Clinical trial NCT06164119: Effects of Diet and Osteopathy on Quality of Life and Inflammation in Breast Cancer Patients Under Hormonal Therapy
Official title: A Randomised Effectiveness-implementation Trial for Evaluating Dietary and Manual Treatment With Osteopathic Techniques on Quality of Life and on Modulation of the Inflammatory State of Patients Diagnosed With Breast Cancer Undergoing Antiestrogenic Hormonal Treatment.
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: NA
Conditions: Breast Cancer
Keywords: hormonal therapy
treatment-related adverse events
osteopathic techniques
diet
quality of life
Lead sponsor: Fondazione IRCCS Istituto Nazionale dei Tumori, Milano
Sponsor class: OTHER
First posted: 2023-12-11
Enrollment: 600
Sex: FEMALE
Minimum age (years): 18
Maximum age (years): 85
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: FACTORIAL
Intervention model description: This is an hybrid type I eﬀectiveness-implementation trial, testing the effectiveness of clinical therapeutic interventions, coupled by exploration of the eﬀects of the implementation of the effective intervention(s) in clinical practice (professional practice changes, changes in processes of care, quality of intervention delivery, patient's satisfaction).

The effectiveness study will be a before-and-after randomized trial performed according to a 2 × 2 factorial design.

Two groups are identified:

* Group A: Premenopausal breast cancer patients treated with tamoxifen and/or luteinizing hormone-releasing hormone (LHRH) analogues.
* Group B: Postmenopausal breast cancer patients treated with aromatase inhibitors.

Patients in each group will be randomly assigned to four treatments arms:

Arm 1, manual treatment with osteopathic techniques and nutritional treatment. Arm 2, manual treatment with osteopathic techniques. Arm 3, nutritional treatment. Arm 4, control.
Primary purpose: TREATMENT

Brief summary: Breast cancer patients under hormonal therapy may experience significant adverse events related to this treatment and as a result, failure to adhere to adjuvant therapies or discontinuation of treatment has been reported to be high.

Promoting weight control and the adoption of healthy lifestyle habits in breast cancer survivors has an impact on hormonal status, quality of life and physical functioning, contributing to reduce cancer recurrence risk, cancer-related and chronic-condition-related mortality.

Manipulation procedures, such as manual treatment with osteopathic techniques, have positive effects on osteoarticular pain, peripheral neuropathies, anxious-depressive disorders, asthenia and sleep disorders, also improving immune and neuroendocrine responses.

The aim of this study is to evaluate the effects of dietary intervention and manual treatment with osteopathic techniques in women diagnosed with breast cancer under antiestrogenic hormonal treatment through the assessment of:

* modifications of quality of life (QoL)
* frequency and severity of symptoms related to antiestrogenic hormonal treatment
* body weight
* body composition
* food habits
* metabolic and inflammatory state
* physical performance
* patient's satisfaction to multidisciplinary treatment.

This study focuses on patient's centricity evaluating the effects that long lasting adjuvant therapies have on breast cancer survivors. Improving personalized patient's treatment through collaborative interactions between clinicians, osteopaths and nutrition specialists might result in implementation strategies to determine novel evidence-based treatments for ameliorating patient's adherence to oncological therapies, impacting prognosis and survival.

Detailed description: Breast cancer patients under hormonal therapy may experience significant adverse events related to this treatment. Premenopausal women may encounter the classic symptoms of menopausal syndrome: hair thinning or loss; hot flashes, sweating, fatigue, insomnia, joint pain, vaginal dryness, decreased libido, anxious-depressive disorders, cognitive dysfunction; dry eyes; weight gain. Postmenopausal women may instead experience joint stiffness and joint pain, depressive and anxious symptoms, fatigue and irritability.

Since most of these adverse events do not resolve spontaneously a few weeks/months after starting treatment, they often negatively impact patient's quality of life.

As a result of treatment-related adverse events, failure to adhere to adjuvant therapies or discontinuation of treatment has been reported to be high and this may negatively impact patient's prognosis and survival.

