RESEARCH
Changes in diet, physical activity, and supplement use
among adults diagnosed with cancer
RUTH E. PATTERSON, PhD, RD; MARIAN L. NEUHOUSER, PhD, RD; MONIQUE M. HEDDERSON, MPH;
STEPHEN M. SCHWARTZ, PhD; LEANNA J. STANDISH, PhD; DEBORAH J. BOWEN, PhD
ABSTRACT
Objective To investigate the prevalence and predictors of
changes in diet, physical activity, and dietary supplement use
among cancer patients.
Design/subjects Telephone interviews of a populationbased sample of 126 breast, 114 prostate, and 116 colorectal
cancer patients from the state of Washington.
Analysis Logistic regression was used to estimate the odds
ratio as a measure of the association of participant characteristics with lifestyle changes in the 12 months before the interview.
Results Overall, 66.3% of patients reported making lifestyle
changes: 40.4% made one or more dietary changes, 20.8%
added new physical activity, and 48.0% started taking new
dietary supplements. Compared with men, women were 2.2
times more likely to take new dietary supplements (P ⬍ .01).
Compared with patients aged 35 to 59, those aged 60 to 69
and 70 or older were statistically significantly less likely to
make dietary changes (odds ratio ⫽ 0.39 and 0.54, respectively) or to take new supplements (odds ratio ⫽ 0.42 and
0.69, respectively). Compared with patients who received
only one medical treatment, those receiving three or more
treatments were more likely to make dietary changes (odds
ratio ⫽ 2.6) or to start new physical activity (odds ratio ⫽
3.0). Patients diagnosed 12 to 24 months before the interview
were as likely to report making lifestyle changes as those diagnosed within one year of the interview. Having a stronger
desire for personal control or internal locus of control predicted use of new dietary supplements (P for trend ⬍ .05 for
both).
Applications/conclusions Cancer survivors are likely to be
making lifestyle changes and represent a group that could
benefit from counseling on diet and physical activity. J Am
Diet Assoc. 2003;103:323-328.
A
pproximately 1,285,000 Americans will be diagnosed
with cancer in 2002 (1). Although cancer is generally
thought of as a life-threatening disease, survival rates
have improved dramatically for many malignancies (2).
For example, five-year survival in the United States is about
80% for prostate and breast cancers and 60% for colorectal
cancer (1,3), and the National Cancer Institute estimates that
approximately 8.9 million Americans with a history of cancer
were alive in 1997 (1).
Life-threatening health events such as a diagnosis of cancer
may prompt psychological distress that motivates individuals
to reduce risk (4,5). The experience of cancer diagnosis and
treatment is difficult and may serve as a critical cue for an
individual to undertake future health promotion activities (6).
In a survey of 1,667 cancer survivors, Demark-Wahnefried and
colleagues reported that there was a strong interest in health
promotion programs aimed at healthier diets, exercise, and
smoking cessation (7). The major role of a dietetics professional in relation to cancer patients is often nutritional status
assessment and support during the early phases of treatment
and recovery. However, nutrition interventions may be beneficial to cancer survivors during the health maintenance phase of
R. Patterson is a research associate professor and S.
Schwartz is an associate professor, Department of Epidemiology and Nutritional Sciences Program, and D. Bowen is a professor, Department of Health Services, University of Washington, Seattle, WA. R. Patterson is an
associate member, M. Neuhouser is a senior staff scientist, and D. Bowen is a member, Cancer Prevention Research Program; and S. Schwartz is a member, Program
in Epidemiology, Fred Hutchinson Cancer Research Center, Seattle, WA. M. Hedderson is a research assistant, Division of Research, Kaiser-Permanente, Oakland, CA. L.
Standish is Director of Research, Bastyr University, Bothell, WA.
Address correspondence to: Ruth E. Patterson, PhD, RD,
Cancer Prevention Research Program, Fred Hutchinson
Cancer Research Center, 1100 Fairview Avenue North,
MP 702, Seattle, WA 98109. E-mail: rpatters@fhcrc.org
Copyright © 2003 by the American Dietetic Association.
