Introduction
Methods
Inclusion/exclusion criteria
Search methods
Data extraction
Data synthesis
Risk of bias assessment
Inter-rater agreement
Results
Search results
Studies’ characteristics and content
Studies | Sample | Design | Intervention | Dietary goal | Physical activity goal | Weight loss goal |
---|---|---|---|---|---|---|
Rock, 2015 (ENERGY trial) [40] | N = 692 | 2- arm: a group-based behavioural intervention & telephone counselling & tailored newsletters OR a less intensive control intervention | 6 months intensive phase: 4 months, 1 h weekly group sessions (av. 15 women/group) Next 2 months: 1 h group sessions every other week 6–12 months, monthly meetings. Every session followed by brief (10–15 min) personalised guidance delivered by tel and/or email 6–24 months: tailored newsletters | 500–1000 kcal deficit for a WL of 1–2 pounds/week by increasing high-fibre vegetables, whole grains & fruits | step-wise increase in time & intensity regular planned aerobic exercise, increased PA in the lifestyle & strength training Long-term goal: 60 min/day of moderate intensity purposeful exercise, 10,000 steps per day & 2–3 times/week strength training at home or an exercise facility | At least 7% of BW at 2 years |
Demark-Wahnefried, 2014 (DAMES trial) [41] | N = 68 dyads (breast cancer survivors & their daughters) | 3- arm: a tailored diet & exercise intervention delivered individually to mothers & daughters (individual) OR emphasised the mother-daughter bond (team) OR control group | Individual arm: individual weight goals plus tailored feedback about their nutrition vs national guidelines & 6 subsequent newsletters Team arm: Same material to those in the individual arm but mother & daughter received the material together | Lower calorie substitutes or provided guidance on portion control | Both interventions groups: 150 min per week of aerobic exercise and twice-weekly strength training | Not specified, personalised |
Mefferd, 2006 (HWM study) [42] | N = 85 | 2- arm: intervention OR wait-list group | 12 months duration: 16 weeks of weekly closed groups sessions followed by once-monthly session till 12 months | 500–1000 kcal deficit for a WL by increasing high-fibre vegetables, whole grains & fruits | Regular aerobic exercise with a step-wise increase in time and intensity Long-term goal of 1 h/day of moderate to vigorous PA & 2–3 times/week muscle strengthening | Not specified |
Djuric, 2002 [43] | N = 48 | 4- arm: control/Weight Watchers (WW)/individualised counselling/WW plus individualised counselling | Individualised arm: weekly sessions for the first 3 months, biweekly for 3–6 months & monthly thereafter, plus monthly packet of written information Comprehensive arm: individualised counselling plus weekly WW meetings without the monthly dietitian-led meetings | 500–1000 kcal deficit for a WL of 1–2 pounds/week, by decreasing energy & fat & increasing fibres. At least 5 servings/day fruits & vegetables. Target fat at 20–25% & protein up to 20% of total energy | 30–45 min/day moderate activity most days of the week | 10% at 6 months |
Sheppard, 2016 (Stepping Stone study) [44] | N = 31 | 2- arm: intervention VS usual care (control) | 12 weeks intervention: once biweekly a 90-min group sessions (30 min PA & 60 min education sessions) co-led by an exercise physiologist & a nutritionist, plus individual telephone (15 min) coaching sessions every other week | 1 pound of WL per week. Dietary recommendations: > 5 fruits and vegetables/day and < 35% kcal from total fat | Moderate intensity exercise of > 30 min/day, ≥ 5 days/week. PA goal of 10,000 steps/day for 12 weeks | 5% in 12 weeks |
Harrigan, 2016 (LEAN study) [45] | N = 100 | 3- arm: in-person counselling OR telephone counselling OR usual care (control) | Same intervention for both intervention groups: 6 months: 11 sessions (30-min counselling), (once weekly the first month, once biweekly the second & third month and once monthly for the months 4,5,6), by a RD specialised in oncology nutrition and trained in exercise physiology & behaviour modification counselling | 500 kcal energy deficit based on a dietary fat goal of < 25% of total energy intake, a plant-based diet reducing sugars and increasing fibre | Home based PA with a goal of 150 min per week moderate-intensity activity, such as brisk walking, with a daily target of 10,000 steps | 10% at 6 months |
