By Jeanna M. Qiu, Summer Research Interna; *Mei R. Fu, PhD, RN, ACNS-BC, FAANa; Deborah Axelrod, MD, FACSb,c; Amber A. Guth, MD, FACSb,c; Jason Fletcher, PhD a; Joan Scagliola, RN, MSNc; Robin Kleinman, RN, MSNc; Kristin Pego RN, NP-BCc; Jo Anne Jaravata RN, BSNc; Caitlin E. Ryan, Summer Research Fellowa; Nicholas Chan, Research Assistanta; Gail D’Eramo Melkus, EdD,C-NP,FAAN a; Judith Haber, PhD, RN, ACNS-BC, FAANa
aCollege of Nursing, New York University, New York, NY; bDepartment of Surgery, New York University School of Medicine, New York, NY; cNYU Laura and Isaac Perlmutter Cancer Center, New York, NY
Vol. 28 No. 3 - Lymphlink Reprint, Archived July 2015
Being obese or gaining weight after a breast cancer diagnosis not only increases the risk of lymphedema, but also the risk of cancer recurrence1-3 as well as other comorbid conditions (eg, type 2 diabetes, asthma, osteoarthritis, cardiovascular disease).4-5 Weight gain is commonly reported by women treated for breast cancer.6,7 There are numerous weight management programs available to assist with weight loss. However, no one program works for the majority of people; weight management is very individualized. Nevertheless, the core of weight management is to eat a nutrition-balanced, portion-appropriate diet. It is also important to stay hydrated, exercise, and get adequate sleep.4,6,7 The purpose of this study was to preliminarily evaluate the feasibility and efficacy of The-Optimal-Lymph-Flow™: Keep a Healthy Weight program to help breast cancer survivors maintain their pre-surgery weight by encouraging 1. a nutrition-balanced (more vegetables, fruits, and quality proteins), portion-appropriate diet (feeling 75% full for each meal), 2. hydration (about 6-8 glasses of water per day), 3. adequate sleep, and 4. daily or weekly physical activities.8 Table 1 provides rationales for the program.
The study was approved by the institutional review board of New York University Langone Medical Center. A prospective, longitudinal, quasi-experimental design with repeated measures was used. The study’s primary outcomes were weight and body mass index (BMI). The secondary outcome was the feasibility of the study in terms of whether patients initiated or maintained the program. We recruited women who were over age 21, had a first-time diagnosis of breast cancer (Stage I-III), and were scheduled for surgical treatment, including lumpectomy or mastectomy, sentinel lymph node biopsy (SLNB), or axillary lymph node dissection (ALND). Women with metastatic cancer (Stage IV) and prior history of breast cancer were excluded. Between December 2011 and April 2014, we prospectively enrolled 140 women and followed the participants for 12 months after surgery at specific time points: pre-surgery, 4-8 weeks post surgery, and 12 months post surgery. All the participants received an education sheet about The-Optimal-Lymph-Flow™: Keep a Healthy Weight.8
Data collection procedure
Demographic and clinical data were collected; weight and BMI pre-surgery, 4-8 weeks, and 12 months after surgery were assessed. An electrical bioimpedance device (InBody 520, Biospace Co., Ltd) was used to measure the participants’ weight. BMI was calculated using the formula: weight (kg) / height (m2). Data were collected through self-reporting concerning the feasibility for patients to initiate and carry out the weight management program in terms of nutrition-balanced diet, sleep, hydration, and large muscle exercises.
Descriptive statistics were calculated for demographic and clinical characteristics including weight, weight change, and BMI. Obesity was defined as BMI over 30 kg/m2, overweight as BMI of 25–29.9 kg/m2, normal weight as BMI of 18.5–24.9 kg/m2, and underweight as under 18.5 kg/m2.9 Weight change was defined as a 5% gain or loss relative to pre-surgery weight and was evaluated at 4 to 8 weeks and 12 months post surgery. Percent of weight change was calculated as: pre-surgery weight (lb) - weight at 12 months post surgery (lb)/weight at 12 months post surgery (lb) x100%. The changes in weight were then categorized into: no change (<5% weight loss or weight gain), over 5% weight gain, or over 5% weight loss.10 Patients identified as underweight were categorized in the underweight/normal weight group due to the very small sample size of 2 patients. Only 4 out of 140 participants did not complete the study, and their data were not included in the data analysis.
Weight and BMI
At enrollment (pre-surgery), more than 60% of the participants were obese (30.8%; n = 42/136) or overweight (32.4%; n = 44/136), while only 2 participants were underweight, and 37% (n = 50/136) were of normal weight. This pattern of obesity and overweight persisted at 4-8 weeks and 12 months post surgery. Average weight and BMI were stable across measurement periods. There were no significant changes in mean weight and mean BMI or BMI categories over 12 months. Approximately 94% (n=128/136) of the participants had no weight gain at 4-8 weeks post surgery and 72 % (n=98/136) at 12-months post surgery.
At 12 months post surgery, 15.4% (n=21/136) of the participants lost more than 5% of their weight, while 12.5% (n=17/136) had over 5% weight gain. There were no significant differences in terms of demographic and clinical characteristics among participants who maintained, lost, or gained weight over the study period, except that significantly more patients who received neo-adjuvant chemotherapy had over 5% of weight gain (p=0.025).
