Effects of an exercise and hypocaloric healthy eating intervention on indices of psychological health status, hypothalamic-pituitary-adrenal axis regulation and immune function after early-stage breast cancer: a randomised controlled trial.

INTRODUCTION: Many women experience emotional distress, depression and anxiety after a diagnosis of breast cancer. Psychological stress and depression have been associated with hypothalamic-pituitary-adrenal (HPA) axis dysregulation that may adversely affect immune system functioning and impact upon survival. This study investigated the effects of a lifestyle intervention on indices of psychological health status, HPA axis regulation and immune function in overweight women recovering from early-stage breast cancer treatment. METHODS: A total of 85 women treated for breast cancer 3 to 18 months previously were randomly allocated to a 6-month exercise and hypocaloric healthy eating program plus usual care or usual care alone (control group). Women in the intervention group received three supervised exercise sessions per week and individualized dietary advice, supplemented by weekly nutrition seminars. Depressive symptoms (Beck Depression Inventory version II: BDI-II), perceived stress (Perceived Stress Scale: PSS), salivary diurnal cortisol rhythms; inflammatory cytokines (IL-6 and Tumor necrosis factor-α), leukocyte phenotype counts, natural killer (NK) cell cytotoxicity and lymphocyte proliferation following mitogenic stimulation were assessed at baseline and 6-month follow up. RESULTS: Compared with the control group, the intervention group exhibited a reduction in depressive symptoms (adjusted mean difference, 95% confidence intervals (95% CI): -3.12, -1.03 to -5.26; P = 0.004) at the 6-month follow-up but no significant decrease in PSS scores (-2.07, -4.96 to 0.82; P = 0.16). The lifestyle intervention also had a significant impact on diurnal salivary cortisol rhythm compared with usual care alone, as evidenced by an increase in morning salivary cortisol at the 6-month follow-up (P <0.04), indicating a change in HPA axis regulation. Women in the control group had higher total leukocyte, neutrophil and lymphocyte counts in comparison to the intervention group at the 6-month follow-up (P ≤0.05), whereas there was no difference in NK cell counts (P = 0.46), NK cell cytotoxicity (P = 0.85) or lymphocyte proliferation responses (P = 0.11) between the two groups. CONCLUSION: Our results show that the lifestyle intervention resulted in a reduction in depressive symptoms and a normalisation of HPA axis regulation. Such changes could have important implications for long-term survival in women recovering from early-breast cancer treatment. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN08045231.

Physical activity, burnout and quality of life in medical students: A systematic review.

BACKGROUND: Medical students are at risk of burnout and reduced quality of life (QoL). The risk of burnout doubles from third to sixth year of medical school, and medical students have an 8%-11% lower QoL than nonmedical students. It is imperative to prevent this, as burnout and reduced QoL is independently associated with errors in practice. This systematic review aims to examine whether physical activity/exercise is associated with burnout and/or QoL in medical students. METHODS: Articles were identified through database searches of Embase, Medline, PsycINFO, Scopus and Web of Science. Studies were included if both physical activity/exercise and burnout or QoL were measured and limited to those focussing on medical students. Risk of bias was assessed using accredited cohort and cross-sectional checklists. A narrative synthesis was conducted due to heterogeneity in the dataset. FINDINGS: Eighteen studies were included, comprising 11,500 medical students across 13 countries. Physical activity was negatively associated with burnout and positively associated with QoL. Furthermore, the findings were suggestive of a dose-response effect of physical activity on both burnout and QoL; higher intensities and frequencies precipitated greater improvements in outcomes. CONCLUSIONS: This multinational review demonstrates that physical activity is associated with reduced burnout and improved QoL in medical students. It also identifies a paucity of research into the optimal intensity, frequency, volume and mode of physical activity. Further research, building on this review, is likely to inform the long overdue development of evidence-based, well-being curricula. This could involve incorporating physical activity into medical education which may improve well-being and better prepare students for the demands of medical practice.