Stolley, 2017 (Moving Forward trial) [46] | N = 246 | 2- arm: 6-months Moving Forward Interventionist—Guided program (MFG) OR the Moving Forward Self—Guided program (SG) | MFG included twice—weekly (for 26 weeks) in-person classes with supervised exercise & text messaging targeting self-efficacy | 500 kcal deficit by increasing fruit & vegetable consumption | Minimum ≥ 150 min per week | 5% at 6 months |
Santa-Maria, 2020 (POWER-remote trial) [47] | N = 87 | 2- arm: POWER-remote VS self-directed (control) | 12-month behavioural weight loss intervention (telephone-based coaching & use of a web-based self-monitoring and learning platform). A total of 21 phone calls: weekly for 3 months & monthly for 9 months (20 min calls per session) | 1200–2200 kcal/day energy intake depending on the body weight through DASH dietary pattern: 7–12 servings of fruits/vegetables, 2–3 servings of low fat dairy, reduced sodium & ≤ 25% of calories from fat | Built to ≥ 300 min/week of moderate intensity PA in bouts ≥ 10 min in length | At least 5% at 6 months |
Reeves, 2017 (Living Well after Breast Cancer trial) [48] | N = 90 | 2- arm: weight loss intervention (diet & PA) VS usual care (control) | 12 months phone-delivered intervention 6 months initial phase: A total of 16 phone calls (weekly for 6 weeks & 10 fortnightly calls) 6 months extended care phase: 6 monthly calls | 2000 kj (≈ 500 kcal) daily energy deficit aiming to ≤ 30% total fat, < 7% saturated fat, 5 servings/day vegetables, 2 servings/day fruits, limit alcohol intake & portion control | Gradually increased moderate intensity planned PA to at least 30-min/day (≥ 210 min/week). To increase incidental activity & to reduce sedentary behaviour | 5–10% at 6 months |
Schmitz, 2019 (WISER Survivor trial) [49] | N = 351 | 4- arm: Home-Based Exercise Intervention/Weight Loss Intervention/ Combined Intervention & Control | 12 months (52 weeks) home-based exercise program of strength training twice/week & 180 min/week walking along with 24 weeks nutritional counseling group sessions | Guidelines from ACS along with a meal replacement program (Nutrisystem) & 7 servings fruits and vegetables daily | Twice per week resistance exercise per 90-min class along with aerobic activity to 180 min per week | 10% at 6 months |
Goodwin, 2014 (LISA trial) [50] | N = 338 | 2- arm: individual lifestyle intervention (LI) VS mail-based education intervention (control) | 24 months telephone-based intervention: 6 months of the intensive (weekly for 4 weeks) & consolidation phase (fortnightly for 2–6 months) & 18 months of the maintenance phase (every 2 months for 7–12 and every 3 months for 12–24 months) | 500–1000 kcal deficit for a WL of 1–2 lbs/week, by decreasing fat to 20% of total intake & increasing fruits, vegetables & fibres | A gradual increase in moderate-intensity aerobic physical activity (walking for the majority of participants) to 150 to 200 min per week | 10% at 6 months |
Studies | 12 items TIDier |
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Rock [40] | Brief Name: Exercise and Nutrition to Enhance Recovery and Good Health for you (ENERGY) Trial WHY: To determine whether a behavioural WL intervention emphasizing increased PA and tailored to BCS would result in greater WL in the IG compared with a CG assigned to a less intensive intervention Theory: Social Cognitive Theory and Cognitive—Behavioural treatment of obesity, with Motivational Interviewing WHAT: Materials: Tailored print materials from previous trials with web-based resources, digital videos, pedometers and weight records. Procedures: The goal was a modest WL of at least 7% BW through behavioural goals such as reduced energy intake and increased physical activity, by personalized guidance WHO: leaders, who had backgrounds in dietetics, psychology and/or exercise physiology HOW: face-to-face group sessions, emails, telephone, newsletters WHERE: USA (University of California, San Diego [UCSD]; University of Colorado Denver; University of Alabama at Birmingham; and Washington University in St. Louis [WUSTL]) WHEN AND HOW MUCH: 6 months intensive phase: 4 months, 1 h weekly group sessions and next 2 months, 1 h group sessions every other week. 6–12 months: monthly meetings, followed by brief (10–15 min) personalised guidance delivered by tel and/or email. 