MD Anderson Cancer Center
Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention, providing the latest information on reducing your family's cancer risk. I'm your host Lisa Garvin. Today we're talking with Wendy Demark-Wahnefried, PhD and Professor of Behavioral Science and Daniel Hughes, PhD who is an Instructor in Behavioral Sciences here at MD Anderson. Welcome to you both today.
Dr. Wendy Demark-Wahnefried: Thank you.
Dr. Daniel Hughes: Thank you.
Lisa Garvin: We're talking about a study that was just published in the May 13th issue of the Journal of the American Medical Association about a home-based diet and exercise program that has shown improvement among older, long-term cancer survivors. First of all, tell us Dr. Demark-Wahnefried about RENEW. What does that stand for and what is it about?
Dr. Wendy Demark-Wahnefried: RENEW was a study of 641 breast, prostate and colorectal cancer survivors that were accrued from 21 U.S. states and 2 Canadian provinces and the United Kingdom. And basically what we did is we tested whether a home-based, exercise and diet program could improve physical functioning and we just got our results in and we have -- the study indeed shows that we can improve physical functioning in older, long-term cancer survivors. And that's important because once people are diagnosed with cancer - particularly those that are elderly - their physical functioning declines. And that's hugely expensive. A lot of older cancer survivors have to be admitted into nursing homes or get home health care. And this study shows that we can prevent that from happening.
Lisa Garvin: Is it true that cancer survivors actually experience more of a physical decline than perhaps the general population?
Dr. Wendy Demark-Wahnefried: Absolutely. Once people are diagnosed with cancer, they are more likely to have physical function decline as well as also declines in other components of quality of life, mental components, those types of things.
Lisa Garvin: Do you find that people once treatment is finished, I think a lot of people drop off the map with follow-up care and think, "Oh I'm cured. I'm healthy again." Is that a perception you have to fight?
Dr. Wendy Demark-Wahnefried: Absolutely. In this study, we had to send out over 20 thousand letters to older cancer survivors that were at least 5 years out from their cancer diagnosis. And usually we don't have to send out that many letters and we had to send out basically 40 times as many letters in order to get our sample as if we had tried to recruit people that were closer to diagnosis.
Lisa Garvin: Tell me about your collaboration with Duke University Medical Center.
Dr. Wendy Demark-Wahnefried: Okay, so I'm here at MD Anderson and the rest of the team is at Duke: Harvey Cohen [assumed spelling], Miriam Morrey [assumed spelling], Denise Snyder [assumed spelling], Rick Sloan [assumed spelling], Bercetis Peterson [assumed spelling]. And originally the study was started at Duke because I was at Duke and as well as the rest of the team obviously. You don't do these studies in isolation. You always have to have a research team that has a multi-disciplinary approach to these sorts of problems. So Miriam Morrey provided the exercise expertise and I'm a nutrition scientist. Dr. Cohen is a geriatrician and that's how we amassed our team.
Lisa Garvin: Tell me about the diet portion of RENEW. What sorts of things were you having the participants do?
Dr. Wendy Demark-Wahnefried: Okay, so RENEW was -- we only accrued individuals that were overweight in the study. And the study was really targeted toward promoting weight loss in these individuals that were overweight through exercise and through a portion controlled healthy diet that was really heavy in fruits and vegetables and whole grains and less -- had lower proportions of fat and meat products.
Lisa Garvin: I understand too that you also used portion controlled plates and cups.
Dr. Wendy Demark-Wahnefried: Yes.
Lisa Garvin: I bet they probably look a lot smaller than what we're used to seeing.
Dr. Wendy Demark-Wahnefried: Absolutely, our plates were pretty small compared to what most Americans use and indeed the portion controlled tableware that we used was considered -- when we did a debriefing of the patients that participated in the study, they really endorsed the portion controlled plates.
Lisa Garvin: Dr. Hughes, can you talk to us about the exercise portion of RENEW? What sorts of things were the participants being asked to do?
