Iris Kanera

2 27 Prevalence and correlates of lifestyle behaviors BACKGROUND A healthy lifestyle is of major importance for cancer survivors, since it has been shown that adherence to an increasing number of health recommendations may lower the risk of lifestyle-related chronic diseases and may lead to a higher health-related quality of life QoL; Blanchard et al., 2008; Blanchard et al., 2004; Davies et al., 2011; Ford et al., 2009; Schlesinger et al., 2014). Moreover, unhealthy behaviors may have a negative impact on QoL and cause new health problems such as cancer recurrence, new primary tumors and other chronic diseases (Baena Ruiz & Salinas Hernandez, 2013; Colditz, Wolin, & Gehlert, 2012; Davies et al., 2011; Inoue-Choi et al., 2013; Kushi, Kwan, Lee, & Ambrosone, 2007; McLaughlin, Trentham-Dietz, Hampton, Newcomb, & Sprague, 2014; Schmid & Leitzmann, 2014). Health recommendations for cancer survivors include the following: achieve and maintain a healthy body weight (body mass index [BMI] within the range of 18.5 to 25.0 kg/m 2 ), engage in at least 30 minutes of moderately intense physical activity (PA) per day at five or more days weekly, eat five servings of fruit and vegetables daily, avoid or limit alcohol consumption to up to two servings per day for men and one serving per day for women, and refrain from smoking (Klosky et al., 2007; Rock et al., 2012; Wilson, Parsons, & Wakefield, 1999). Previous research suggested that adherence to PA recommendations might be the most important lifestyle behavior associated with lower mortality and higher QoL in cancer survivors (Inoue-Choi et al., 2013; Schmid & Leitzmann, 2014; Sehl et al., 2013). Recent research showed that cancer survivors do not adhere consistently to these health recommendations. More than half is overweight, less than half adhere to PA recommendations, about only one fifths adhere to fruit en vegetable recommendations, about 90% do not smoke, and approximately 90% of cancer survivors adhere to the alcohol recommendations (Bellizzi et al., 2005; Blanchard et al., 2008; Inoue-Choi et al., 2013; LeMasters et al., 2014). Broadly, similar results were found in people without a history of cancer (Coups & Ostroff, 2005; Eakin et al., 2007; Mayer et al., 2007; Williams et al., 2013). Until now, research about the adherence to a combination of health behaviors showed mixed results: European studies report about 10%-28% of the cancer survivors followed zero or one recommendation, about one third adhered to two, and also about one third adhered to three, and about 10 - 23% adhered to four recommendations (Ford et al., 2009; Schlesinger et al., 2014). American studies reported even lower adherence scores to multiple health behaviors (Blanchard et al., 2008; Mayer et al., 2007; O’Neill et al., 2013). In comparison, research conducted in the general population among older adults indicated that most of them followed three or more lifestyle recommendations (86%; Pronk et al., 2004), suggesting less adherence among cancer survivors compared to the general population. Considering that cancer survivors are at increased risk of cancer recurrence and lifestyle-related chronic diseases, adhering to multiple lifestyle recommendations is however very important for the health related QoL of this specific group. This underlines the need to understand which