6–24 months: tailored newsletters. Physical Activity: Step-wise increase to 60 min/day of moderate intensity purposeful exercise, 10,000 steps per day & 2–3 times/week strength training at home or an exercise facility TAILORING: individualize the feedback, goal setting, planning and follow-through for the behavioural goals, diet and PA MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Demark-Wahnefried [41] | Brief Name: Daughters and Mothers Against Breast Cancer (DAMES) trial WHY: endeavored to capitalize on the mother-daughter bond and the teachable moment created by a cancer diagnosis to promote weight loss in overweight or obese women recently diagnosed with breast cancer and their overweight or obese daughters Theory: Social Cognitive Theory & Transtheoretical model of behaviour change, plus concepts of independence theory and the theory of communal coping WHAT: Materials: workbook that was personalized with reinforced goals proposed by the ACS and the US dietary guidelines, 6 newsletters, logbooks, reference manuals, web sites, portion control tableware, iPods, shoes chips. Procedures: promoted portion control and diets high in nutrients and low in energy as well as 150 min per week of aerobic exercise and twice-weekly strength training WHO: Not described HOW: emails and newsletters WHERE: USA, Puerto Pico or Guam WHEN AND HOW MUCH: 6 months intervention and 6 months follow-up phase TAILORING: interventions differed with respect to tailoring MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Mefferd [42] | Brief Name: The Healthy Weight Management (HWM) Study WHY: The intervention incorporated CBT, emphasizing PA, diet modification to facilitate a modest reduction in energy intake, and strategies to improve body image and self-acceptance Theory: Cognitive Behavioural Therapy WHAT: Materials: food diaries, exercise logs, pedometers and intervention material. Procedures: 500–1000 kcal deficit for a WL by increasing high-fibre vegetables, whole grains & fruits and regular aerobic exercise with a step-wise increase in time and intensity (1 h/day of moderate to vigorous PA & 2–3 times/week muscle strengthening) WHO: trained investigators and research staff HOW: in-person group sessions and telephone contacts WHERE: USA (San Diego) WHEN AND HOW MUCH: 16 weeks of weekly closed groups sessions followed by once-monthly session till 12 months TAILORING: Individualized telephone counseling to individualize goal setting and assess progress MODIFICATIONS: None described HOW WELL (planned): Not described HOW WELL (actual): in appendix |
Djuric [43] | Brief Name: Randomized pilot study tested an individualized approach toward weight loss in obese Breast cancer survivors WHY: individualized counseling methods typically have not been used in WL research studies but this approach is sensitive to the needs and abilities of each individual Theory: Social Cognitive Theory WHAT: Materials: A monthly packet of written information on various WL topics (environmental control, serving-size control, exercise, motivation, goal setting, holiday eating, seasonal foods), pedometers, exercise and dietary logs. Procedures: 10% WL of BW through 500–1000 kcal deficit for a WL of 1–2 pounds/week, by decreasing energy & fat & increasing fibres and at least 5 servings/day fruits & vegetables plus 30–45 min/day moderate activity most days of the week WHO: Registered dietitian HOW: in-person group meetings, telephone individual counselling and emails WHERE: USA WHEN AND HOW MUCH: weekly sessions for the first 3 months, biweekly for 3–6 months & monthly thereafter TAILORING: depending on individual needs MODIFICATIONS: None described HOW WELL (planned): Not described HOW WELL (actual): in appendix |
