not associated with depression symptoms. Objectively assessed MVPA was associated with SWL and anxiety outcomes in colon cancer survivors. Implications for Cancer Survivors Colon cancer survivors should continue to engage in regular and sustained MVPA for the accrual of psychological health benefits. Keywords Physical activity . Sedentary time . Psychological health . Colon cancer . Accelerometer
Introduction A colorectal cancer diagnosis and related treatments are associated with increased psychological distress. Several studies of colorectal cancer survivors suggest a high prevalence of both depression [1, 2] and anxiety [3, 4]. In this group, it is estimated that the overall prevalence of psychological distress ranges between 44 and 32 % [5]. Physical activity is a safe and effective intervention to facilitate favorable psychosocial health outcomes across various cancer survivor groups [6]. However, all cross-sectional studies to date have exclusively utilized self-report measures of physical activity. Self-report estimates of these behaviors are prone to measurement error that often leads to incorrect
J Cancer Surviv
inferences about physical activity behaviors (and associated outcomes) and may bias study results [7]. Objective activity monitoring, using accelerometers and inclinometers, provides the means for precise estimates of physical activity. To date, no studies have examined objectively assessed physical activity and psychological health among colon cancer survivors. New evidence has suggested that sedentary behavior is a health risk, even for physically active individuals [8]. This risk likely extends to cancer survivors as well [9]. Not to be confused with physical inactivity (i.e., not meeting physical activity guidelines), sedentary behaviors are performed in a seated or reclining posture and require very low energy expenditure (≤1.5 metabolic equivalents) [10, 11]. In a recently published commentary, we noted that cancer survivors spend over two thirds of their waking hours in sedentary behaviors [9]. While no studies have considered associations between sedentary behavior and psychological health in the cancer context, objectively assessed sedentary behavior has been linked to depression in the general population [12]. The primary objective of this study was to determine associations of objectively assessed moderate-to-vigorous intensity physical activity (MVPA) with psychological health outcomes including depression symptoms, anxiety symptoms, and overall satisfaction with life, among colon cancer survivors. The secondary objectives were to determine (a) associations of objectively assessed sedentary time with psychological health and (b) whether meeting physical activity guidelines (i.e., engaging in at least 150 min of MVPA per week, accumulated in bouts of at least 10 min) were associated with depression symptoms, anxiety symptoms, and satisfaction with life, and (c) whether prolonged bouts of sedentary time (i.e., total sedentary time accumulated in at least 30-min bouts) were associated with depression symptoms, anxiety symptoms, and satisfaction with life. We hypothesized objectively assessed MVPA and sedentary time would be significantly associated with fewer depression symptoms, anxiety symptoms, and higher satisfaction with life.
Method Participants The methods of this cross-sectional study have been described in detail elsewhere [13]. Briefly, colon cancer survivors were recruited through the Alberta Cancer Registry (Alberta, Canada) and the Western Australia (WA) Cancer Registry. The study was approved by local ethics boards at Alberta Health Services, Athabasca University, and the Department of Health WA and The University of WA. The Alberta Cancer Registry and the WA Cancer Registry identified colon cancer survivors with histologically confirmed diagnosis of a first, primary colon cancer. Eligibility
criteria included speaking English and being between the ages of 18 and 80. Eligible survivors had to (a) not be currently undergoing any adjuvant therapy, (b) be able to understand and provide written informed consent, and (c) be willing and able to wear an accelerometer for 7 days. The recruitment protocol for the two study sites was identical. Registry procedures Survivors were mailed a study invitation package containing (1) a letter from the registry describing the role of the registry in this study and the general purpose of the registry and (2) an invitation letter from the research team explaining the nature of the research study and what would be required of the participant. Survivors received a follow-up reminder postcard 2 weeks after the initial mailout. Participants were then sent a package containing a survey, one Actigraph® GT3X+ accelerometer (Actigraph, LLC, Pensacola, FL), a detailed instructional pamphlet describing how to use the accelerometer, an accelerometer diary (for the participant to record when accelerometer was taken off and put on), and a postage-paid priority post return envelope. Measures The Alberta Cancer Registry provided participants’ date of diagnosis, age at diagnosis, stage, and types of treatments received. In WA, date of diagnosis and stage were provided by the WA Cancer Registry while treatment information was gathered from the participant via self-report. Demographic and medical information including sex, age, employment, marital status, income, education, ethnicity, height and weight, and comorbidities were collected via self-report. MVPA and sedentary time were derived from an Actigraph GT3X+ accelerometer. This instrument records acceleration using a triaxial accelerometer. Participants were provided with the accelerometer and instructed to wear it on their right hip attached by an elastic belt during all waking hours for seven consecutive days. Participants were asked to record, in a daily log, the time they put on and took off the monitor each day. Participants returned their accelerometer, survey, and logbook to the study coordinators by express post. A pragmatic cutoff of 20,000 counts/min).