0002-8223/03/10303-0002$35.00/0
doi: 10.1053/jada.2003.50045
Journal of THE AMERICAN DIETETIC ASSOCIATION / 323
RESEARCH
cancer, in which the goals are improved quality of life as well as
preventing cancer recurrence, second primary tumors, and
other preventable diseases (8).
Data regarding changes in lifestyle in response to a diagnosis
of cancer are scarce. This report examines self-reported
changes in diet, physical activity, and dietary supplement use
among cancer patients diagnosed up to 24 months in the past.
We investigate whether patients felt that these changes improved their health and well-being and identify sociodemographic, clinical, and selected psychosocial characteristics that
predict these lifestyle changes.
METHODS
Overview and Study Participants
Participants were identified from the population-based Cancer
Surveillance System, which is part of the National Cancer Institute’s Surveillance Epidemiology and End Results program
(9). The registry catchment area includes 13 counties in western Washington state. We obtained permission from each patient’s physician before sending a letter of invitation to participate in the survey, which was followed up by a telephone call
approximately one week later. We made at least 15 attempts to
contact patients by telephone. Trained interviewers used a
computer-assisted telephone interview system to administer a
structured questionnaire. Interviews were conducted between
February and July of 1999. The protocol for the study was
approved by the Institutional Review Board of the Fred
Hutchinson Cancer Research Center.
Data regarding changes in
lifestyle in response to a
diagnosis of cancer are scarce
Eligible participants were English-speaking patients, aged
20 to 79, diagnosed with first primary invasive breast, prostate,
or colorectal cancer between February 1997 and December
1998. We chose to examine these cancers because they are the
major ones affecting Americans that also have high survival
rates (1). We randomly selected a sample of 511 adult patients
to obtain approximately equal numbers of breast, prostate, and
colon cancers such that half were diagnosed within the previous 11 months and the other half were diagnosed 12 to 24
months before sampling. Two patients were ineligible because
they did not speak English, and five patients were deceased.
We completed interviews with 356 (70.6%) of 504 eligible participants. Reasons for nonparticipation were physician refusal
(5.0%), inability to locate (7.9%), patient refusal (15.3%), and
illness (1.2%).
Changes in Diet, Physical Activity, and Supplement
Use
Each patient was asked to report on lifestyle changes made in
the past 12 months. For all changes made, each respondent was
asked whether he or she strongly agreed, agreed, disagreed or
strongly disagreed with the following statement: “This ⬍lifestyle change/dietary supplement⬎ has improved my physical
and mental well-being.”
324 / March 2003 Volume 103 Number 3
Diet Each patient was asked if he or she had made any major
changes in dietary intake that were aimed at coping with cancer
or reducing the risk of cancer spreading or returning. If yes, the
patient was asked to specify the dietary changes. Interviewers
coded the response(s) from a list of options: (a) became a
vegetarian; (b) ate more fruits and vegetables; (c) ate less red
meat; (d) ate less fat; (e) ate more healthy in general; (f)
fasted; (g) juiced; (h) used special supplements such as Ensure, Boost, or protein powders; (i) followed a weight-loss diet;
or (j) other. The exact text of “other” responses was entered
into computers by interviewers. More than one response was
allowed. This method of assessing recent change in consumption has proven useful in other studies of trends in diet (10,11).
Physical activity Each patient was asked if he or she had
begun physical activities in the past 12 months that were aimed
at coping with cancer or reducing the risk of cancer spreading
or returning. If yes, the patient was asked to specify the activities. Interviewers entered the response(s) from a list of options: (a) aerobic exercise, (b) other exercise such as weight
training, (c) breathing exercises, (d) qi gong, (e) tai chi, (f)
yoga, or (g) other. Again, the exact text of “other” responses
was entered into the computer, and more than one response
was allowed.
Dietary supplements Each patient was asked whether in the
past 12 months he or she had taken any vitamin, mineral,
herbal, or other supplements. If yes, we recorded the type of
supplement, such as one-a-day type multivitamins (with or
without minerals); single supplements of vitamins, minerals, or
herbals; and other mixtures. For other mixtures, we recorded
the ingredients (ie, the exact mixture of vitamins, minerals,
and/or herbals) and flagged the entry as being a single pill. For
each supplement taken, each patient was asked whether he or
she had taken the product before the cancer diagnosis.