Patients with breast cancer frequently experience weight gain during and after adjuvant hormonal treatment. Indeed, menopause, musculoskeletal pain and the consequent physical activity reduction, work together to reduce the basal energy metabolism. On the other side, the psychological distress and the eventual use of food for emotional reward, do promote weight gain. Notably, breast cancer patients who are overweight or obese show an increased risk of overall mortality, cancer-specific mortality, breast cancer relapse or second primary contralateral breast cancer. The explanation lies in the fact that the increase in fat mass is directly correlated to an increased production of estrogens, insulin, leptin and proinflammatory cytokines which, all together, exhibit a mitogenic activity on mammary cells. Proinflammatory cytokines and insulin deregulation on their turn, favor with time the onset of other chronic diseases such as diabetes, dyslipidemia, metabolic syndrome in general, thus increasing the risk of overall mortality. Conversely, weight loss can improve hormonal status, quality of life and physical functioning and contribute to reduce cancer recurrence risk, cancer-related and chronic-condition-related mortality. Therefore, it is important to promote weight control and the adoption of healthy lifestyle habits in breast cancer survivors.

Manipulation procedures, such as manual treatment with osteopathic techniques, involve the mechanical displacement of fluids and the removal of toxic substances with neurovascular and neuromuscular effects, thus producing positive alterations at the metabolic, biochemical and circulatory level. Several studies conducted on patients with breast cancer have supported the positive effect of manual therapy (acupuncture, shiatsu treatments, massages) on the control of various problems such as osteoarticular pain, peripheral neuropathies, anxious-depressive disorders, asthenia and sleep disorders, also improving immune and neuroendocrine responses.

Nevertheless, there are no studies on the effect of manual treatment with osteopathic techniques on the control of symptoms related to the side effects induced by anti-tumor therapies.

The aim of this study is to evaluate the effects of dietary intervention and manual treatment with osteopathic techniques in women diagnosed with breast cancer under antiestrogenic hormonal treatment through the assessment of:

* modifications of quality of life (QoL)
* frequency and severity of symptoms related to antiestrogenic hormonal treatment
* body weight
* body composition
* food habits
* metabolic and inflammatory state
* physical performance
* patient's satisfaction to multidisciplinary treatment.

This study focuses on patient's centricity evaluating the effects that long lasting adjuvant therapies have on breast cancer survivors. Improving personalized patient's treatment through collaborative interactions between clinicians, osteopaths and nutrition specialists might result in implementation strategies to determine novel evidence-based treatments for ameliorating patient's adherence to oncological therapies, impacting prognosis and survival.

Eligibility criteria: Inclusion Criteria:

* Age \>18 years
* Voluntary written informed consent
* Histologically confirmed estrogen receptor-positive invasive breast cancer or in situ breast cancer after breast surgery
* Absence of locoregional relapse or distant metastasis
* Premenopausal or postmenopausal status
* Hormonal therapy with tamoxifen and/or LHRH analogues or aromatase inhibitors
* Patients with or without neoadjuvant or adjuvant chemotherapy
* Patients with a BMI \> 18.5 kg/m\^2
* Absence of language barrier

Exclusion Criteria:

* Previous hormonal therapy
* Use of medical treatments that contrast adjuvant hormonal therapy adverse effects (e.g. menopausal symptoms and arthralgia).
* Underweight patients (BMI \<18.5 kg/m\^2)
* Patients diagnosed with eating disorders (e.g. anorexia nervosa, bulimia, binge eating, orthorexia)
* Psychiatric disorders or cognitive impairments
* Previous malignancies other than in situ cervical carcinoma or non-melanoma skin cancer
* Non-epithelial breast cancer at histological examination
* In situ lobular breast cancer
* Participation in other randomized clinical trials that could interfere with current study
* Patients living distant from trial center and unable to attend for check-ups and meetings.

