A Systematic Review of Telehealth-Based Pediatric Cancer Rehabilitation Interventions on Disability

Background: Telehealth is an emerging method which may overcome barriers to rehabilitation access for pediatric cancer survivors (aged ≤19 years). This systematic review aimed to examine telehealth-based rehabilitation interventions aimed at preventing, maintaining, or improving disability in pediatric cancer survivors. Methods: We performed systematic searches in Ovid MEDLINE, Ovid EMBASE, Cochrane Library, SCOPUS, Web of Science, and CINAHL Plus between 1994 and 2022. Eligible studies included telehealth-based interventions assessing disability outcomes in pediatric cancers. Results: Database searches identified 4,040 records. Nine unique interventions met the eligibility criteria. Telehealth delivery methods included telephone (n = 6), email (n = 3), mobile health applications (n = 3), social media (n = 3), videoconferencing (n = 2), text messaging (n = 2), active video gaming (n = 2), and websites (n = 2). Interventions focused on physical activity (n = 8) or self-management (n = 1). Outcomes assessing disability varied (n = 6). Three studies reported statistically and clinically significant results. Narrative synthesis of findings was constructed based on the Picker's principles for patient-centered care: (1) values, preferences, and needs; (2) involve family and friends; (3) coordination of care; (4) provide social support; (5) holistic well-being; and (6) information and communication. Conclusions: Telehealth-based rehabilitation interventions for pediatric cancer survivors is an emerging research area with potential to improve disability outcomes. Adequately powered trials with consistency in disability outcome measures are warranted. Additional research is needed to determine the effectiveness and best practices for telehealth-based pediatric cancer rehabilitation.

Association of cancer diagnosis with disability status among older survivors of colorectal cancer: a population-based retrospective cohort study

Background

Older cancer survivors likely experience physical function limitations due to cancer and its treatments, leading to disability and early mortality. Existing studies have focused on factors associated with surgical complications and mortality risk rather than factors associated with the development of poor disability status (DS), a proxy measure of poor performance status, in cancer survivors. We aimed to identify factors associated with the development of poor DS among older survivors of colorectal cancer (CRC) and compare poor DS rates to an age-sex-matched, non-cancer cohort.

Methods

This retrospective cohort study utilized administrative data from the Texas Cancer Registry Medicare-linked database. The study cohort consisted of 13,229 survivors of CRC diagnosed between 2005 and 2013 and an age-sex-matched, non-cancer cohort of 13,225 beneficiaries. The primary outcome was poor DS, determined by Davidoff's method, using predictors from 12 months of Medicare claims after cancer diagnosis. Multivariable Cox proportional hazards regression was used to identify risk factors associated with the development of poor DS.

Results

Among the survivors of CRC, 97% were 65 years or older. After a 9-year follow-up, 54% of survivors of CRC developed poor DS. Significant factors associated with future poor DS included: age at diagnosis (hazard ratio [HR] = 3.50 for >80 years old), female sex (HR = 1.50), race/ethnicity (HR = 1.34 for Hispanic and 1.21 for Black), stage at diagnosis (HR = 2.26 for distant metastasis), comorbidity index (HR = 2.18 for >1), and radiation therapy (HR = 1.21). Having cancer (HR = 1.07) was significantly associated with developing poor DS in the pooled cohorts; age and race/ethnicity were also significant factors.

Conclusions

Our findings suggest that a CRC diagnosis is independently associated with a small increase in the risk of developing poor DS after accounting for other known factors. The study identified risk factors for developing poor DS in CRC survivors, including Hispanic and Black race/ethnicity, age, sex, histologic stage, and comorbidities. These findings underscore the importance of consistent physical function assessments, particularly among subsets of older survivors of CRC who are at higher risk of disability, to prevent developing poor DS.

Association of Patient-Reported Health-Related Quality of Life With Physician-Reported Toxicities in Adolescents and Young Adults Receiving Radiation Therapy for Cancer

PURPOSE

Radiation therapy (RT) may cause toxicities in adolescents and young adults (AYAs, age 15-39 years) with cancer. However, the range of RT-related toxicities in AYAs and the affect on health-related quality of life (HRQOL) has not been well studied. We performed a cross-sectional study in AYAs with cancer who received RT to identify RT-related toxicities and examine their impact on HRQOL.

