Physical activity and pain in people with and without cancer.

BACKGROUND: Performing physical activity may provide analgesic benefit, although this effect is more established for noncancer pain rather than cancer pain. The relationship between physical activity and pain outcomes in adults with and without a history of cancer was examined. METHODS: Totals of 51,439 adults without a cancer history and 10,651 adults with a cancer history from the Cancer Prevention Study II Nutrition Cohort were included. Exposures included self-reported moderate to vigorous physical activity (MVPA) as well as 2-year change in MVPA. Pain outcomes included pain intensity (primary outcome) and analgesic use (secondary outcome). RESULTS: MVPA was inversely associated with pain intensity for adults with (odds ratio [OR], 0.84 [≥15 metabolic equivalent of task (MET) h/week vs. <7.5 MET h/week]; 95% confidence interval [CI], 0.76-0.93) and without (OR, 0.79; 95% CI, 0.75-0.82) a history of cancer. Compared to remaining inactive, participants who became sufficiently active (cancer: OR, 0.76; 95% CI, 0.68-0.86; no cancer: OR, 0.73; 95% CI, 0.69-0.77), became inactive (cancer: OR, 0.79; 95% CI, 0.71-0.88; no cancer: OR, 0.84; 95% CI, 0.80-0.89), or remained sufficiently active (cancer: OR, 0.66; 95% CI, 0.60-0.72; no cancer: OR, 0.62; 95% CI, 0.60-0.65) also reported less pain. Physical activity was not related to analgesic use. CONCLUSIONS: The relationship between physical activity and pain intensity was not substantially different between people with and without a history of cancer. Cancer survivors who perform more activity, or who increase their activity, may experience less pain than cancer survivors who consistently perform less. PLAIN LANGUAGE SUMMARY: People who have had cancer often experience ongoing pain. Being physically active may help reduce the intensity of the pain they experience.

Comparative Analysis of ActiGraph Step Counting Methods in Adults: A Systematic Literature Review and Meta-Analysis.

PURPOSE: The primary aim of this study was to compare steps per day across ActiGraph models, wear locations, and filtering methods. A secondary aim was to compare ActiGraph steps per day to those estimated by the ankle-worn StepWatch. METHODS: We conducted a systematic literature review to identify studies of adults published before May 12, 2022, that compared free-living steps per day of ActiGraph step counting methods and studies that compared ActiGraph to StepWatch. Random-effects meta-analysis compared ActiGraph models, wear locations, filter mechanisms, and ActiGraph to StepWatch steps per day. A sensitivity analysis of wear location by younger and older age was included. RESULTS: Twelve studies, with 46 comparisons, were identified. When worn on the hip, the AM-7164 recorded 123% of the GT series steps (no low-frequency extension (no LFE) or default filter). However, the AM-7164 recorded 72% of the GT series steps when the LFE was enabled. Independent of the filter used (i.e., LFE, no LFE), ActiGraph GT series monitors captured more steps on the wrist than on the hip, especially among older adults. Enabling the LFE on the GT series monitors consistently recorded more steps, regardless of wear location. When using the default filter (no LFE), ActiGraph recorded fewer steps than StepWatch (ActiGraph on hip 73% and ActiGraph on wrist 97% of StepWatch steps). When LFE was enabled, ActiGraph recorded more steps than StepWatch (ActiGraph on the hip, 132%; ActiGraph on the wrist, 178% of StepWatch steps). CONCLUSIONS: The choice of ActiGraph model, wear location, and filter all impacted steps per day in adults. These can markedly alter the steps recorded compared with a criterion method (StepWatch). This review provides critical insights for comparing studies using different ActiGraph step counting methods.

Long-term multimorbidity trajectories in older adults: The role of cancer, demographics, and health behaviors.

