Research
Perspectives in Practice
Implementing a Low-Fat Eating Plan in the Women's Intervention Nutrition Study

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Abstract

The Women's Intervention Nutrition Study is a randomized clinical trial designed to evaluate if a lifestyle intervention targeting fat intake reduction influences breast cancer recurrence in women with early stage, resected disease receiving conventional cancer management. This report details the concept, content, and implementation of the low-fat eating plan used in the dietary intervention group of this trial. Intervention group participants were given a daily fat gram goal. The intervention was delivered by centrally trained, registered dietitians who applied behavioral, cognitive, and motivational counseling techniques. The low-fat eating plan was implemented in an intensive phase with eight biweekly (up to Month 4), individual counseling sessions followed by a maintenance phase (Month 5 up to and including Year 5) with registered dietitian visits every 3 months and optional monthly group sessions. Self-monitoring (daily fat gram counting and recording), goal setting, and motivational interviewing strategies were key components. Dietary fat intake was equivalent at baseline and consistently lower in the intervention compared with the control group at all time points (percent eneregy from fat at 60 months 23.2%±8.4% vs 31.2%±8.9%, respectively, P<0.0001) and was associated with mean 6.1 lb mean weight difference between groups (P=0.005) at 5 years (baseline and 5 years, respectively: control 160.0±35.0 and 161.7±32.8 lb; intervention 160.2±35.1 and 155.6±32.1 lb). Together with previously reported efficacy results, this information suggests that a lifestyle intervention that reduces dietary fat intake and is associated with modest weight loss may favorably influence breast cancer recurrence. The Women's Intervention Nutrition Study low-fat eating plan can serve as a model for implementing such a long-term dietary intervention in clinical practice.

Section snippets

Methods

The goal of the dietary intervention (the WINS low-fat eating plan) was to reduce the percentage of total energy intake from fat down to 15% while maintaining nutritional adequacy. This goal was based on findings from feasibility trials indicating that a 15% goal would result in a sustained reduction of fat intake of about 20% of energy intake (4, 5). Randomization for this trial was 40:60 for the low-fat intervention vs control group to save resources at minimal loss in statistical power.

Results

A total of 2,437 women were randomly assigned, 975 to the dietary intervention and 1,462 to the control group. Dietary data is available for at least three of six time periods after baseline on 80% of participants. In the control group, 66 were lost to follow-up and 106 discontinued study participation. In the intervention group, 45 were lost to follow-up and 170 discontinued the dietary intervention. Only six women cited that they “did not like the low-fat eating plan” as the reason.

Dietary

Discussion

The WINS low-fat eating plan resulted in significant and sustained reductions in both fat intake as well as body weight. These results, together with outcomes from other full scale trials (16, 17, 18) indicate that demanding lifestyle interventions involving significant modification of dietary intake can be successfully implemented over extended periods of time (16, 17, 18, 19). In an interim efficacy report from the WINS trial, breast cancer recurrence was less frequent in women randomized to

Conclusions

The WINS low-fat eating plan is a comprehensive, theory-based lifestyle intervention that resulted in reduced fat intake, modest weight loss and a suggested favorable affect on breast cancer recurrence especially in postmenopausal women with hormone receptor negative disease. A description of the methodology used in implementing this low-fat eating plan can serve as a model for its use by RDs in clinical practice.

Because both reduced fat intake and modest weight loss were seen in the WINS

M. K. Hoy is research manager, Produce for Better Health Foundation, Wilmington, DE; at the time of the study, she was Women's Intervention Nutrition Study (WINS) national coordinator and WINS assistant national coordinator, Institute for Cancer Prevention, formerly American Health Foundation, New York, NY

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    M. K. Hoy is research manager, Produce for Better Health Foundation, Wilmington, DE; at the time of the study, she was Women's Intervention Nutrition Study (WINS) national coordinator and WINS assistant national coordinator, Institute for Cancer Prevention, formerly American Health Foundation, New York, NY

    B. L. Winters is a research scientist, Campbell Soup Company, Camden NJ; at the time of the study, she was WINS national coordinator, American Health Foundation, New York, NY

    R. Chlebowski is WINS principal investigator, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA

    C. Papoutsakis is a teaching and research Associate, Laboratory of Nutrition and Clinical Dietetics, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece; at the time of the study, she was WINS protocol coordinator, American Health Foundation, New York, NY

    A. Shapiro is a research scientist, Institute at Park Nicollet Health Services, Minneapolis, MN; at the time of the study, she was principal investigator, Institute for Park Nicollet Health Services, Minneapolis, MN

    M. P. Lubin is a nutritionist, Winthrop University Hospital Department of Surgery, Mineola, NY; at the time of the study, she was WINS intervention coordinator, Institute for Cancer Prevention, formerly American Health Foundation, New York, NY

    C. A. Thomson is an associate professor, University of Arizona, Arizona Cancer Center and Department of Nutritional Sciences, Tucson; at the time of the study, she was principal investigator, University of Arizona Cancer Center, Tucson

    M. B. Grosvenor is an adjunct professor, Delta Montrose Technical College, Department of Nursing, Delta, CO; at the time of the study, she was WINS dietary assessment coordinator, Institute for Cancer Prevention, formerly American Health Foundation, New York, NY

    T. Copeland is a research coordinator, Harvard School of Public Health, Boston, MA; at the time of the study, she was national assessment operations manager, Beth Israel Deaconess Hospital, Boston, MA

    E. Falk is a nutritionist, Cedar Associates Eating Disorder Center, Mt Kisco, NY; at the time of the study, she was WINS protocol coordinator, Institute for Cancer Prevention, formerly American Health Foundation, New York, NY

    K. Day is research nutritionist and G. L. Blackburn is WINS principal investigator, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

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