MATERIALS AND METHODS

A total of 178 AYAs received RT and completed PROMIS HRQOL instruments from 2018 to 2022. Acute and late physician-graded Common Terminology Criteria for Adverse Events RT-related toxicities were extracted and described. Multivariable linear regression was used to evaluate the association of RT-related toxicity with HRQOL scores during and post-RT. Minimally important differences were used to evaluate the clinical relevance of relationships.

RESULTS

Eighty-four AYAs completed HRQOL surveys during RT and 94 post-RT. In the during-RT cohort, 75 AYAs (89%) had acute RT-related toxicities, a majority of which were grade 1 (n = 49, 65%). AYAs who experienced acute grade 2 or greater toxicities reported worse global mental health (B = -7.35, P < .01) and worse pain (B = 5.25, P = .01) than those with acute grade 1 or no toxicities. In the post-RT cohort, the median (IQR) time from RT to survey completion was 24 (14-27) months. Forty-eight AYAs (51%) had late RT-related toxicities, a majority of which were grade 1 (n = 37, 77%). AYAs who experienced late grade 2 or greater toxicities reported worse global mental health (B = -8.07, P = .01), worse social roles (B = -9.96, P < .01), and greater sleep disturbance (B = 10.75, P < .01) than those with late grade 1 or no RT toxicities.

CONCLUSION

The presence of acute and late grade 2 or greater RT-related toxicities may contribute to worse HRQOL, especially global mental health, in AYAs. Screening and early interventions to mitigate RT-related toxicities are needed to improve AYA HRQOL.

Patient-reported quality of life in adolescents and young adults with cancer who received radiation therapy

BACKGROUND

Radiation therapy (RT) is a common treatment for adolescents and young adults (AYAs, 15-39 years old) with cancer; however, it may cause toxicities that affect health-related quality-of-life (HRQOL). Thus, we assessed HRQOL in AYAs before, during, and after RT.

METHODS

We identified 265 AYAs who completed HRQOL PROMIS® surveys before (n = 87), during (n = 84), or after (n = 94) RT. Higher PROMIS® score represents more of the concept. Mean scores were compared to the general US population and minimally important differences (MIDs) were used to evaluate the impact of cancer on HRQOL. Linear regression modeling was used to evaluate the effect of clinical and demographic factors on PROMIS scores.

RESULTS

Median [IQR] age was 26 [20-31] years. Cancer types varied; most had sarcoma (26%) or CNS malignancy (23%). Compared to the general US population, the before RT cohort had worse anxiety (mean score 55.2 vs. 50, MID 3, p < 0.001) and the during RT cohort had worse global physical health (mean score 44.9 vs. 50, MID 5, p < 0.001). In the during RT cohort, patients with regional/distant disease had significantly worse pain (B = 15.94, p < 0.01) and fatigue (B = 14.20, p = 0.01) than patients with localized disease. In the after RT cohort, adolescents (15-18 years) and young adults (26-39 years) had worse global physical health (B = -6.87, p < 0.01, and B = -7.87, p < 0.01, respectively) and global mental health (B = -6.74, p < 0.01, and B = -5.67, p = 0.01, respectively) than emerging adults (19-25 years).

CONCLUSIONS

AYAs with cancer receiving RT experience impairments in various domains of HRQOL. Advanced cancer stage may contribute to poorer short-term HRQOL and developmental stage may contribute to differing long-term HRQOL.

Abstract 6731: Gut microbiome associated with the psychoneurological symptom cluster among children with solid tumors receiving chemotherapy

Background: Children with cancer (CWC) receiving chemotherapy (chemo) report significant suffering from a cluster of psychoneurological symptoms (PNS), including pain, fatigue, anxiety, depression, and cognitive dysfunction. Continuous or severe PNS reduce a child’s quality of life. Chemo can disturb the gut microbiome (GM), which is associated with PNS based on the gut-brain axis. This study aimed to examine associations of GM with PNS and the PNS cluster in CWC undergoing chemo.