BACKGROUND: Multimorbidity is associated with premature mortality and excess health care costs. The burden of multimorbidity is highest among patients with cancer, yet trends and determinants of multimorbidity over time are poorly understood. METHODS: Via Medicare claims linked to Cancer Prevention Study II data, group-based trajectory modeling was used to compare National Cancer Institute comorbidity index score trends for cancer survivors and older adults without a cancer history. Among cancer survivors, multinomial logistic regression analyses evaluated associations between demographics, health behaviors, and comorbidity trajectories. RESULTS: In 82,754 participants (mean age, 71.6 years [SD, 5.1 years]; 56.9% female), cancer survivors (n = 11,265) were more likely than older adults without a cancer history to experience the riskiest comorbidity trajectories: (1) steady, high comorbidity scores (remain high; odds ratio [OR], 1.36; 95% CI, 1.29-1.45), and (2) high scores that increased over time (start high and increase; OR, 1.51; 95% CI, 1.38-1.65). Cancer survivors who were physically active postdiagnosis were less likely to fall into these two trajectories (OR, 0.73; 95% CI, 0.64-0.84, remain high; OR, 0.42; 95% CI, 0.33-0.53, start high and increase) compared to inactive survivors. Cancer survivors with obesity were more likely to have a trajectory that started high and increased (OR, 2.83; 95% CI, 2.32-3.45 vs. normal weight), although being physically active offset some obesity-related risk. Cancer survivors who smoked postdiagnosis were also six times more likely to have trajectories that started high and increased (OR, 6.86; 95% CI, 4.41-10.66 vs. never smokers). CONCLUSIONS: Older cancer survivors are more likely to have multiple comorbidities accumulated at a faster pace than older adults without a history of cancer. Weight management, physical activity, and smoking avoidance postdiagnosis may attenuate that trend.

Physical activity, obesity, and bladder cancer incidence.

PURPOSE: Cigarette smoking is an established risk factor for bladder cancer (BC), but evidence for physical inactivity and obesity is limited. METHODS: This analysis included 146,027 participants from the Cancer Prevention Study-II (CPS-II) Nutrition Cohort, a large prospective cohort of cancer incidence established in 1992. Multivariable-adjusted Cox proportional hazards models were used to examine associations between body mass index (BMI), moderate-to-vigorous intensity aerobic physical activity (MVPA), leisure-time spent sitting, and BC risk. Effect modification by stage, smoking status, and sex was examined. RESULTS: Only participants accumulating 15.0- < 30.0 MET-hrs/wk of MVPA had a lower risk of BC overall (RR 0.88, 95% CI 0.78, 0.99, compared to > 0-7.5 MET-hrs/wk) in the fully adjusted models. When stratifying on BC stage, MVPA (15- < 30 MET-hrs/wk vs. > 0- < 7.5 MET-hrs/wk, RR 0.83, 95% CI 0.70-0.99) and excess sitting time (≥ 6 h/day vs. 0- < 3 h/day RR 1.22, 95% CI 1.02, 1.47) were associated with risk of invasive BC only. There was no consistent evidence for effect modification by smoking status or sex. CONCLUSION: This study supports that MVPA and sitting time may play a role in BC incidence, but associations likely differ by stage at diagnosis. While additional studies are needed to confirm associations by stage, this study adds to the evidence of the importance of being physically active for cancer prevention.

Consistent and changing consumption of fast-food and full-service meals and 3-year weight change in a large population cohort study.

BACKGROUND: An average American consumes 3 meals weekly from fast-food or full-service restaurants, which contain more calories, fat, sodium, and cholesterol than meals prepared at home. OBJECTIVES: This study examined whether consistent and changing fast-food or full-service consumption was associated with weight change over a 3-y period. METHODS: Among 98,589 US adults from the American Cancer Society's Cancer Prevention Study-3, self-reported weight and fast-food and full-service consumption from 2015 and 2018 were examined using a multivariable-adjusted linear regression analysis to assess the association of consistent and changing consumption on 3-y weight change. RESULTS: Individuals who made no changes to their fast-food or full-service intake over the study period gained weight regardless of consumption frequency, although low consumers gained less weight than high consumers (low fast-food: ß = -1.08; 95% CI: -1.22, -0.93; low full-service: ß = -0.35; 95% CI: -0.50, -0.21; P < 0.001). Decreased fast-food intake during the study period (e.g., from high [>1 meal/wk] to low [≤0.5 meal/wk], high to medium [>0.5 to ≤1 meal/wk], or medium to low) and decreased full-service intake from high (≥1 meal/wk) to low (<1 meal/mo) were significantly associated with weight loss (high-low: ß = -2.77; 95% CI: -3.23, -2.31; high-medium: ß = -1.53; 95% CI: -1.72, -1.33; medium-low: ß = -0.85; 95% CI: -1.06, -0.63; high-low full-service: ß = -0.92; 95% CI: -1.36, -0.49; P < 0.001). Decreased consumption of both fast-food and full-service restaurant meals was associated with greater weight loss than decreasing fast-food alone (both: ß = -1.65; 95% CI: -1.82, -1.37; fast-food only: ß = -0.95; 95% CI: -1.12, -0.79; P < 0.001). CONCLUSIONS: Decreased consumption of fast-food and full-service meals over 3 y, particularly among high consumers at baseline, was associated with weight loss and may be an effective approach to weight loss. Moreover, decreasing both fast-food and full-service meal consumption was associated with a greater weight loss than decreasing only fast-food meal consumption.