Sheppard [44] | Brief Name: Stepping Stone (Survivors Taking on Nutrition and Exercise) study WHY: Studies with white survivors suggest that interventions are more effective when they are multifaceted, personalized, teach behavioural skills, provide social support, and increase self- efficacy. This is also likely true for black survivors, but documentation of successful strategies for them are lacking Theory: Social Cognitive Theory & Theory of Planned Behaviour, with Motivational Interviewing WHAT: Materials: pedometers, notebooks, tools to monitor and track their daily food intake, and binders to store resources and session materials. Procedures: WL of at least 5% BW in 12 weeks, through 1 pound of WL per week, > 5 fruits and vegetables/day and < 35% kcal from total fat and moderate intensity exercise of > 30 min/day, ≥ 5 days/week, and 10,000 steps/day WHO: exercise physiologist, nutritionist and trained survivor coach HOW: in-person group sessions, plus individual telephone coaching sessions WHERE: USA WHEN AND HOW MUCH: 12 weeks intervention: once biweekly a 90-min group sessions (30 min PA & 60 min education sessions), plus individual telephone (15 min) coaching sessions every other week TAILORING: individualized sessions were tailored to baseline intentions, attitudes, and subjective norms MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Harrigan [45] | Brief Name: The Lifestyle, Exercise, and Nutrition (LEAN) Study WHY: Telephone-based weight loss counselling may be a viable time-effective alternative to in-person visits Theory: Social Cognitive Theory WHAT: Materials: 11-chapter LEAN book, daily record of all food and beverage intake, minutes of physical activity, and pedometer steps in the LEAN Journal and weighed themselves once per week with a scale, and recorded their weight in the LEAN Journal. Procedures: WL of at least 10% BW in 6 months, through 500 kcal energy deficit based on a plant-based diet reducing sugars and increasing fibre and home-based PA with a goal of 150 min per week moderate-intensity activity, such as brisk walking, with a daily target of 10,000 steps WHO: RD specialised in oncology nutrition and trained in exercise physiology & behaviour modification counselling HOW: either in-person or telephone individual sessions WHERE: Yale, USA (p.670) WHEN AND HOW MUCH: 6 months, 11 sessions (30-min counselling), (once weekly the first month, once biweekly the second & third month and once monthly for the months 4,5,6) TAILORING: participants received individualised counselling sessions MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Stolley [46] | Brief Name: Moving Forward trial, a WL intervention for African-American BCS on weight, body composition and behaviour WHY: Body composition and biological data will enhance the understanding of how WL may impact BC recurrence risk and overall health risk among African-American women Theory: Social Cognitive Theory and Socio-Ecological Model, with Motivational Interviewing WHAT: Materials: classes with specific topics of diet and exercise, weight, food and activity records, program binder with handouts, recipes, and other supportive materials. Procedures: WL of at least 5% BW in 6 months, through 500 kcal deficit by increasing fruit & vegetable consumption and PA ≥ 150 min per week WHO: a community dietitian, a community cancer exercise instructor, and a health psychologist HOW: in-person group sessions, text messages through a software application, mytapp and newsletters WHERE: USA, Chicago area WHEN AND HOW MUCH: twice—weekly (for 26 weeks) in-person classes with supervised exercise & text messaging TAILORING: Not described MODIFICATIONS: Intervention goals change briefly HOW WELL (planned): Not described HOW WELL (actual): in appendix |