"Booster" interventions to sustain increases in physical activity in middle-aged adults in deprived urban neighbourhoods: internal pilot and feasibility study.

BACKGROUND: Systematic reviews have identified a range of brief interventions which increase physical activity in previously sedentary people. A randomised controlled trial is needed to assess whether providing motivational interviewing, three months after giving initial advice, sustains physical activity levels in those who recently became physically active. This paper reports the results of an internal pilot study designed to test the feasibility of the study in terms of recruitment, per protocol delivery of the intervention and retention at three months. METHODS: Participants were: aged 40-64 years; resident in deprived areas of Sheffield, UK; and, had recently become physically active as a result of using a brief intervention following an invitation from a mass mail out. INTERVENTIONS: Motivational Interviewing 'boosters' aimed at sustaining change in physical activity status delivered face-to-face or over the telephone compared with no further intervention. Outcomes of the feasibility study: recruitment of 60 participants from mail out of 3,300; retention of 45 participants with 3-month follow-up accelerometry measurements; 70% of those randomised to boosters receiving intervention per protocol. Sample size and power were recalculated using the accelerometry data collected. RESULTS: Forty-seven participants were randomised (78% of the feasibility target); 37 participants were retained at three months, 29 with at least four days of accelerometry data (64% of the feasibility target); 79% of those allocated boosters received them per protocol (surpassing the feasibility target). The proposed sample size of 600 was confirmed as appropriate and power is expected to be sufficient to detect a difference between groups. CONCLUSIONS: The main study will continue with the original recruitment target of 600 participants but to ensure feasibility, it is necessary to increase recruitment and improve the numbers of those followed-up who have evaluable data. Strategies will include increasing the number of initial invitations sent out and improving the training of research assistants and participants in the positioning of the accelerometer.

A randomised controlled trial and cost-effectiveness evaluation of "booster" interventions to sustain increases in physical activity in middle-aged adults in deprived urban neighbourhoods.

BACKGROUND: Systematic reviews have identified a range of brief interventions which increase physical activity in previously sedentary people. There is an absence of evidence about whether follow up beyond three months can maintain long term physical activity. This study assesses whether it is worth providing motivational interviews, three months after giving initial advice, to those who have become more active. METHODS/DESIGN: Study candidates (n = 1500) will initially be given an interactive DVD and receive two telephone follow ups at monthly intervals checking on receipt and use of the DVD. Only those that have increased their physical activity after three months (n = 600) will be randomised into the study. These participants will receive either a "mini booster" (n = 200), "full booster" (n = 200) or no booster (n = 200). The "mini booster" consists of two telephone calls one month apart to discuss physical activity and maintenance strategies. The "full booster" consists of a face-to-face meeting with the facilitator at the same intervals. The purpose of these booster sessions is to help the individual maintain their increase in physical activity. Differences in physical activity, quality of life and costs associated with the booster interventions, will be measured three and nine months from randomisation. The research will be conducted in 20 of the most deprived neighbourhoods in Sheffield, which have large, ethnically diverse populations, high levels of economic deprivation, low levels of physical activity, poorer health and shorter life expectancy. Participants will be recruited through general practices and community groups, as well as by postal invitation, to ensure the participation of minority ethnic groups and those with lower levels of literacy. Sheffield City Council and Primary Care Trust fund a range of facilities and activities to promote physical activity and variations in access to these between neighbourhoods will make it possible to examine whether the effectiveness of the intervention is modified by access to community facilities. A one-year integrated feasibility study will confirm that recruitment targets are achievable based on a 10% sample. DISCUSSION: The choice of study population, study interventions, brief intervention preceding the study, and outcome measure are discussed. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN56495859; ClinicalTrials.gov: NCT00836459.

Accessibility of salient beliefs about the outcomes of physical activity.