Dr. Daniel Hughes: Well I really can't because I wasn't part of her study but I can talk about exercise in terms of energy balance and why it's really key I think to have exercising and diet in terms of an intervention. And specifically talking about energy balance, I think that my sense is that people tend to complicate something that maybe doesn't need to be complicated because in the final analysis when it all boils down, it really is about energy balance. How much you consume in terms of energy and calories and how much you burn by your activities and also about how obese or not obese you are because fat free mass has a lot higher metabolism than fat mass. And little changes in percent body fat can have big impacts on resting energy expenditure.
Lisa Garvin: And that's probably a good point because I think you know any dieters at whatever age they may be, you know they may feel like "Oh I've only lost a couple of pounds in the last month." And they tend to give up so little changes do make a big difference?
Dr. Daniel Hughes: Little changes do make a big difference. In fact, if you use the constant which is approximate of 3500 calories to a pound, if you have as little as for example 100 calories favorable balance - that is less energy balance - you're consuming less and then you're burning of a hundred calories - just a hundred calories - can make a difference of about a pound a month or twelve pounds a year. But the key is that if you lose -- if you say you do that for 6 days and on the 7th day you decide, "Well you know, I've been good for 6 days. Now I'm going to go for that mango slushie." And you consume all those calories and then you lose the battle. So it's a constant habitual thing which is why it's important to have really changed behavior. I think the wrong thing to say is, "I'm on a diet" because that denotes short term thinking. I think the right thinking is, "I'm on a behavioral change" or "I'm going to change my behavior." And I think Dr. Demark-Wahnefried's absolutely correct. It really takes both a diet and an exercise component to really be effective because then you can really double the effect on the energy balance.
Lisa Garvin: Because I think -- of course we're talking about an older population here - mostly over 65 - so they may not be the ones who would exercise a lot and then eat junk you know. So I guess they really, really have to find that balance in an older population.
Dr. Daniel Hughes: Right and as we age we tend to burn less calories at rest you know because we're not as metabolically active. However, it's important to note that really all populations can benefit and there are incremental things you can do. You don't have to go to the gym. I always like to say "You don't have to wear spandex to get in shape." You can do things at home. You can do things around the neighborhood. You can just walk instead of ride maybe 1 or 2 blocks. All those little things add up because as we talked about little changes in that energy balance can have long term effects.
Lisa Garvin: Well what about people with mobility problems? I know there's a popular PBS program called "Sit and Be Fit" where you can actually do exercises in your chair.
Dr. Daniel Hughes: Sure.
Lisa Garvin: So I mean there are things that people with you know maybe mobility problems still can do.
Dr. Daniel Hughes: Absolutely and it's a -- you know you can use arm motion and with arm motion you can even get what's called arm ergometers which is basically a bicycle for arms. But you can just do motions as you're sitting there is raising your hand and pumping your arms. And it gets your heart rate elevated and you can burn the energy. So yeah, I mean there are things you can do.
Dr. Wendy Demark-Wahnefried: I think that as far as the arm motion goes, the more that people could get their lower body moving, the more benefit they will see. And this is particularly apparent in an older population because they tend to lose function when they don't -- as you get older, if you don't exercise your legs, you start to lose that mobility and once you start to become sedentary, it just -- you know the physical decline that you'd experience is much greater. So it's important to get the legs in motion if at all possible. And the other thing to remember is most of your muscle lies below your waist. And so you could be pumping you know doing curls with your arms for hours and you won't burn as many calories as if you took a good vigorous walk -- you know walk of a few minutes.
Dr. Daniel Hughes: She's absolutely right. The higher energy demands are with the bigger muscle groups so the more you can use the bigger muscles groups, the better. But if you can't, you know there's still other options available.
Lisa Garvin: Does weight bearing exercise or you know like using weights, does that have a benefit in the over 65 population as much as it does the younger?
Dr. Daniel Hughes: Yes, in fact it probably can help them percentage wise even more. There's a misconception that elderly people once they lose the lean mass, they lose the lean mass in muscle. But in reality there's been studies that have shown that older populations can actually gain muscle mass back in terms of doing resistance training. You have to be careful in that the programs are designed right and safe. One of the things you don't want to have somebody do is for example someone that's older and has a hypertension problem, do -- you know, standing on an inclined branch but leaning backwards and doing -- what do they call them? Butterflies or something like that with high blood pressure. You can just see their - you know - veins pop. But as long as they're properly designed and they're using good technique then they can get tremendous benefit. Just as little as doing 2 days per week.