Psychosocial factors The diagnosis of cancer and the health
effects of the associated treatment regimens can leave patients
with a sense of hopelessness and loss of control (4,5,12), and
lifestyle is an area in which cancer patients can regain a sense
of personal control. Therefore we assessed three psychosocial
factors that we hypothesized might predict changes in health
behavior: perceived health status, desire for personal control,
and internal locus of control.
For perceived health status, each patient was asked whether
they would classify their health as excellent, very good, good,
fair, or poor.
To assess each patient’s desire for control over cancer, we
used questions from a validated scale developed to measure
desire for control among dental patients (13). Each patient was
asked how much control he or she wanted in decisions related
to cancer treatment and in decisions related to cancer-related
symptoms. Response options were on a four-point scale from
strongly disagree to strongly agree and were summed to create
a summary score.
The six-item internal health locus of control scale from the
Multidimensional Health Locus of Control Instrument was administered (14). This model was developed to assess people’s
beliefs that their own behavior determines their health. People
with a stronger internal locus of control regard their health as
largely within their own control and are more likely to engage in
health-maintaining behavior. To facilitate patient comprehension of the tool during a telephone interview, we shortened the
RESEARCH
response categories from the standard six-point scale to a fourpoint scale with Likert-type responses from strongly disagree
(rated as one) to strongly agree (rated as four). A single score
was calculated by summing responses to the six questions. The
Cronbach coefficient alpha for this scale was 0.73, indicating
that it had high internal consistency.
Other measures Sociodemographic data were collected on
age, sex, race, and education. Patients were asked to list the
medical treatments received: surgery, radiotherapy, chemotherapy, and/or hormone therapy. We created a variable for
these data to indicate intensity of medical treatment by grouping participants by number of treatments received (zero, one,
two, or more). Seventeen participants reported no medical
treatment and were excluded from this analysis. Clinical information on type of cancer and stage of disease were abstracted
from the Cancer Surveillance System registry.
Statistical Analysis
We provide data on prevalence of lifestyle changes after cancer
diagnosis, including changes in diet, physical activity, and use
of dietary supplements. We give data only for the most common
changes, defined as those made by at least 5% of patients. For
each lifestyle change, we present the percent of participants
who strongly agreed or agreed that the change improved their
health and well-being.
Lifestyle is an area in which
cancer patients can regain a
sense of personal control
Logistic regression was used to estimate odds ratios (OR) as
the measure of association of lifestyle changes with sex, age (in
years, 35 to 54, 55 to 69, 70 or older), education (in years, ⱕ12,
13 to 15, 16 or more), type of cancer, stage at diagnosis, number of medical treatments, and time since diagnosis (in months,
⬍12, 12 to 24). Psychosocial predictors of lifestyle changes
were divided into approximate tertiles to provide stable estimates of associations. All ORs are adjusted for confounding
factors (age, sex, education, stage, and medical treatments).
For ordered independent variables (age, education, medical
treatments, and psychosocial factors), the association with lifestyle changes was assessed with a test for trend using the logistic regression analogue to the Mantel extension test (ie, a
test based on the significance of a single trend variable coded as
the category of exposure). It is important to note that because
of the choice of cancer sites included in this study, sex and type
of cancer are confounded. All breast cancer cases were female,
all prostate cancer cases were male, and colorectal cancer
cases were 44.8% female. Therefore we are unable to fully
separate the effects of sex vs type of cancer, and in models
adjusted for sex, we are also partially adjusting for the type of
cancer. For the models of associations of type of cancer with
use of alternative medicine use, we are unable to adjust for sex
because of this confounding.