J Cancer Surviv
Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) [16, 17]. The PHQ-9 scores each of the nine DSM-IV criteria, and item responses range from “0” (not at all) to “3” (nearly every day). Participants were asked, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” for each of the nine DSM-IV criteria, which included such items as “feeling tired or having little energy” and “feeling down, depressed, or hopeless.” Symptoms were considered present if reported for at least “more than half the days” or at least “several days” in the case of “thoughts that you would be better off dead or of hurting yourself in some way.” In this study, the PHQ-9 was used as a screener to monitor depression symptom severity. To obtain the symptom severity index, item responses were] summed for a total score. Total scores can be categorized as minimal depression (1–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19), and severe depression (20–27). A difference of 5 points on the PHQ-9 is considered a minimum important difference [18]. Anxiety State anxiety was assessed using Spielberger’s State Anxiety Inventory (SAI) [19]. The SAI contains 10 items that measures how participants feel at a particular time (e.g., “I feel calm,” “I am relaxed,” “I feel worried”). The SAI state scale is scored on four levels of anxiety intensity ranging from 1 (not at all) to 4 (very much so). Scores on the SAI range from 10 to 40 with lower anxiety scores indicating fewer feelings of anxiety experiences by the participant. Satisfaction with life Satisfaction with life (SWL) was assessed using Diener’s Satisfaction With Life Scale [20]. The SWLS is a short five-item instrument designed to measure global cognitive judgments of satisfaction with one’s life (e.g., “The conditions of my life are excellent,” “In most ways my life is close to my ideal”). Participants were asked to indicate their degree of agreement or disagreement on a scale ranging from 1 (strongly disagree) to 7 (strongly agree). Scores on the SWL scale range from 5 to 35 with higher scores indicating greater life satisfaction. Statistical analyses Descriptive statistics were used to examine the demographic, health, and medical characteristics of the sample. Multivariate analysis of variance (MANOVA) procedures were used to test for differences in depression and anxiety symptoms and SWL across quartiles of overall MVPA minutes. Participants were also classified as either meeting physical activity guidelines (i.e., both overall MVPA and MVPA accumulated in at least 10-min bouts) or not (i.e.,
Accelerometer-assessed physical activity and sedentary time among colon cancer survivors: associations with psychological health outcomes Jeff K. Vallance & Terry Boyle & Kerry S. Courneya & Brigid M. Lynch
Received: 19 May 2014 / Accepted: 24 October 2014 # Springer Science+Business Media New York 2015
Abstract Purpose The purpose of this study was to determine associations of objectively assessed moderate-to-vigorous intensity physical activity (MVPA) and sedentary time with psychological health outcomes including depression symptoms, anxiety symptoms, and overall satisfaction with life in colon cancer survivors. Methods Colon cancer survivors (N=180) from Alberta, Canada (n=91), and Western Australia (n=89) completed a mailed survey that assessed depression symptom severity, state anxiety, and satisfaction with life (SWL). Sedentary time and MVPA were assessed using the Actigraph® GT3X+ accelerometer (60-s epochs) via a 7-day monitoring protocol. MVPA and sedentary time were corrected for wear time and then examined as quartiles (Q). Multivariate analysis of variance was used to examine associations of MVPA and sedentary time with psychological health. Results There was a significant association between psychological health outcomes and objectively assessed MVPA J. K. Vallance (*) Faculty of Health Disciplines, Athabasca University, 1 University Drive, AB, Athabasca T9S 3A3, Canada e-mail: [email protected] T. Boyle Epidemiology Group, Harry Perkins Institute for Medical Research, The University of Western Australia, Perth, Australia K. S. Courneya Faculty of Physical Education and Recreation, University of Alberta, Edmonton, Canada B. M. Lynch Physical Activity Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia B. M. Lynch Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
