Iris Kanera

100 Chapter 4 of the Mental Adjustment to Cancer Scale (MAC; Watson & Homewood, 2008). Concerning the HADS, seven items for anxiety and seven items for depression were measured on a 4-point scale with scores ranging from 0-21. Negative mental adjustment comprises 16 items of the MAC as described by Watson et al. (2008) with scores ranging from 16-64, and a cut-off score of 36 indicating problematic functioning. Scores lower than 8 on the subscale anxiety and the subscale depression on the HADS, and a MAC score of 36 or lower resulted in a green MRA, indicating no/low psychological distress and no/low problematic functioning. A MAC score higher than 36 in combination with a score of 8-15 on one of the HADS subscales was categorized into an orange MRA. When the scores on one of the HADS subscales were higher than 15, or when both subscale scores were higher than 15, a red MRA was provided. Physical Activity and Diet The MRA for physical activity (PA) and diet was constructed according to the lifestyle recommendations of the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) and the American Cancer Society (World Cancer Research Fund, 2009; Rock et al., 2012). The classification criteria are displayed inTable 4.1. PAwas assessed by applying the validated 11-item self-report Short Questionnaire to Assess Health Enhancing PA (SQUASH; de Hollander et al., 2012; Wendel-Vos et al., 2003). The number of days a week of PA (≥ 30 minutes of moderate intensity), the average number of minutes per day, and the intensity (light, moderate, vigorous) were rated for activities during commuting, work, household, leisure time, and sports (Kanera et al., 2016b). Dietary behavior wasmeasured by using eight items from the Dutch StandardQuestionnaire on Food Consumption to assess vegetable, fruit, fish, whole-grain bread, oatmeal, cereal, potato, whole-grain rice, and whole-grain pasta consumption (van den Brink et al., 2005; Kanera et al., 2016b). A green MRA was provided when respondents met four out of five dietary recommendations as displayed in Table 4.1. When reporting that two or three out of five conditions were met an orange MRA was provided, and respondents who met one or none of the five conditions received a red MRA. Smoking The smoking MRA was based on current and former smoking behavior, which was measured by using three standardized questions from the Dutch Measuring Instruments for Research on Smoking and Smoking Cessation (Kanera et al., 2016b; Mudde et al., 2006). Respondents who had never smoked before and former smokers who quit smoking prior to the cancer diagnosis received a green MRA, former smokers who quit when the cancer was diagnosed received an orange MRA, and current smokers received a red MRA.