Santa-Maria [47] | Brief Name: POWER-remote trial, Practice-based Opportunities for Weight Reduction for breast cancer survivors WHY: BC Patients with obesity experience inferior outcomes, biologically related to metabolic and inflammatory pathways, and other molecular changes. WL may be associated with decreases in leptin and other inflammatory markers, which may have antioncogenic effects Theory: Social Cognitive Theory with Motivational Interviewing WHAT: Materials: educational materials included oncology-relevant information such as lymphedema prevention exercises and general information about BC, web-based resources with objectives, educational content, quizzes, and supporting worksheet and self-monitoring tools and graphs (weight, minutes of exercise/day, calories consumed/day). Procedures: WL of at least 5% BW in 6 months, through 1200–2200 kcal/day energy intake depending on BW based on DASH dietary pattern: 7–12 servings of fruits/vegetables, 2–3 servings of low fat dairy, reduced sodium & ≤ 25% of calories from fat and built up to ≥ 300 min/week of moderate intensity PA in bouts ≥ 10 min in length WHO: health coaches with a background in delivering weight loss interventions HOW: telephone-based behavioural WL coaching and use of a web-based self-monitoring and learning platform WHERE: USA WHEN AND HOW MUCH: 12-months (telephone-based coaching & use of a web-based self-monitoring and learning platform). A total of 21 phone calls: weekly for 3 months & monthly for 9 months (20 min calls per session) TAILORING: Individually tailored MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Reeves [48] | Brief Name: Living Well after Breast Cancer Pilot Trial WHY: Comparisons of interventions against usual care are still warranted, particularly when examining patient-reported outcomes and treatment-related side-effects, as these may naturally improve over time following treatment completion Theory: Social Cognitive Theory with Motivational Interviewing WHAT: Materials: a detailed workbook, self-monitoring diary, digital scales, pedometer, calorie-counter book, food model booklet. Procedures: WL of 5–10% BW in 6 months, through 2000 kj ( ≈ 500 kcal) daily energy deficit aiming to ≤ 30% total fat, < 7% saturated fat, 5 servings/day vegetables, 2 servings/day fruits, limit alcohol intake & portion control and gradually increased moderate intensity planned PA to at least 30-min/day (≥ 210 min/week) and 10,000 steps/daily WHO: lifestyle coaches, who were accredited practicing dietitians trained in exercise promotion and motivational interviewing HOW: individual telephone sessions, optional supportive text messages and newsletters WHERE: Australia, within 50 km of the state capital, Brisbane WHEN AND HOW MUCH: 12 months: 6 months initial phase: A total of 16 phone calls (weekly for 6 weeks & 10 fortnightly calls) and 6 months extended care phase: 6 monthly calls (p5, 2016, study TAILORING: tailored to the participant’s preferences and individualised guidance MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Schmitz [49] | Brief Name: Women in Steady Exercise Research (WISER) Survivor clinical trial WHY: to test the effects of exercise and/or WL on lymphedema, biomarkers for recurrence and quality of life. The hypothesis is that exercise and weight loss will affect these outcomes, but that the combined effect will be larger Theory: Social Cognitive Theory and Behavioural Self-Management Theory, with Motivational Interviewing WHAT: Materials: exercise and food logs using an electronic food diary accessible through the WISER Survivor website. Procedures: WL of 10% BW in 6 months, based on the guidelines from ACS along with a meal replacement program & 7 servings fruits and vegetables daily, plus twice per week resistance exercise per 90-min class along with aerobic activity to 180 min per week WHO: registered dietitians experienced with the NutriSystem program and exercise by certified exercise instructors HOW: in-person group meetings along with telephone individual counselling WHERE: USA, Pennsylvania WHEN AND HOW MUCH: 12 months (52 weeks) home-based exercise program of strength training twice/week & 180 min/week walking along with 24 weeks nutritional counselling group sessions TAILORING: will develop a tailored diet that meets the same calorie control goals and the WL intervention was tailored to the needs of BCS MODIFICATIONS: None described HOW WELL (actual & planned): in appendix |