Lisa Garvin: Are there programs that older people can find that are like geriatric physical fitness programs that have been designed that you know of? I mean...
Dr. Daniel Hughes: I would advise people if they're interested in doing that to go to the American College of Sports Medicine web. There is a site there and they can find certified personal trainers that are certified to work with older populations and special populations. And they can tap into those and then they can get some safe programs. For the most part, most of the certified personal trainers out there are good, but with that level of certification they're guaranteed they're going to be safe and have some safe programs.
Lisa Garvin: And let's turn back to the diet portion. I feel like we need to discuss a little bit more. You had a control group. Tell me about the 2 groups in the study.
Dr. Wendy Demark-Wahnefried: Okay. Well the first group, we had what was called a wait-less control. So that meant that the people that were in the control group basically waited a year before they got started on the intervention. And so what we did is we compared that group to the group that got this diet and exercise intervention. And I think that in some ways what Dr. Hughes is saying here as far as exercise is very important. Exercise has been shown to be one of the constants as far as being able to promote weight loss and keep the weight loss off. And so it's very important to exercise. The other thing is the energy balance is also key. And this notion that, "Oh I can eat a little bit more if I exercise" is one of those things that is a myth that we need to fight. We had to fight with this study. For example, one of the examples that we used in RENEW is that 6 jelly beans. Well 6 jelly beans, in order to wear off 6 measly little jelly beans you have to either walk at a moderate pace for 22 minutes or you really have to go and exercise full tilt at something more strenuous for 5 minutes. And it doesn't take any time at all to eat 6 jelly beans. So energy balance is a big key here and to eat more fruits and vegetables is one way to kind of slow you up, get a lot of crunching in so that your mouth is happy. It occupies the stomach. And in this older population of which RENEW participants were over age 65, often times we see that when we go into homes of people who -- well all people, but particularly those that are elderly, because there are taste changes that occur as we age and one of the tastes that we tend to never lose is our affinity for sweets. And often times you will see older people really gravitating towards sweets and having candy dishes and those types of things around which make it very easy to just take a handful of jelly beans or a few extra chocolates or that sort of thing. So it's something that one needs to be aware of.
Lisa Garvin: Well I wonder too because my parents are in their 80s and they're like, "We don't care about our cholesterol. We don't care what we eat anymore." And I wonder if people reach a certain age it's like you know "I don't care anymore."
Dr. Wendy Demark-Wahnefried: I want to have a cookie.
Lisa Garvin: Right. I can have a cookie. I'm old.
Dr. Wendy Demark-Wahnefried: Yeah and to some extent, you know we don't want people to think that they're totally deprived and that's where this balance with diet and exercise does come in because truly yes you could have a cookie if you had a - you know - ate a moderate diet and then also did some physical activity. So the key is not to starve but to choose foods wisely.
Lisa Garvin: Great, well thank you both for coming. Do either of you have some final thoughts before we go?
Dr. Daniel Hughes: Ladies first.
Dr. Wendy Demark-Wahnefried: Okay, well I'll take that anyway. [Laughter] The key is just to keep moving, to keep exercising. Try to keep the lower body in motion and as a way to keep active throughout the balance of life. And then also to have moderate consumption, portion controlled diet that's high in fruits and vegetables and low in fats and sweets.
Dr. Daniel Hughes: And what I would add is to echo what Dr. Demark-Wahnefried has said but also I would add that don't think that you cannot do anything. Find something that you enjoy doing whether it be dancing, swimming, you know Sit and Be Fit, water aerobics, living room aerobics, anything that you enjoy and incorporate into your daily routine. And don't be fooled. It really is that simple as Dr. Demark-Wahnefried is saying. It really is about energy balance and keeping consistent on an energy balance. We see a lot of commercials, a lot of things that try to complicate that and really introduce a lot of noise that doesn't really need to be there. The bottom line is how much you're consuming and how much you're burning.
Lisa Garvin: Great, thank you both very much for joining us today.
Dr. Wendy Demark-Wahnefried: Thank you.
Dr. Daniel Hughes: Our pleasure. My pleasure.
Lisa Garvin: If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-mda-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.
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