Prospective Association of Daily Steps With Cardiovascular Disease: A Harmonized Meta-Analysis.

BACKGROUND: Taking fewer than the widely promoted "10 000 steps per day" has recently been associated with lower risk of all-cause mortality. The relationship of steps and cardiovascular disease (CVD) risk remains poorly described. A meta-analysis examining the dose-response relationship between steps per day and CVD can help inform clinical and public health guidelines. METHODS: Eight prospective studies (20 152 adults [ie, ≥18 years of age]) were included with device-measured steps and participants followed for CVD events. Studies quantified steps per day and CVD events were defined as fatal and nonfatal coronary heart disease, stroke, and heart failure. Cox proportional hazards regression analyses were completed using study-specific quartiles and hazard ratios (HR) and 95% CI were meta-analyzed with inverse-variance-weighted random effects models. RESULTS: The mean age of participants was 63.2±12.4 years and 52% were women. The mean follow-up was 6.2 years (123 209 person-years), with a total of 1523 CVD events (12.4 per 1000 participant-years) reported. There was a significant difference in the association of steps per day and CVD between older (ie, ≥60 years of age) and younger adults (ie, <60 years of age). For older adults, the HR for quartile 2 was 0.80 (95% CI, 0.69 to 0.93), 0.62 for quartile 3 (95% CI, 0.52 to 0.74), and 0.51 for quartile 4 (95% CI, 0.41 to 0.63) compared with the lowest quartile. For younger adults, the HR for quartile 2 was 0.79 (95% CI, 0.46 to 1.35), 0.90 for quartile 3 (95% CI, 0.64 to 1.25), and 0.95 for quartile 4 (95% CI, 0.61 to 1.48) compared with the lowest quartile. Restricted cubic splines demonstrated a nonlinear association whereby more steps were associated with decreased risk of CVD among older adults. CONCLUSIONS: For older adults, taking more daily steps was associated with a progressively decreased risk of CVD. Monitoring and promoting steps per day is a simple metric for clinician-patient communication and population health to reduce the risk of CVD.

Fracture Risk Among Older Cancer Survivors Compared With Older Adults Without a History of Cancer.

Importance: The number of cancer survivors living in the US is projected to be 26.1 million by 2040. Cancer survivors may be at increased risk of bone fractures, but research is limited in several important ways. Objective: To investigate the associations of cancer diagnoses, including time since diagnosis and stage at diagnosis, with risks of pelvic, radial, and vertebral fractures (separately and combined) among older cancer survivors and compared with fracture risk among older adults without a history of cancer. Secondarily, to examine differences in risk of fracture stratified by modifiable behaviors, treatment, and cancer type. Design, Setting, and Participants: This longitudinal cohort study used data from 92 431 older adults in the US Cancer Prevention Study II Nutrition Cohort linked with 1999 to 2017 Medicare claims. Data were analyzed from July 15, 2021, to May 3, 2022. Exposures: Cancer history, time since cancer diagnosis, and stage at cancer diagnosis. Main Outcomes and Measures: Hazard ratios (HRs) and 95% CIs for the risk of pelvic, radial, vertebral, and total frailty-related fractures were estimated using multivariate Cox proportional hazards regression. Stratification was used for secondary aims. Results: Among 92 431 participants (mean [SD] age, was 69.4 [6.0] years, 51 820 [56%] women, and 90 458 [97.9%] White], 12 943 participants experienced a frailty-related bone fracture. Compared with participants without a history of cancer, cancer survivors who were diagnosed 1 to less than 5 years earlier with advanced stage cancer had higher risk of fracture (HR, 2.12; 95% CI, 1.75-2.58). The higher fracture risk in cancer survivors with recent advanced stage diagnosis (vs no cancer) was driven largely by vertebral (HR, 2.46; 95% CI, 1.93-3.13) and pelvic (HR, 2.46; 95% CI, 1.84-3.29) fracture sites. Compared with cancer survivors who did not receive chemotherapy, survivors who received chemotherapy were more likely to have a fracture; this association was stronger within 5 years of diagnosis (HR, 1.31; 95% CI, 1.09-1.57) than 5 or more years after diagnosis (HR, 1.22; 95% CI, 0.99-1.51). Although the HR for risk of fracture was lower among physically active cancer survivors 5 or more years after diagnosis (HR, 0.76; 95% CI, 0.54-1.07), this result was not statistically significant, whereas current smoking was significantly associated with higher risk of fracture (HR, 2.27; 95% CI, 1.55-3.33). Conclusions and Relevance: Findings from this cohort study suggest that older adults with a history of cancer may benefit from clinical guidance on prevention of frailty-related fractures. If study findings are replicated, fracture prevention programs for survivors might include referrals for physical activity with cancer exercise professionals and smoking cessation programs.