RESULTS
The final sample was composed of 356 adult cancer patients, of
whom 126 had breast cancer, 114 had prostate cancer, and 116
Table 1
Most common lifestyle changes among breast (n⫽126), prostate
(n⫽114), and colorectal (n⫽116) cancer patients diagnosed up to
2 years previously
Lifestyle change
Dietary changes
Eat more fruits and
vegetables
Eat less red meat
Eat less fat
Eat more healthily
New physical activity
Aerobic exercise
Qi gong, tai chi, yoga,
others
Participants
making change in
past 12 months
Participants reporting
that change improved
health and well-being
4
144 (40.4)
n (%)
128 (88.9)
65 (45.1)
38 (26.4)
41 (28.5)
18 (12.5)
62 (95.4)
31 (81.6)
36 (87.8)
18 (100.0)
74 (20.8)
61 (82.4)
73 (98.6)
61 (100.0)
16 (21.6)
20 (95.2)
New dietary supplements
Multivitamins
Vitamin E compound(s)a
Calcium
Vitamin C compound(s)a
Garlic
Echinacea
171 (48.0)
50 (29.2)
48 (28.1)
29 (17.0)
25 (14.6)
16 (9.4)
14 (8.2)
158 (92.3)
46 (92.0)
43 (89.6)
27 (93.1)
25 (100.0)
16 (100.0)
14 (100.0)
Number of changes made
None
One change
Two changes
ⱖThree changes
120 (33.7)
117 (32.9)
85 (23.9)
34 (9.6)
Not
Not
Not
Not
3
applicable
applicable
applicable
applicable
a
Any mixture or single supplement containing vitamin E (or vitamin C), not
including multivitamins.
had colorectal cancer. Half of the patients were female, 91.3%
were white, the mean age was 62.5 years (SD ⫽ 10.7), and
37.1% had a college education. Fifty-one percent of patients
had been diagnosed within the past 12 months, and the remainder were diagnosed 12 to 24 months in the past.
Table 1 gives the most common changes in lifestyle, defined
as changes that at least five percent of patients reported making. Overall, lifestyle changes were very common after a cancer
diagnosis. Two thirds of patients reported making at least one
behavior change in the past 12 months: about 40% made dietary changes, 20% began a new physical activity, and 50%
started taking new dietary supplements. Approximately 25% of
patients made two changes, and almost 10% made all three
lifestyle changes. Among those making dietary changes, the
most common was eating more fruits and vegetables; for physical activity, the most common change was adding aerobic exercise; and for supplements, the most common change was
starting to take multivitamins and/or vitamin E. The vast majority of patients reported that these lifestyle changes improved their health and well-being.
Table 2 gives the ORs of making these lifestyle changes by
sociodemographic and other characteristics. Female patients
were more than twice as likely to take new dietary supplements
as males (P ⬍ .01). Compared with younger patients (35-59),
older patients were about half as likely to make dietary changes
(P for trend ⬍ .001) and to take new dietary supplements (P
for trend ⬍ .05). More educated patients were statistically significantly more likely to make dietary changes and to take new
supplements (P for trend ⬍ .05), with a similar trend for physical activity that did not reach statistical significance. ComJournal of THE AMERICAN DIETETIC ASSOCIATION / 325
RESEARCH
Table 2
Association of lifestyle changes with sociodemographic and clinical characteristics among breast (n⫽126), prostate (n⫽114), and colorectal
(n⫽116) cancer patients diagnosed up to 2 years previously
Lifestyle changes made in past 12 months
Diet changes
Began new physical
activity
Took new dietary
supplements
%
Adjusted
ORb
%
Adjusted
ORb
%
Adjusted
ORb
356
40.4
–
20.8
–
48.0
–
178
178
31.4
49.4
1.0
1.19
15.2
26.4
1.0
1.53
36.0
60.1
1.0
2.19**
Age (y)
35-59
60-69
70 or more
P for trend
132
119
101
59.9
31.9
24.7
1.0
0.39***
0.52***
⬍.001
27.3
14.3
17.8
1.0
0.57
0.80
65.9
37.8
37.6
1.0
0.42**
0.69*
⬍.05
Education (y)
ⱕ12
13-15
16 or more
P for trend
130
93
132
26.9
49.5
47.7
1.0
3.09
2.12
⬍.05
16.1
18.3
27.3
1.0
1.27
1.93
36.9
49.5
58.3
1.0
1.53
2.21**
⬍.01
Type of cancer
Colorectal
Prostate
Breast
116
114
126
32.8
27.7
59.5
1.0
0.83
1.72
15.5
15.8
30.2
1.0
0.70
1.0
46.5
31.6
64.3
1.0
0.50*
1.63
Stage at diagnosis
I (local)
II/III (distant/regional)
192
140
37.5
45.0
1.0
1.41
20.3
21.4
1.0
1.02
44.8
55.0
1.0
1.65*
132
107
100
25.0
43.0
58.0
1.0
1.89
2.62
⬍.01
14.4
16.8
34.0
1.0
1.33
3.01
⬍.01
37.1
48.6
62.0
1.0
1.13
1.26
183
173
37.2
43.9
1.0
1.51
18.6
23.1
1.0
1.54
46.5
49.7
1.0
1.06
Characteristic
Na
All
Sex
Male
Female
Medical treatmentc
One treatment
Two treatments
Three treatments or more
P for trend
Diagnosis date
⬍12 mo
12-24 mo
a
Sample sizes vary slightly because of missing data.