[Wilks’ λ=0.886, F(3382.2)=2.156, p=0.024] that suggested a small and significant association between MVPA and SWL (p=0.032). A significant multivariate analysis of variance (MANOVA) [Wilks’ λ=0.945, F(3159)=3.1, p=0.028] suggested participants meeting guidelines reported significantly fewer anxiety symptoms (Mdiff =−1.23, p=0.027) and higher perceptions of SWL (Mdiff =3.0, p=0.008). No significant associations emerged for sedentary time [Wilks’ λ=0.956, F(9382.3)=0.788, p=0.628]. Conclusions Contrary to previously published research using self-reports, objectively assessed MVPA and sedentary time were not associated with depression symptoms. Objectively assessed MVPA was associated with SWL and anxiety outcomes in colon cancer survivors. Implications for Cancer Survivors Colon cancer survivors should continue to engage in regular and sustained MVPA for the accrual of psychological health benefits. Keywords Physical activity . Sedentary time . Psychological health . Colon cancer . Accelerometer
Introduction A colorectal cancer diagnosis and related treatments are associated with increased psychological distress. Several studies of colorectal cancer survivors suggest a high prevalence of both depression [1, 2] and anxiety [3, 4]. In this group, it is estimated that the overall prevalence of psychological distress ranges between 44 and 32 % [5]. Physical activity is a safe and effective intervention to facilitate favorable psychosocial health outcomes across various cancer survivor groups [6]. However, all cross-sectional studies to date have exclusively utilized self-report measures of physical activity. Self-report estimates of these behaviors are prone to measurement error that often leads to incorrect
J Cancer Surviv
inferences about physical activity behaviors (and associated outcomes) and may bias study results [7]. Objective activity monitoring, using accelerometers and inclinometers, provides the means for precise estimates of physical activity. To date, no studies have examined objectively assessed physical activity and psychological health among colon cancer survivors. New evidence has suggested that sedentary behavior is a health risk, even for physically active individuals [8]. This risk likely extends to cancer survivors as well [9]. Not to be confused with physical inactivity (i.e., not meeting physical activity guidelines), sedentary behaviors are performed in a seated or reclining posture and require very low energy expenditure (≤1.5 metabolic equivalents) [10, 11]. In a recently published commentary, we noted that cancer survivors spend over two thirds of their waking hours in sedentary behaviors [9]. While no studies have considered associations between sedentary behavior and psychological health in the cancer context, objectively assessed sedentary behavior has been linked to depression in the general population [12]. The primary objective of this study was to determine associations of objectively assessed moderate-to-vigorous intensity physical activity (MVPA) with psychological health outcomes including depression symptoms, anxiety symptoms, and overall satisfaction with life, among colon cancer survivors. The secondary objectives were to determine (a) associations of objectively assessed sedentary time with psychological health and (b) whether meeting physical activity guidelines (i.e., engaging in at least 150 min of MVPA per week, accumulated in bouts of at least 10 min) were associated with depression symptoms, anxiety symptoms, and satisfaction with life, and (c) whether prolonged bouts of sedentary time (i.e., total sedentary time accumulated in at least 30-min bouts) were associated with depression symptoms, anxiety symptoms, and satisfaction with life. We hypothesized objectively assessed MVPA and sedentary time would be significantly associated with fewer depression symptoms, anxiety symptoms, and higher satisfaction with life.