Association of Socioeconomic and Geographic Factors With Diet Quality in US Adults.

Importance: Poor diet quality is a key factor associated with obesity and chronic disease. Understanding associations of socioeconomic and geographic factors with diet quality can inform public health and policy efforts for advancing health equity. Objective: To identify socioeconomic and geographic factors associated with diet quality in a large US cohort study. Design, Setting, and Participants: This cross-sectional study included adult men and women who enrolled in the Cancer Prevention Study-3 at American Cancer Society community events in 35 US states, the District of Columbia, and Puerto Rico between 2006 and 2013. Participants completed a validated food frequency questionnaire between 2015 and 2017. Data were analyzed from February to November 2021. Exposures: The main exposures included self-reported race and ethnicity, education, and household income. Geocoded addresses were used to classify urbanization level using Rural-Urban Commuting Area codes; US Department of Agriculture's Food Access Research Atlas database classified residence in food desert. Main Outcomes and Measures: Poor diet quality was defined as lowest quartile of dietary concordance with the 2020 American Cancer Society recommendations for cancer prevention score, based on sex-specific intake categories of vegetables and legumes, whole fruits, whole grains, red and processed meat, highly processed foods and refined grains, and sugar-sweetened beverages. Results: Among 155 331 adults, 123 115 were women (79.3%), and the mean (SD) age was 52 (9.7) years), and there were 1408 American Indian or Alaskan Native individuals (0.9%); 2721 Asian, Native Hawaiian, or Pacific Islander individuals (1.8%); 3829 Black individuals (2.5%); 7967 Hispanic individuals (5.1%); and 138 166 White individuals (88.9%). All key exposures assessed were statistically significantly and independently associated with poor diet quality. Compared with White participants, Black participants had a 16% (95% CI, 8%-25%) higher risk of poor diet quality, while Hispanic/Latino had 16% (95% CI, 12%-21%) lower risk and Asian, Native Hawaiian, and Pacific Islander participants had 33% (95% CI, 26%-40%) lower risk of poor diet quality. After controlling for other characteristics, rural residence was associated with a 61% (95% CI, 48%-75%) higher risk of poor diet quality, and living in a food desert was associated with a 17% (95% CI, 12%-22%) higher risk. Associations of income with diet quality and education with diet quality varied by race and ethnicity (income: P for interaction = .01; education: P for interaction < .001). All diet score components were associated with disparities observed. Conclusions and Relevance: This cross-sectional study found that multiple individual-level socioeconomic and geographic variables were independently associated with poor diet quality among a large, racially and ethnically and geographically diverse US cohort. These findings could help to identify groups at highest risk of outcomes associated with poor diet to inform future approaches for advancing health equity.

Racial, Ethnic, and Nativity Disparities in Physical Activity and Sedentary Time among Cancer Prevention Study-3 Participants.

