Project 3: Simultaneous Combined Or Sequential (S.O.S.) Approaches to Behavior Change for Survivors

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Health risks (poor diet, excess weight, physical inactivity) in rising numbers of cancer survivors represent a substantial public health concern and can lead to second primaries and cancer recurrence, as well as other comorbidities and functional decline. Effective behavioral interventions are needed for this population. Studies to date have largely addressed individual lifestyle behaviors as independent factors, but there often are multiple health risks that require attention amongst survivors. Thus, intervening upon multiple modifiable risk factors is much more likely to impact public health than intervening on a single behavior. Multiple behavior change interventions have shown success in the general population, as well as promising results in the few available studies in cancer survivors. However, several gaps in this research remain. First, there is no consensus on the best approach to multiple behavior change and the few studies that have compared simultaneous vs. sequential multiple behavior interventions yielded mixed findings. Clarifying best practices for multiple behavior change has important clinical implications and will be key to moving the field forward. Second, this line of research has yet to be fully extended to at risk populations. As noted, there have been some multiple behavior change studies conducted in cancer survivors, but none have examined simultaneous vs. sequential intervention approaches and most involved predominantly younger, well-educated White samples. The National Cancer Institute has called for multiple behavior change research in underserved populations, i.e., survivors of various cancers who also are rural, older and minority. Thus, the proposed Project 3, which builds upon Projects 1-2 of AMPLIFI, will test the efficacy of simultaneous vs. sequential interventions targeting diet, weight loss, and/or exercise, and explore which combination or order is best to maximize change for cancer survivors. The study will use a randomized controlled design with 652 cancer survivors from mostly older, rural, and minority groups. Primary aims include determining the relative efficacy of two approaches (simultaneous vs. sequenced) to multiple health behavior change, with meeting behavioral goals (improved diet quality, 3% weight loss, ≥150 weekly minutes of ≥moderate intensity physical activity) post-intervention as endpoints of interest. Secondary aims include examining maintenance of gains at 6 months post-intervention and arm differences in physical activity and function, lean body mass, quality of life, and biomarkers of successful aging, immune status, and systemic inflammation; identifying potential mediators (SCT constructs) and moderators (education) of intervention efficacy; and evaluating the cost-effectiveness of sequenced vs. simultaneous technology-based interventions. This will be one of the largest trials ever to compare sequential vs. simultaneous interventions. Findings will be of high public health impact given the diversity and high risk nature of the patient population.