Goodwin [50] | Brief Name: Lifestyle Intervention in Adjuvant Treatment of Early Breast Cancer (LISA) trial WHY: Obesity is a complex physiologic state associated with insulin resistance, higher levels of circulating insulin, an altered adipocytokine profile (increased leptin, decreased adiponectin), and generalized inflammation. WL may improve BC outcomes Theory: Social Cognitive Theory with Motivational Interviewing WHAT: Materials: Detailed patient workbook which focus on weight control through healthy diet and exercise with logs and pedometer. Procedures: WL of 10% BW in 6 months, through 500–1000 kcal deficit for a WL of 1–2 lbs/week, by decreasing fat to 20% of total intake & increasing fruits, vegetables & fibres and a gradual increase in moderate-intensity aerobic physical activity (walking for the majority of participants) to 150–200 min per week WHO: trained lifestyle coaches HOW: individual telephone sessions and newsletters WHERE: Canada, Ontario Clinical Oncology Group WHEN AND HOW MUCH: 24 months telephone-based intervention: 6 months of the intensive (weekly for 4 weeks) & consolidation phase (fortnightly for 2–6 months) & 18 months of the maintenance phase (every 2 months for 7–12 and every 3 months for 12–24 months) TAILORING: Lifestyle coaches individualized the intervention as necessary MODIFICATIONS: Patients with N3 tumour characteristic were allowed in initial protocol, amended June 2008, when 49 patients had been accrued HOW WELL (actual & planned): in appendix |
Interventions design and strategies
Lifestyle modification
Body weight change goal
Studies | ROB-2 | Weight loss results | Promise | BCTs |
---|---|---|---|---|
Rock [40] | Some concerns | 6% (12 months) | “quite promising” | 19 |
Demark-Wahnefried [41] | Some concerns | 4.6% (12 months) | “quite promising” | 10 |
Mefferd [42] | High | 6.8% (16 weeks) | “very promising” | 18 |
Djuric [43] | High | 60% of the women in the intervention reached 10% of WL. (-9.3 kg) | “very promising” | 12 |
Sheppard [44] | High | 0.8% (12 weeks) | “non-promising” | 14 |
Harrigan [45] | Some concerns | 6.4% (6 months, in-person) 5.4% (6 months, telephone) | “very promising” | 11 |
Stolley [46] | Some concerns | 3.6% (6 months) | “very promising” | 17 |
Santa-Maria [47] | Some concerns | 51% of the women in the intervention reached 5% of WL | “quite promising” | 20 |
Reeves [48] | Some concerns | 5.7% (6 months) | “very promising” | 23 |
Schmitz [49] | Some concerns | 8.6% (6 months) | “very promising” | 21 |
Goodwin [50] | Some concerns | 5.3% (6 months) | “very promising” | 20 |
Risk of bias
Results of synthesis
Intervention promise
Behaviour change theory
Behaviour change techniques (BCTs)
BCT’s | Time used | Promising interventions | Non promising intervention | Promise Ratio |
---|---|---|---|---|
1.1 Goal setting (behaviour) | 11 | 10 | 1 | 10 |
2.3 Self-monitioring of behaviour | 11 | 10 | 1 | 10 |
4.1 Instruction on how to perform the behaviour | 11 | 10 | 1 | 10 |
9.1 Credible source | 11 | 10 | 1 | 10 |
1.2 Problem solving | 10 | 9 | 1 | 9 |
2.2 Feedback on behaviour | 9 | 9 | 0 | 9 |
1.3 Goal setting (outcome) | 9 | 8 | 1 | 8 |
8.7 Graded tasks | 9 | 8 | 1 | 8 |
1.4 Action planning | 8 | 7 | 1 | 7 |
6.1 Demonstration of the behaviour | 8 | 7 | 1 | 7 |
2.4 Self-monitoring of outcome(s) of behaviour | 6 | 6 | 0 | 6 |
3.3 Social support (emotional) | 6 | 5 | 1 | 5 |
1.5 Review behaviour goal(s) | 5 | 5 | 0 | 5 |
8.1 Behavioural practice/rehearsal | 5 | 5 | 0 | 5 |
8.2 Behaviour substitution | 5 | 5 | 0 | 5 |
8.4 Habit reversal | 5 | 5 | 0 | 5 |
11.2 Reduce negative emotions | 5 | 4 | 1 | 4 |
2.7 Feedback on outcome(s) of behaviour | 4 | 4 | 0 | 4 |
3.1 Social support (unspecified) | 4 | 4 | 0 | 4 |
7.1 Prompts/cues | 4 | 4 | 0 | 4 |
12.3 Avoidance/Reducing exposure to cues for the behaviour | 4 | 4 | 0 | 4 |
1.7 Review outcome goal(s) | 3 | 3 | 0 | 3 |
5.1 Information about health consequences | 3 | 3 | 0 | 3 |
8.6 Generalisation of target behaviour | 3 | 3 | 0 | 3 |
13.2 Framing/reframing | 3 | 3 | 0 | 3 |
8.3 Habit formation | 2 | 2 | 0 | 2 |
9.2 Pros and cons | 2 | 2 | 0 | 2 |
12.2 Restructuring the social environment | 2 | 2 | 0 | 2 |
15.4 Self-talk | 2 | 2 | 0 | 2 |