PURPOSE: Understanding racial/ethnic and nativity disparities in physical activity (PA) is important, as certain subgroups bear a disproportionate burden of physical inactivity-related diseases. This descriptive study compared mean leisure-time moderate-to-vigorous intensity physical activity (LTMVPA) by race/ethnicity and nativity. METHODS: The Cancer Prevention Study-3 (78.1% women; age, 47.9 ± 9.7 yr) includes 4722 (1.9%) Asian/Pacific Islander; 1232 (0.5%) Black/Indigenous (non-White) Latino; 16,041 (6.5%) White Latino; 9295 (3.8%) non-Latino Black; 2623 (1.1%) Indigenous American; and 210,504 (85.7%) non-Latino White participants across the United States and Puerto Rico. Participants completed validated LTMVPA and 24-h time use surveys at enrollment (2006-2013). Differences in LTMVPA across race/ethnicity and nativity were examined by ANCOVA with paired Tukey tests adjusting for age and sex. The proportion of time spent sitting, sleeping, and on PA by race/ethnicity was also compared. RESULTS: There were significant differences in LTMVPA by race/ethnicity (race main effect, P < 0.001; nativity, P = 0.072; interaction, P < 0.001). Pairwise comparisons showed that White participants born abroad were the most active (23.8 MET-h·wk-1) and non-White Latino participants born abroad were the least active (17.9 MET-h·wk-1). Among Latinos, participants born in Puerto Rico were 6.6-7.3 MET-h·wk-1 less active than participants born in Mexico, the United States/Canada, or other countries. There were variations in time use by race/ethnicity, with the largest difference in time spent sitting while watching TV. Black participants spent 14.8% of the day (~3.5 h) sitting watching TV, which was 78 min longer than Asian/Pacific Islander participants. CONCLUSIONS: This study suggests that there are differences in LTMVPA accumulation by race, ethnicity, and nativity. Results can be used to identify demographic groups that may benefit from culturally tailored PA interventions.

Daily steps and all-cause mortality: a meta-analysis of 15 international cohorts.

BACKGROUND: Although 10 000 steps per day is widely promoted to have health benefits, there is little evidence to support this recommendation. We aimed to determine the association between number of steps per day and stepping rate with all-cause mortality. METHODS: In this meta-analysis, we identified studies investigating the effect of daily step count on all-cause mortality in adults (aged ≥18 years), via a previously published systematic review and expert knowledge of the field. We asked participating study investigators to process their participant-level data following a standardised protocol. The primary outcome was all-cause mortality collected from death certificates and country registries. We analysed the dose-response association of steps per day and stepping rate with all-cause mortality. We did Cox proportional hazards regression analyses using study-specific quartiles of steps per day and calculated hazard ratios (HRs) with inverse-variance weighted random effects models. FINDINGS: We identified 15 studies, of which seven were published and eight were unpublished, with study start dates between 1999 and 2018. The total sample included 47 471 adults, among whom there were 3013 deaths (10·1 per 1000 participant-years) over a median follow-up of 7·1 years ([IQR 4·3-9·9]; total sum of follow-up across studies was 297 837 person-years). Quartile median steps per day were 3553 for quartile 1, 5801 for quartile 2, 7842 for quartile 3, and 10 901 for quartile 4. Compared with the lowest quartile, the adjusted HR for all-cause mortality was 0·60 (95% CI 0·51-0·71) for quartile 2, 0·55 (0·49-0·62) for quartile 3, and 0·47 (0·39-0·57) for quartile 4. Restricted cubic splines showed progressively decreasing risk of mortality among adults aged 60 years and older with increasing number of steps per day until 6000-8000 steps per day and among adults younger than 60 years until 8000-10 000 steps per day. Adjusting for number of steps per day, comparing quartile 1 with quartile 4, the association between higher stepping rates and mortality was attenuated but remained significant for a peak of 30 min (HR 0·67 [95% CI 0·56-0·83]) and a peak of 60 min (0·67 [0·50-0·90]), but not significant for time (min per day) spent walking at 40 steps per min or faster (1·12 [0·96-1·32]) and 100 steps per min or faster (0·86 [0·58-1·28]). INTERPRETATION: Taking more steps per day was associated with a progressively lower risk of all-cause mortality, up to a level that varied by age. The findings from this meta-analysis can be used to inform step guidelines for public health promotion of physical activity. FUNDING: US Centers for Disease Control and Prevention.

American Cancer Society nutrition and physical activity guideline for cancer survivors.