OBJECTIVES: Attitudes may influence behaviour through both deliberative and automatic processes. To investigate the automatic influences of attitudes, this study explores the accessibility of modally salient beliefs about physical activity outcomes using response latency measures. DESIGN: Response latencies for modally salient beliefs for physically activity outcomes were compared with latencies for non-salient, hygiene outcomes. Possible relationships between self-report and response latency was assessed between- and within-subjects. METHOD: Regularly active participants (N=148) completed a computer-based response latency task in which they indicated whether an outcome, for example more fit, was a likely or unlikely consequence of six different physical activities, for example go running. Self-reports of the likelihood of these outcomes, their importance, intentions to participate in the physical activities and frequency of participation were obtained. RESULTS: As expected, the physical activity outcomes were more accessible than control outcomes. In addition, the outcome strong heart was less accessible than the outcomes more fit and have fun. There was only weak evidence, however, of any relationship between self-reports and the accessibility of the physical activity outcomes. CONCLUSION: Response latency data may represent a source of between-subject variation that differs from self-report. Discussion focuses on the possible origins of such a discrepancy.

Using the affective priming paradigm to explore the attitudes underlying walking behaviour.

UNLABELLED: Objectives. Walking is poorly represented in memory, making it difficult to measure using self-report and even harder to predict. To circumvent this, we used the affective priming paradigm (Fazio, Sanbonmatsu, Powell, & Kardes, 1986) to assess implicit attitudes towards walking. METHODS: Royal Air Force trainee aircraftsmen (N=188) wore pedometers for 1 week prior to completing the affective priming paradigm, questionnaire and interview. The affective priming paradigm involved a computer-based response latency task containing physical activity words as primes followed by adjectives as targets to be evaluated. Targets were drawn from two bipolar dichotomies, good-bad (the original Fazio et al. items) and happy-sad (mood). RESULTS: Priming for mood items was related to levels of physical activity with high frequency participants priming for the positive (happy) pole and low frequency participants priming for the negative (sad). Both groups primed for the negative element of the Fazio (good-bad) dichotomy. Regarding walking and running, there was no differentiation on the basis of participation level. Instead, facilitated responses to happy targets contrasted with inhibited responses to sad targets for both types of locomotion. There was weak evidence that intentions to run were associated with priming of positive target items, irrespective of category. CONCLUSIONS: The relationship between implicit attitudes and behaviour is complex. Whereas implicit attitudes were related to overall exercise participation, they were not related to the specific activity of walking, despite the behaviour being mainly under automatic control.

The theory of planned behaviour predicts self-reports of walking, but does not predict step count.

OBJECTIVES: This paper compares multiple measures of walking in two studies, and the second study compares how well Theory of Planned Behaviour (TPB) constructs perform in predicting these different measures. METHODS: In Study 1, 41 participants wore a New Lifestyles NL-2000 pedometer for 1 week. Subsequently, participants completed a questionnaire containing measures of the TPB constructs and two self-report measures of walking, followed by two interview measures of walking. For Study 2, 200 RAF trainee aircraftsmen wore pedometers for 2 weeks. At the end of each week, participants completed the questionnaire and interview measures of walking. RESULTS: Both studies found no significant association between questionnaire measures of walking and pedometer measures. In Study 1, the interview measures produced significant, large correlations with the pedometer measure, but these relationships were markedly weaker in the second study. TPB variables were found to explain 22% of variance in intention to walk in Study 1 and 45% of the variance in Study 2. In Study 2, prediction of subsequent measures of behaviour was found to be weak, except when using a single-item measure of walking. CONCLUSIONS: Recall of walking is poor, and accurate measurement by self-report is problematic. Although the TPB predicts intentions to walk well, it does not predict actual amount of walking, as assessed by pedometer. Possible reasons for these findings include the unique nature of walking as an activity primarily used to facilitate higher order goals. The use of single-item measures may exaggerate the effectiveness of the TPB model for walking, and possibly other forms of physical activity.