Primary outcomes:
measure: Evaluation of the effect of dietary intervention and manual treatment with osteopathic techniques on quality of life (QoL) of women diagnosed with breast cancer under hormonal treatment
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
Secondary outcomes:
measure: Treatment-related adverse events of hormonal treatment in premenopausal and postmenopausal patients
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Body weight
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Body composition
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Food habits
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Hemoglobin
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Red blood cells
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Platelets
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: White blood cells
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Lymphocytes
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Monocytes
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Neutrophils
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Inflammatory state: erythrocyte sedimentation rate
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Vitamin D
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Metabolic state: plasma glycemia
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Metabolic state: serum insulin concentration
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Metabolic state: total cholesterol
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Metabolic state: low-density lipoprotein (LDL) cholesterol
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Metabolic state: high-density lipoprotein (HDL) cholesterol
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Metabolic state: triglycerides
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Inflammatory state: c-reactive protein (CRP)
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Sex hormone binding globulin (SHBG)
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Inflammatory state: Interleukin-6 (IL-6)
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Inflammatory state: Tumour necrosis factor-α (TNF-α)
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Testosterone
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Modifications of blood lipid profile
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Physical performance
timeFrame: baseline (T0), after 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
measure: Patient's satisfaction to multidisciplinary treatment
timeFrame: 12 weeks (T1), after 24 weeks (T2) and after 52 weeks (T3)
Other outcomes:
Locations:
city: Milan
country: Italy
facility: Fondazione IRCCS Istituto Nazionale dei Tumori
Study officials:
affiliation: Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
name: Cristina Ferraris, MD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Sauter ER. Breast Cancer Prevention: Current Approaches and Future Directions. Eur J Breast Health. 2018 Apr 1;14(2):64-71. doi: 10.5152/ejbh.2018.3978. eCollection 2018 Apr.
citation: Sharma R, Hamilton A, Beith J. LHRH agonists for adjuvant therapy of early breast cancer in premenopausal women. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD004562. doi: 10.1002/14651858.CD004562.pub3.
citation: Martino G, Catalano A, Agostino RM, Bellone F, Morabito N, Lasco CG, Vicario CM, Schwarz P, Feldt-Rasmussen U. Quality of life and psychological functioning in postmenopausal women undergoing aromatase inhibitor treatment for early breast cancer. PLoS One. 2020 Mar 26;15(3):e0230681. doi: 10.1371/journal.pone.0230681. eCollection 2020.