The overall 5-year relative survival rate for all cancers combined is now 68%, and there are over 16.9 million survivors in the United States. Evidence from laboratory and observational studies suggests that factors such as diet, physical activity, and obesity may affect risk for recurrence and overall survival after a cancer diagnosis. The purpose of this American Cancer Society guideline is to provide evidence-based, cancer-specific recommendations for anthropometric parameters, physical activity, diet, and alcohol intake for reducing recurrence and cancer-specific and overall mortality. The audiences for this guideline are health care providers caring for cancer survivors as well as cancer survivors and their families. The guideline is intended to serve as a resource for informing American Cancer Society programs, health policy, and the media. Sources of evidence that form the basis of this guideline are systematic literature reviews, meta-analyses, pooled analyses of cohort studies, and large randomized clinical trials published since 2012. Recommendations for nutrition and physical activity during cancer treatment, informed by current practice, large cancer care organizations, and reviews of other expert bodies, are also presented. To provide additional context for the guidelines, the authors also include information on the relationship between health-related behaviors and comorbidities, long-term sequelae and patient-reported outcomes, and health disparities, with attention to enabling survivors' ability to adhere to recommendations. Approaches to meet survivors' needs are addressed as well as clinical care coordination and resources for nutrition and physical activity counseling after a cancer diagnosis.

Pilot Randomized Controlled Trial of Feasibility, Acceptability, and Preliminary Efficacy of a Web-Based Physical Activity and Sedentary Time Intervention for Survivors of Physical Inactivity-Related Cancers.

BACKGROUND: This pilot study explored the feasibility, acceptability, and usability of a web-based intervention for survivors of physical inactivity-related cancers through a two-arm, 12-week randomized controlled trial. Secondarily, this study tested the change in physical activity (PA) and sedentary time with intervention exposure. METHODS: Prior to randomization to the intervention (n = 45) or behavior "as usual" wait-listed control (n = 40) groups, participants completed baseline surveys and an accelerometer protocol. The intervention focused on increasing PA and decreasing sedentary time through social cognitive theory techniques. Follow-up acceptability/usability surveys (intervention group only) and accelerometers were sent after the intervention period. Information on intervention completion, adverse events, and user statistics were collected to determine feasibility. Median login time and mean acceptability/usability scores were calculated. RESULTS: Participants (mean age = 60 ± 7 years) included female (n = 80, 94%) and male survivors of breast (82%), colon (6%), endometrial (6%), bladder (4%), and kidney (2%) cancer. Seventy-eight (91.7%) participants returned partially or fully complete post-intervention data. There were no reported injuries or safety concerns. Intervention participants logged into the website for a total of 95 min (Q1, Q3 = 11, 204). System usability scores (72 ± 3) indicated above average usability of the website. Changes in time spent active and sedentary were not statistically significantly different between groups (p = 0.45), but within-group changes suggested intervention group participants spent more time active and less time sedentary after the intervention. CONCLUSION: Results of this pilot study suggest its feasibility and acceptability for survivors of several inactivity-related cancers. Additional research to determine long-term efficacy is warranted. This low-cost online-only intervention has the potential to have a very broad reach. TRIAL REGISTRATION: Clinical Trials Number: NCT03983083. Date registered: June 12th, 2019.

Prospective associations of hemoglobin A1c and c-peptide with risk of diabetes-related cancers in the Cancer Prevention Study-II Nutrition Cohort.

Self-reported type 2 diabetes mellitus (T2DM) is a risk factor for many cancers, suggesting its pathology relates to carcinogenesis. We conducted a case-cohort study to examine associations of hemoglobin A1c (HbA1c) and c-peptide with cancers associated with self-reported T2DM. This study was drawn from a prospective cohort of 32,383 women and men who provided blood specimens at baseline: c-peptide and HbA1c were assessed in 3,000 randomly selected participants who were cancer-free-at-baseline and an additional 2,281 participants who were cancer-free-at-baseline and subsequently diagnosed with incident colorectal, liver, pancreatic, female breast, endometrial, ovarian, bladder, or kidney cancers. Weighted-Cox regression models estimated hazards ratios (HRs) and 95% confidence intervals (CI), adjusted for covariates. C-peptide was associated with higher risk of liver cancer (per standard deviation (SD) HR: 1.80; 95%CI: 1.32-2.46). HbA1c was associated with higher risk of pancreatic cancer (per SD HR: 1.21 95%CI 1.05-1.40) and with some suggestion of higher risks for all-cancers-of-interest (per SD HR: 1.05; 95%CI: 0.99-1.11) and colorectal (per SD HR: 1.09; 95%CI: 0.98-1.20), ovarian (per SD HR: 1.18; 95%CI 0.96-1.45) and bladder (per SD HR: 1.08; 95%CI 0.96-1.21) cancers. Compared to no self-reported T2DM and HbA1c <6.5% (reference group), self-reported T2DM and HbA1c <6.5% (i.e., T2DM in good glycemic control) was not associated with risk of colorectal cancer, whereas it was associated with higher risks of all-cancers-of-interest combined (HR: 1.28; 95%CI: 1.01-1.62), especially for breast and endometrial cancers. Additional large, prospective studies are needed to further explore the roles of hyperglycemia, hyperinsulinemia, and related metabolic traits with T2DM-associated cancers to better understand the mechanisms underlying the self-reported T2DM-cancer association and to identify persons at higher cancer risk.