Method Participants The methods of this cross-sectional study have been described in detail elsewhere [13]. Briefly, colon cancer survivors were recruited through the Alberta Cancer Registry (Alberta, Canada) and the Western Australia (WA) Cancer Registry. The study was approved by local ethics boards at Alberta Health Services, Athabasca University, and the Department of Health WA and The University of WA. The Alberta Cancer Registry and the WA Cancer Registry identified colon cancer survivors with histologically confirmed diagnosis of a first, primary colon cancer. Eligibility
criteria included speaking English and being between the ages of 18 and 80. Eligible survivors had to (a) not be currently undergoing any adjuvant therapy, (b) be able to understand and provide written informed consent, and (c) be willing and able to wear an accelerometer for 7 days. The recruitment protocol for the two study sites was identical. Registry procedures Survivors were mailed a study invitation package containing (1) a letter from the registry describing the role of the registry in this study and the general purpose of the registry and (2) an invitation letter from the research team explaining the nature of the research study and what would be required of the participant. Survivors received a follow-up reminder postcard 2 weeks after the initial mailout. Participants were then sent a package containing a survey, one Actigraph® GT3X+ accelerometer (Actigraph, LLC, Pensacola, FL), a detailed instructional pamphlet describing how to use the accelerometer, an accelerometer diary (for the participant to record when accelerometer was taken off and put on), and a postage-paid priority post return envelope. Measures The Alberta Cancer Registry provided participants’ date of diagnosis, age at diagnosis, stage, and types of treatments received. In WA, date of diagnosis and stage were provided by the WA Cancer Registry while treatment information was gathered from the participant via self-report. Demographic and medical information including sex, age, employment, marital status, income, education, ethnicity, height and weight, and comorbidities were collected via self-report. MVPA and sedentary time were derived from an Actigraph GT3X+ accelerometer. This instrument records acceleration using a triaxial accelerometer. Participants were provided with the accelerometer and instructed to wear it on their right hip attached by an elastic belt during all waking hours for seven consecutive days. Participants were asked to record, in a daily log, the time they put on and took off the monitor each day. Participants returned their accelerometer, survey, and logbook to the study coordinators by express post. A pragmatic cutoff of 20,000 counts/min).
J Cancer Surviv
Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) [16, 17]. The PHQ-9 scores each of the nine DSM-IV criteria, and item responses range from “0” (not at all) to “3” (nearly every day). Participants were asked, “Over the last 2 weeks, how often have you been bothered by any of the following problems?” for each of the nine DSM-IV criteria, which included such items as “feeling tired or having little energy” and “feeling down, depressed, or hopeless.” Symptoms were considered present if reported for at least “more than half the days” or at least “several days” in the case of “thoughts that you would be better off dead or of hurting yourself in some way.” In this study, the PHQ-9 was used as a screener to monitor depression symptom severity. To obtain the symptom severity index, item responses were] summed for a total score. Total scores can be categorized as minimal depression (1–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19), and severe depression (20–27). A difference of 5 points on the PHQ-9 is considered a minimum important difference [18]. Anxiety State anxiety was assessed using Spielberger’s State Anxiety Inventory (SAI) [19]. The SAI contains 10 items that measures how participants feel at a particular time (e.g., “I feel calm,” “I am relaxed,” “I feel worried”). The SAI state scale is scored on four levels of anxiety intensity ranging from 1 (not at all) to 4 (very much so). Scores on the SAI range from 10 to 40 with lower anxiety scores indicating fewer feelings of anxiety experiences by the participant. Satisfaction with life Satisfaction with life (SWL) was assessed using Diener’s Satisfaction With Life Scale [20]. The SWLS is a short five-item instrument designed to measure global cognitive judgments of satisfaction with one’s life (e.g., “The conditions of my life are excellent,” “In most ways my life is close to my ideal”). Participants were asked to indicate their degree of agreement or disagreement on a scale ranging from 1 (strongly disagree) to 7 (strongly agree). Scores on the SWL scale range from 5 to 35 with higher scores indicating greater life satisfaction. Statistical analyses Descriptive statistics were used to examine the demographic, health, and medical characteristics of the sample. Multivariate analysis of variance (MANOVA) procedures were used to test for differences in depression and anxiety symptoms and SWL across quartiles of overall MVPA minutes. Participants were also classified as either meeting physical activity guidelines (i.e., both overall MVPA and MVPA accumulated in at least 10-min bouts) or not (i.e.,