citation: Glaus A, Boehme Ch, Thurlimann B, Ruhstaller T, Hsu Schmitz SF, Morant R, Senn HJ, von Moos R. Fatigue and menopausal symptoms in women with breast cancer undergoing hormonal cancer treatment. Ann Oncol. 2006 May;17(5):801-6. doi: 10.1093/annonc/mdl030. Epub 2006 Feb 28.
citation: Mantas, D., Kostakis, J.D. & Markopoulos, C. Aromatase inhibitors: A comprehensive review in mechanisms of action, side effects and treatment in postmenopausal early breast cancer patients. Hellenic J Surg 88, 245-251 (2016). https://doi.org/10.1007/s13126-016-0326-6
citation: Henry NL, Azzouz F, Desta Z, Li L, Nguyen AT, Lemler S, Hayden J, Tarpinian K, Yakim E, Flockhart DA, Stearns V, Hayes DF, Storniolo AM. Predictors of aromatase inhibitor discontinuation as a result of treatment-emergent symptoms in early-stage breast cancer. J Clin Oncol. 2012 Mar 20;30(9):936-42. doi: 10.1200/JCO.2011.38.0261. Epub 2012 Feb 13.
citation: Sestak I, Cuzick J, Sapunar F, Eastell R, Forbes JF, Bianco AR, Buzdar AU; ATAC Trialists' Group. Risk factors for joint symptoms in patients enrolled in the ATAC trial: a retrospective, exploratory analysis. Lancet Oncol. 2008 Sep;9(9):866-72. doi: 10.1016/S1470-2045(08)70182-7. Epub 2008 Aug 12.
citation: Vance V, Mourtzakis M, Hanning R. Relationships Between Weight Change and Physical and Psychological Distress in Early-Stage Breast Cancer Survivors. Cancer Nurs. 2019 May/Jun;42(3):E43-E50. doi: 10.1097/NCC.0000000000000612.
citation: Kangas M, Henry JL, Bryant RA. Posttraumatic stress disorder following cancer. A conceptual and empirical review. Clin Psychol Rev. 2002 May;22(4):499-524. doi: 10.1016/s0272-7358(01)00118-0.
citation: Kadakia KC, Snyder CF, Kidwell KM, Seewald NJ, Flockhart DA, Skaar TC, Desta Z, Rae JM, Otte JL, Carpenter JS, Storniolo AM, Hayes DF, Stearns V, Henry NL. Patient-Reported Outcomes and Early Discontinuation in Aromatase Inhibitor-Treated Postmenopausal Women With Early Stage Breast Cancer. Oncologist. 2016 May;21(5):539-46. doi: 10.1634/theoncologist.2015-0349. Epub 2016 Mar 23.
citation: Murphy CC, Bartholomew LK, Carpentier MY, Bluethmann SM, Vernon SW. Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review. Breast Cancer Res Treat. 2012 Jul;134(2):459-78. doi: 10.1007/s10549-012-2114-5. Epub 2012 Jun 12.
citation: Hershman DL, Shao T, Kushi LH, Buono D, Tsai WY, Fehrenbacher L, Kwan M, Gomez SL, Neugut AI. Early discontinuation and non-adherence to adjuvant hormonal therapy are associated with increased mortality in women with breast cancer. Breast Cancer Res Treat. 2011 Apr;126(2):529-37. doi: 10.1007/s10549-010-1132-4. Epub 2010 Aug 28.
citation: Greenlee H, DuPont-Reyes MJ, Balneaves LG, Carlson LE, Cohen MR, Deng G, Johnson JA, Mumber M, Seely D, Zick SM, Boyce LM, Tripathy D. Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment. CA Cancer J Clin. 2017 May 6;67(3):194-232. doi: 10.3322/caac.21397. Epub 2017 Apr 24.
citation: Hernandez-Reif M, Ironson G, Field T, Hurley J, Katz G, Diego M, Weiss S, Fletcher MA, Schanberg S, Kuhn C, Burman I. Breast cancer patients have improved immune and neuroendocrine functions following massage therapy. J Psychosom Res. 2004 Jul;57(1):45-52. doi: 10.1016/S0022-3999(03)00500-2.
citation: Lissoni P, Messina G, Lissoni A, Franco R. The psychoneuroendocrine-immunotherapy of cancer: Historical evolution and clinical results. J Res Med Sci. 2017 Apr 26;22:45. doi: 10.4103/jrms.JRMS_255_16. eCollection 2017.
citation: Borreani C, Alfieri S, Infante G, Miceli R, Mariani P, Bosisio M, Vernieri C, Bianchi GV, Capri G. Aromatase Inhibitors in Postmenopausal Women with Hormone Receptor-Positive Breast Cancer: Profiles of Psychological Symptoms and Quality of Life in Different Patient Clusters. Oncology. 2021;99(2):84-95. doi: 10.1159/000509651. Epub 2020 Sep 29.