The Role of Individual-Level Factors in Rural Mortality Disparities.

Introduction: The role of individual risk factors in the rural‒urban mortality disparity is poorly understood. The purpose of this study was to explore the role of individual-level demographics and health behaviors on the association between rural residence and the risk of mortality. Methods: Cancer Prevention Study-II participants provided updated addresses throughout the study period. Rural‒Urban Commuting Area codes were assigned to participants' geocoded addresses as a time-varying exposure. Cox proportional hazards regression was used to estimate hazard ratios and 95% CIs for mortality associated with Rural‒Urban Commuting Area groups. Results: After adjustment for age and sex, residents of rural areas/small towns had a small but statistically significant elevated risk of all-cause mortality compared with metropolitan residents (hazard ratio=1.04; 95% CI=1.01, 1.06). Adjustment for additional covariates attenuated the association entirely (hazard ratio=0.99; 95% CI=0.97, 1.01). Individually, adjustment for education (hazard ratio=0.99; 95% CI=0.97, 1.01), alcohol use (hazard ratio=1.01; 95% CI=0.99, 1.04), and moderate-to-vigorous intensity aerobic physical activity (hazard ratio=1.00; 95% CI=0.97, 1.02) eliminated the elevated risk. Conclusions: The elevated risk of death for rural compared with that for metropolitan residents appeared to be largely explained by individual-level demographics and health behaviors. If replicated in other subpopulations, these results suggest that modifiable factors may play an important role in reducing the rural mortality disparity.

Prospective changes in physical activity, sedentary time and sleep during the COVID-19 pandemic in a US-based cohort study.

OBJECTIVES: Assess differences in movement behaviours within the 24-hour cycle, including light intensity physical activity (LPA), moderate-to-vigorous physical activity (MVPA), sedentary time and sleep, before and during the COVID-19 pandemic and assess these differences stratified by several relevant factors in a subcohort of the Cancer Prevention Study-3. DESIGN AND SETTING: US-based longitudinal cohort study (2018-August 2020). PARTICIPANTS: N=1992 participants, of which 1304 (65.5%) are women, and 1512 (75.9%) are non-Latino white, with a mean age 57.0 (9.8) years. MEASURES: Age, sex, race/ethnicity, education; self-reported LPA, MVPA, sedentary time and sleep duration collected before and during the pandemic; pandemic-related changes in work, childcare and living arrangement; COVID-19 health history. RESULTS: Compared to 2018, participants spent an additional 104 min/day sedentary, 61 fewer min/day in LPA and 43 fewer min/day in MVPA during the pandemic. Time spent sleeping was similar at the two time points. Differences in movement behaviours were more pronounced among men, those with a higher level of education, and those who were more active before the pandemic. CONCLUSIONS: From 2018 to Summer 2020, during the COVID-19 pandemic, US adults have made significant shifts in daily time spent in LPA, MVPA and sedentary. There is an urgent need to promote more physical activity and less sedentary time during this public health crisis to avoid sustaining these patterns long-term.

A method for remotely measuring physical function in large epidemiologic cohorts: Feasibility and validity of a video-guided sit-to-stand test.