Large muscle exercises
Over the study period, 49.2% (n=67/136) of the participants reported 30 minutes of daily large muscle exercises, and 27.9% (n=38/136) reported large muscle exercise 2-3 times weekly. However, 23.5% (n=32/136) reported no large muscle exercises.
Diet, hydration, and sleep
In terms of following nutrition-balanced and portion-appropriate diet and staying hydrated, 79.4% (n=108/136) had practiced a nutrition-balanced diet and hydration guide daily, and 18.3% (n=25/136) have 2-3 times weekly, while only 4% (n=6/136) did not follow the diet and hydration guide. 77.9% (n=106/136) reported getting at least 7-8 hours of sleep per night.
Discussion and conclusions
Our study demonstrates that obesity and overweight are common among women at the time of cancer diagnosis, and the patterns of obesity and overweight persist during the first year of treatment. Recent research reported that more than 60% of women treated for breast cancer had weight gain and more than 47% had at least 5% weight gain during the first year of cancer treatment.10 In our study, over 5% weight gain was observed in only 1.5% (n=2/136) of participants at 4-8 weeks post surgery and 12.5% (n=17/136) at 12 months post surgery. Meanwhile, 94.1% (n=128/136) and 72.1% (n=98/136) had no changes in their weight at 4-8 weeks and 12 months post surgery, respectively.
From our previous experience, “too much trouble” (when a project requires a daily log or researchers frequently contact the participants) is a major reason for potential participants to decline study participation and for participants to drop out of a study.8,11 In addition, from our previous qualitative study, we understand that patients desire self-care, including weight management that works for them, can be part of their daily routine, and are perceived as their own initiative and motivation, rather than the behaviors that they have to adhere to because the clinicians or researchers want them to do so.8,11 Furthermore, one goal of this study was to discern which behaviors are initiated, continued, or discontinued by the participants in terms of weight management. We designed the study to only assess the weight management behaviors at the study endpoint of 12 months after intervention with the intention that participants would initiate and sustain the behaviors that work for them in their daily lives for weight management. It should be noted that more than 75% of participants followed the diet, hydration, and sleep recommendation on a daily basis during the study time. It is possible that those patients will continue the established weight management plan in the future.
However, 20% of participants did not follow the daily or weekly large muscle exercises and sleep recommendations. Those patients may need more intense intervention to help to initiate or sustain weight management behaviors. Future research should investigate the characteristics of those patients for targeted interventions. It should be also noted that we consider diet, hydration, sleep, and large muscle exercises as integral components of The-Optimal-Lymph-Flow™: Keep a Healthy Weight program, thus we did not intended to analyze the individual effect of each component on weight management in this study.
It is unknown whether post-diagnosis weight loss can lead to beneficial improvement for prognosis and disease-free survival from breast cancer. At the very least, maintaining pre-surgery weight is important to reduce the risk of lymphedema and other related comorbid conditions for women treated for breast cancer.4,5 The-Optimal-Lymph-Flow™: Keep a Healthy Weight is feasible and effective to maintain pre-surgery weight by providing general instructions on following a nutrition-balanced, portion-appropriate diet, achieving adequate sleep, and participating in physical activities daily or weekly. Such general instructions may result in less burden on and stress in women when facing diagnosis of and treatment for breast cancer.
This study was supported by the National Institute of Health (NINR Project # 1R21NR012288-01A and NIMHD Project # P60 MD000538-03). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH and other funders. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
- Ridner SH, Dietrich MS, Stewart BR, Armer JM. Body mass index and breast cancer treatment- related lymphedema. Support Care Cancer. 2011; 19(6):853–857
- Helyer LK, Varnic M, Le LW, Leong W, McCready D. Obesity is a risk factor for developing postoperative lymphedema in breast cancer patients. Breast J. 2010; 16(1):48–54.
- Jammallo LS, Miller CL, Singer M, Horick NK, Skolny MN, Specht MC, et al. Impact of body mass index and weight fluctuation on lymphedema risk in patients treated for breast cancer. Breast Cancer Res Treat [Internet]. 2013 Nov [cited 2015 Jan 23]; 142(1): 59-67. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3873728/
- Demark-Wahnefried W, Campbell K, Hayes, SC. Weight management and its role in breast cancer rehabilitation. Cancer [Internet]. 2012 Apr [cited 2015 Jan 23]; 118(80):2277-2287. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812811/
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- Fu MR, Axelrod D, Guth A, Cartwright- Alcarese F,Qiu Z, Goldberg J, et al. Proactive approach to lymphedema risk reduction: a prospective study. Ann Surg Oncol. 2014; 21(11): 3481-3498.
- WHO (World Health Organization). Obesity and overweight fact sheet N°311 Updated August 2014. 2014 [cited 2014 Nov 3]; Available from: http://www.who.int/mediacentre/factsheets/fs311/en/.
- Yaw YH, Kandiah M, Shariff ZM, Mun CY, Hashim Z, Yusof RM, et al. Pattern of weight changes in women with breast cancer. Asian Pacific J Cancer Prev [Internet]. 2010[cited 2015 Jan 23] 11(6):1535-1540. Available from: http://www.apocpcontrol.org/page/apjcp_issues_view.php?sid=Entrez:PubMed&id=pmid:21338193&key=2010.11.6.1535
- Fu MR, Rosedale M. Breast cancer survivors’ experiences of lymphedema-related symptoms. J Pain Symptom Manage 2009; 38: 849-859 [PMID: 19819668]