citation: Wolfenden L, Foy R, Presseau J, Grimshaw JM, Ivers NM, Powell BJ, Taljaard M, Wiggers J, Sutherland R, Nathan N, Williams CM, Kingsland M, Milat A, Hodder RK, Yoong SL. Designing and undertaking randomised implementation trials: guide for researchers. BMJ. 2021 Jan 18;372:m3721. doi: 10.1136/bmj.m3721.
citation: Pearson N, Naylor PJ, Ashe MC, Fernandez M, Yoong SL, Wolfenden L. Guidance for conducting feasibility and pilot studies for implementation trials. Pilot Feasibility Stud. 2020 Oct 31;6(1):167. doi: 10.1186/s40814-020-00634-w.
citation: Ingber DE, Wang N, Stamenovic D. Tensegrity, cellular biophysics, and the mechanics of living systems. Rep Prog Phys. 2014 Apr;77(4):046603. doi: 10.1088/0034-4885/77/4/046603.
citation: Rizkalla MN, Henderson KK, Huntington-Alfano K, Heinking KP, Koronkiewicz A, Knees M, Hoffman H, Elahi F, Impens A. Does Osteopathic Manipulative Treatment Make a Neuropsychological Difference in Adults With Pain? A Rationale for a New Approach. J Am Osteopath Assoc. 2018 Sep 1;118(9):617-622. doi: 10.7556/jaoa.2018.136.
citation: Williams NH, Hendry M, Lewis R, Russell I, Westmoreland A, Wilkinson C. Psychological response in spinal manipulation (PRISM): a systematic review of psychological outcomes in randomised controlled trials. Complement Ther Med. 2007 Dec;15(4):271-83. doi: 10.1016/j.ctim.2007.01.008. Epub 2007 Mar 8.
citation: Vance V, Mourtzakis M, McCargar L, Hanning R. Weight gain in breast cancer survivors: prevalence, pattern and health consequences. Obes Rev. 2011 Apr;12(4):282-94. doi: 10.1111/j.1467-789X.2010.00805.x. Epub 2010 Sep 29.
citation: Chan DSM, Vieira AR, Aune D, Bandera EV, Greenwood DC, McTiernan A, Navarro Rosenblatt D, Thune I, Vieira R, Norat T. Body mass index and survival in women with breast cancer-systematic literature review and meta-analysis of 82 follow-up studies. Ann Oncol. 2014 Oct;25(10):1901-1914. doi: 10.1093/annonc/mdu042. Epub 2014 Apr 27.
citation: Majed B, Moreau T, Asselain B; Curie Institute Breast Cancer Group. Overweight, obesity and breast cancer prognosis: optimal body size indicator cut-points. Breast Cancer Res Treat. 2009 May;115(1):193-203. doi: 10.1007/s10549-008-0065-7. Epub 2008 Jun 12.
citation: Rock CL, Byers TE, Colditz GA, Demark-Wahnefried W, Ganz PA, Wolin KY, Elias A, Krontiras H, Liu J, Naughton M, Pakiz B, Parker BA, Sedjo RL, Wyatt H; Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial Group. Reducing breast cancer recurrence with weight loss, a vanguard trial: the Exercise and Nutrition to Enhance Recovery and Good Health for You (ENERGY) Trial. Contemp Clin Trials. 2013 Mar;34(2):282-95. doi: 10.1016/j.cct.2012.12.003. Epub 2012 Dec 22.
citation: Patterson RE, Cadmus LA, Emond JA, Pierce JP. Physical activity, diet, adiposity and female breast cancer prognosis: a review of the epidemiologic literature. Maturitas. 2010 May;66(1):5-15. doi: 10.1016/j.maturitas.2010.01.004. Epub 2010 Jan 25.
citation: Li CI, Daling JR, Porter PL, Tang MT, Malone KE. Relationship between potentially modifiable lifestyle factors and risk of second primary contralateral breast cancer among women diagnosed with estrogen receptor-positive invasive breast cancer. J Clin Oncol. 2009 Nov 10;27(32):5312-8. doi: 10.1200/JCO.2009.23.1597. Epub 2009 Sep 8.
citation: Protani M, Coory M, Martin JH. Effect of obesity on survival of women with breast cancer: systematic review and meta-analysis. Breast Cancer Res Treat. 2010 Oct;123(3):627-35. doi: 10.1007/s10549-010-0990-0. Epub 2010 Jun 23.
citation: Sauter ER, Scott S, Hewett J, Kliethermes B, Ruhlen RL, Basarakodu K, de la Torre R. Biomarkers associated with breast cancer are associated with obesity. Cancer Detect Prev. 2008;32(2):149-55. doi: 10.1016/j.cdp.2008.06.002. Epub 2008 Jul 17.