OR⫽Odds ratio; adjusted for age, sex, education, stage, and number of medical treatments.
Treatments included surgery, radiation, chemotherapy, and hormone therapy.
*P⬍.05.
**P⬍.001.
***P⬍.001.
b
c
pared with colorectal cancer patients, men with prostate cancer were half as likely to take new dietary supplements (P ⬍
.05). Compared with those with local disease, patients with
distant/regional disease were about 1.7 times more likely to
take new supplements (P ⬍ .05). Patients receiving three or
more medical treatments were two to three times more likely to
make dietary changes or to start new physical activity compared with patients receiving only one medical treatment (P for
trend ⱕ .05). Patients diagnosed 12 to 24 months in the past
were equally as likely to report making lifestyle changes as
those diagnosed less than 12 months ago.
Table 3 gives psychosocial factors that could predict making
lifestyle changes after a cancer diagnosis. Perceived health status did not significantly predict lifestyle changes. However,
stronger desire for personal control and having a high internal
locus of control were associated with almost a two times
greater likelihood of taking new dietary supplements (P for
trend ⬍ .05).
326 / March 2003 Volume 103 Number 3
DISCUSSION
This article indicates that about two thirds of cancer patients
reported making changes in diet, physical activity, and/or supplement use in the past 12 months. Most of these changes were
healthful (ie, eating more fruits and vegetables and less fat,
adding new aerobic activity) and are consistent with recommendations made by the American Cancer Society for cancer
prevention (15). Other changes were more controversial (taking dietary supplements such as vitamin C, garlic, or echinacea), especially during the treatment phase, in which antioxidants may interfere with chemotherapy or radiotherapy
(16,17). It is important to note that patients overwhelmingly
thought that these lifestyle changes improved their health and
well-being.
We know of no research on changes in health-related behavior after cancer diagnosis, although a number of studies have
reported on the prevalence of health behavior in cancer survivors. In a survey of 1,667 cancer survivors, investigators found
RESEARCH
Table 3
Lifestyle changes by psychosocial characteristics among breast (n⫽126), prostate (n⫽114), and colorectal (n⫽116) cancer patients
diagnosed up to 2 years previously
Lifestyle changes made in past 12 months
Diet changes
Began new physical activity
Took new dietary supplements
Psychosocial characteristic
Na
%
Adjusted ORb
%
Adjusted ORb
%
Adjusted ORb
Perceived health status
Excellent/very good
Good
Fair/poor
175
118
60
41.7
39.0
36.7
1.0
1.19
1.31
21.7
22.0
13.3
1.0
1.31
0.71
53.7
39.8
46.7
1.0
0.76
1.06
169
45
133
32.5
44.4
51.9
1.0
1.52
1.40
17.7
11.1
27.8
1.0
0.47
1.31
36.7
51.1
61.6
1.0
1.52
1.74
⬍.05
71
127
134
45.1
39.4
38.8
1.0
0.68
0.82
21.1
17.3
23.1
1.0
0.80
1.44
42.3
44.1
56.0
1.0
1.07
1.94
Desire for personal control
Low
Medium
High
P for trend
Internal locus of control
Low
Medium
High
P for trend
⬍.05
a
Sample sizes vary slightly because of missing data.