INTRODUCTION: Traditional measures of muscular strength require in-person visits, making administration in large epidemiologic cohorts difficult. This has left gaps in the literature regarding relationships between strength and long-term health outcomes. The aim of this study was to test the feasibility and validity of a video-led, self-administered 30-second sit-to-stand (STS) test in a sub-cohort of the U.S.-based Cancer Prevention Study-3. METHODS: A video was created to guide participants through the STS test. Participants submitted self-reported scores (n = 1851), and optional video recordings of tests (n = 134). Two reviewers scored all video tests. Means and standard deviations (SD) were calculated for self-reported and video-observed scores. Mean differences (95% confidence intervals (CI)) and Spearman correlation coefficients between self-reported and observed scores were calculated, stratifying by demographic characteristics. RESULTS: Participants who uploaded a video reported 14.1 (SD = 3.5) stands, which was not significantly different from the number of stands achieved by the full cohort (13.9 (SD = 4.2), P-difference = 0.39). Self-reported and video-observed scores were highly correlated (ρ = 0.97, mean difference = 0.3, 95% CI = 0.1-0.5). There were no significant differences in correlations by sociodemographic factors (all P-differences ≥0.42). CONCLUSIONS: This study suggests that the self-administered, video-guided STS test may be appropriate for participants of varying ages, body sizes, and activity levels, and is feasible for implementation within large, longitudinal studies. This video-guided test would also be useful for remote adaptation of the STS test during the COVID-19 pandemic.

Prospective COVID-19 related changes in physical activity and sedentary time and associations with symptoms of depression and anxiety.

PROBLEM: The COVID-19 pandemic is associated with psychological distress. Decreased moderate-vigorous physical activity (MVPA) and increased sedentary time may be exacerbating pandemic-related symptoms of anxiety and depression, but existing studies exploring these associations are almost entirely cross-sectional. METHODS: Reported data from 2018 and Summer 2020 were used to create change categories based on compliance with MVPA guidelines and relative sedentary time. Participants completed the Patient Health Questionnaire-4 (PHQ-4) in Summer 2020. Associations among changes in MVPA and sedentary time (separately and jointly) with psychological distress (total PHQ-4 score) were examined with ordinal logistic regression and associations with depressive or anxiety symptoms were examined with logistic regression. RESULTS: Among 2,240 participants (65% women, mean age 57.5 years), 67% increased sedentary time and 21% became inactive between the two time points. After multivariate adjustment, participants who became (OR = 1.71, 95% CI: 1.05-2.78) or remained inactive (OR = 2.07, 1.34-3.22) were more likely to experience depressive symptoms compared to those who remained active. Participants who increased sedentary time were also more likely to experience depressive symptoms compared to those who maintained sedentary time (OR = 1.78, 1.13-2.81). Jointly, those who increased sedentary time while remaining (OR = 3.67, 1.83-7.38) or becoming inactive (OR = 3.02, 1.44-6.34) were much more likely to have depressive symptoms compared to the joint referent (remained active/maintained sedentary time). Associations with anxiety symptoms were not statistically significant. CONCLUSIONS: These findings support the value of promoting MVPA and limiting sedentary time during stressful events associated with psychological distress, like the COVID-19 pandemic.

Stressors and Other Pandemic-related Predictors of Prospective Changes in Psychological Distress.

BACKGROUND: Numerous studies have documented mental health challenges during the COVID-19 pandemic. Few studies included pre-pandemic levels of mental health or were comprehensive in assessing factors likely associated with longer-term mental health impacts. METHODS: Analyses used prospective data from a subset of participants in the nationwide Cancer Prevention Study-3 (CPS-3) United States cohort (N=2,359; 1,534 women; 825 men) who completed surveys in 2018 and during the COVID-19 pandemic (July-September 2020). Logistic regressions examined associations of pandemic-related stressors, sociodemographic and other predictors with (i) overall psychological distress (PD) and depression and anxiety separately during the COVID-19 pandemic and (ii) change in PD from 2018 to during the pandemic (low/low; high to low; low to high; high/high). FINDINGS: During the pandemic, 10% of participants reported moderate-to-severe PD and almost half (42%) reported at least mild PD. Pandemic PD levels were associated with pre-pandemic PD (female OR=5.65; male OR=9.70), financial stressors (female OR=2.48; male OR=3.68), and work/life balance stressors (female OR=3.03; male OR=3.33) experienced since the pandemic began. These stressors also predicted an escalation from low PD in 2018 to high PD during the pandemic. Factors associated with high PD at both time points included younger age, female sex, and financial stressors. INTERPRETATION: These results highlight the importance of regular mental health assessment and support among those with a history of mental health problems and those experiencing pandemic-related stressors, such as those with caregiving responsibilities or job changes. FUNDING: The American Cancer Society funds the creation, maintenance, and updating of the CPS-3.