citation: Hursting SD, Berger NA. Energy balance, host-related factors, and cancer progression. J Clin Oncol. 2010 Sep 10;28(26):4058-65. doi: 10.1200/JCO.2010.27.9935. Epub 2010 Aug 9.
citation: Reeves MM, Terranova CO, Eakin EG, Demark-Wahnefried W. Weight loss intervention trials in women with breast cancer: a systematic review. Obes Rev. 2014 Sep;15(9):749-68. doi: 10.1111/obr.12190. Epub 2014 May 29.
citation: Morey MC, Snyder DC, Sloane R, Cohen HJ, Peterson B, Hartman TJ, Miller P, Mitchell DC, Demark-Wahnefried W. Effects of home-based diet and exercise on functional outcomes among older, overweight long-term cancer survivors: RENEW: a randomized controlled trial. JAMA. 2009 May 13;301(18):1883-91. doi: 10.1001/jama.2009.643.
citation: Newman AB, Simonsick EM, Naydeck BL, Boudreau RM, Kritchevsky SB, Nevitt MC, Pahor M, Satterfield S, Brach JS, Studenski SA, Harris TB. Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA. 2006 May 3;295(17):2018-26. doi: 10.1001/jama.295.17.2018.
citation: Piccoli A, Rossi B, Pillon L, Bucciante G. A new method for monitoring body fluid variation by bioimpedance analysis: the RXc graph. Kidney Int. 1994 Aug;46(2):534-9. doi: 10.1038/ki.1994.305. No abstract available.
citation: Buffa R, Mereu E, Comandini O, Ibanez ME, Marini E. Bioelectrical impedance vector analysis (BIVA) for the assessment of two-compartment body composition. Eur J Clin Nutr. 2014 Nov;68(11):1234-40. doi: 10.1038/ejcn.2014.170. Epub 2014 Aug 20.
citation: Kim Y, Park I, Kang M. Convergent validity of the international physical activity questionnaire (IPAQ): meta-analysis. Public Health Nutr. 2013 Mar;16(3):440-52. doi: 10.1017/S1368980012002996. Epub 2012 Jul 2.
citation: Craig CL, Marshall AL, Sjostrom M, Bauman AE, Booth ML, Ainsworth BE, Pratt M, Ekelund U, Yngve A, Sallis JF, Oja P. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003 Aug;35(8):1381-95. doi: 10.1249/01.MSS.0000078924.61453.FB.
citation: Bach-Faig A, Berry EM, Lairon D, Reguant J, Trichopoulou A, Dernini S, Medina FX, Battino M, Belahsen R, Miranda G, Serra-Majem L; Mediterranean Diet Foundation Expert Group. Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutr. 2011 Dec;14(12A):2274-84. doi: 10.1017/S1368980011002515.
citation: Vergnaud AC, Romaguera D, Peeters PH, van Gils CH, Chan DS, Romieu I, Freisling H, Ferrari P, Clavel-Chapelon F, Fagherazzi G, Dartois L, Li K, Tikk K, Bergmann MM, Boeing H, Tjonneland A, Olsen A, Overvad K, Dahm CC, Redondo ML, Agudo A, Sanchez MJ, Amiano P, Chirlaque MD, Ardanaz E, Khaw KT, Wareham NJ, Crowe F, Trichopoulou A, Orfanos P, Trichopoulos D, Masala G, Sieri S, Tumino R, Vineis P, Panico S, Bueno-de-Mesquita HB, Ros MM, May A, Wirfalt E, Sonestedt E, Johansson I, Hallmans G, Lund E, Weiderpass E, Parr CL, Riboli E, Norat T. Adherence to the World Cancer Research Fund/American Institute for Cancer Research guidelines and risk of death in Europe: results from the European Prospective Investigation into Nutrition and Cancer cohort study1,4. Am J Clin Nutr. 2013 May;97(5):1107-20. doi: 10.3945/ajcn.112.049569. Epub 2013 Apr 3.
citation: Yumuk V, Tsigos C, Fried M, Schindler K, Busetto L, Micic D, Toplak H; Obesity Management Task Force of the European Association for the Study of Obesity. European Guidelines for Obesity Management in Adults. Obes Facts. 2015;8(6):402-24. doi: 10.1159/000442721. Epub 2015 Dec 5.
citation: Lachenbruch PA. A note on sample size computation for testing interactions. Stat Med. 1988 Apr;7(4):467-9. doi: 10.1002/sim.4780070403.
citation: FREEMAN GH, HALTON JH. Note on an exact treatment of contingency, goodness of fit and other problems of significance. Biometrika. 1951 Jun;38(1-2):141-9. No abstract available.