b
OR⫽Odds ratio; adjusted for age, sex, education, stage, and number of medical treatments.
that 69% reported adhering to a low-fat diet, 45% ate five or
more daily servings of fruits and vegetables, and 58% reported
routine exercise (7). A study of dietary supplement use by
women at risk for breast cancer reoccurrence (n ⫽ 435) reported that 80.9% of respondents reported using supplements
(18). However, this was among a sample of women enrolled in
a diet intervention to reduce breast cancer recurrence, and
therefore was a self-selected volunteer sample of patients that
were likely to be very interested in health issues. In the same
sample of women, 60% of women reported weight gain, 26%
reported weight loss, and 14% reported no change within the
four years after a diagnosis of breast cancer; suggesting
changes in diet, physical activity, or both (19).
Older patients were less likely to adopt new lifestyle practices in response to a diagnosis of cancer, whereas more educated patients, females, and patients undergoing multiple
treatments were more likely to make changes. These results
are similar to findings from studies on prevalence of alternative
medicine use and taking supplements among cancer patients
(12,20-26). It is interesting to note that a high desire for control
was only associated with increased use of dietary supplements
and did not predict making changes in diet or physical activity,
which may be motivated more by other psychosocial factors
such as belief in a diet-disease connection (10) or concerns
about weight changes (19). It is possible that taking supplements may be a coping behavior for dealing with the emotional
aftermath of cancer rather than a health improvement strategy.
Research into patients’ beliefs about the functions of supplements is needed.
This study has several limitations. First, although our response rate was good (70.8%), we cannot ensure that our respondents have the same behavior as the nonrespondents. It is
possible that patients with less favorable behavior change
might be less likely to participate in a cancer study. Therefore
our estimates of health behavior change may be somewhat inflated. Our prevalence estimates cannot be completely generalized to all cancer patients because our sample was composed
only of breast, colon, and prostate cancer patients selected up
to two years postdiagnosis. Because survival rates for these
cancers are high, motivations for making lifestyle changes
among these patients may be different than for patients having
cancers with a poor prognosis, such as lung or pancreatic cancers. In addition, this study population reflects western Washington population demographics, and therefore was mostly
white. Additional studies would be needed to assess lifestyle
changes in other race and ethnicity groups. Finally, lifestyle
changes are entirely based on self-report and were collected as
patient memories of the change rather than by gathering data
at two or more time points. It is possible that the experiences of
cancer diagnosis, treatment, and coping may have affected
these memories.
These data suggest that cancer survivors are highly motivated to attempt lifestyle changes in diet, physical activity, and
dietary supplement use as much as two years postdiagnosis.
Little is known about how lifestyle behaviors affect cancer recurrence and prognosis. Nonetheless, family, friends, media,
and health food stores may readily give advice, much of which
is offered with a degree of certainty that is out of proportion
with the evidence available (6). Therefore studies are needed
that test hypotheses about changing health behavior to improve postdiagnosis survival rates.
APPLICATIONS
The results of these analyses indicate that cancer patients
often make lifestyle changes months to years after diagnosis
and represent a group of adults that could benefit from counseling on diet and physical activity. We suggest that dietetics
professionals who interact with these patients provide them
counseling and/or resources to make these lifestyle changes.
Finally, dietetics professionals working with cancer survivors
need to be wary of dismissing or discounting dietary supple■
Journal of THE AMERICAN DIETETIC ASSOCIATION / 327
RESEARCH
ments or other diet or physical activity regimens because patients overwhelmingly thought that these activities improved
their health and well-being.
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This study was supported by contracts N01-PC-67009 and
N01-CN-05230, both from the National Cancer Institute,
as well as funds from the Fred Hutchinson Cancer Research Center.