Methods: An observational prospective study was conducted in 21 CWC enrolled from Children’s Healthcare of Atlanta. Children with at least 1 cycle of chemo were consented pre-cycle 2 chemo (T1) and followed at the end of chemo (T2). At T1, parents reported children’s demographics; at T1 and T2, PNS (pain, fatigue, anxiety, depression, cognitive dysfunction) were reported by children by the Pediatric PROMIS scales and fecal specimens were collected for GM. T-score of the PROMIS scales was computed; an average of T-scores of the five PNS was computed for the PNS cluster. T-score &gt;50 indicates a significant symptom or symptom cluster. 16S rRNA V4 gene from fecal specimens was sequenced for GM. QIIME 2 was used to examine associations of α- and β-diversity with PNS. Linear discriminant analysis effect size identified microbial taxa associated with each PNS and the PNS cluster.

Results: We analyzed 21 CWC with a mean age of 13 years, 67% male, and 67% white. Children at T2 had higher fatigue (54% vs. 43%), cognitive dysfunction (69% vs. 43%), depressive symptoms (23% vs. 19%), and multiple PNS (62% vs. 48%), but lower pain interference (31% vs. 38%) and anxiety (23% vs. 38%) than those at T1. No association was found for α-diversity at T1; higher α-diversity was associated with lower cognitive dysfunction (Faith’s phylogenetic diversity, p=0.04) and anxiety (Pielou’s_e, p=0.08) at T2; β-diversity (Jaccard distance) showed the GM dissimilarities by levels of pain interference (moderate vs. severe, p=0.02) and levels of anxiety (mild vs. moderate, p=0.07). After controlling for study timepoint, children with low pain interference had an enriched Bacteroides; those with low fatigue had enriched Bacteroides and Turicibacter; those with normal cognitive function had enriched Parasutterella, UBA1819, NK4A214, Sellimonas, and Ruminococcaceae. Children without the PNS cluster had enriched Bacteroides, while those with the PNS cluster had enriched Enterobacteriaceae. Children without multiple PNS had enriched UCG_003.

Conclusions: Children with low PNS showed a higher α-diversity and a higher abundance of taxa involved in nutrition and vitamin metabolism (eg, Bacteroides), reducing inflammation (eg, Turicibacter), and producing short chain fatty acids (eg, Ruminococcaceae). These findings provide potential solutions to treat PNS. Further work is needed to corroborate these associations in CWC.

Citation Format: Jinbing Bai, Melissa Martin, Kathryn S. Sutton, Christie Powell, Thomas Olson, Hye In Noh, Maria C. Swartz, Deborah Watkins Bruner. Gut microbiome associated with the psychoneurological symptom cluster among children with solid tumors receiving chemotherapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6731.

Assessing the Suitability of a Virtual 'Pink Warrior' for Older Breast Cancer Survivors during COVID-19: A Pilot Study

The COVID-19 pandemic impacted the conduct of in-person physical activity (PA) interventions among older survivors of BC, who need such interventions to stay active and prevent functional decline. We tested the feasibility of virtually delivering an exergame-based PA intervention to older BC survivors. We enrolled 20 female BC survivors ≥55 years and randomly assigned them to two groups. The intervention group (Pink Warrior 2) received 12 weekly virtual exergame sessions with behavioral coaching, survivorship navigation support, and a Fitbit for self-monitoring. The control group received 12 weekly phone-based survivorship discussion sessions and wore a Mi Band 3. Feasibility was evaluated by rates of recruitment (≥0.92 participants/center/month), retention (≥80%), and group attendance (≥10 sessions), percentage of completed virtual assessments, and number of technology-related issues and adverse events. Intervention acceptability was measured by participants' ratings on a scale of 1 (strongly disagree) to 5 (strongly agree). The recruitment rate was 1.93. The retention and attendance rates were 90% and 88% (≥10 sessions), respectively. Ninety-six percent completed virtual assessments without an adverse event. Acceptability was high (≥4). The intervention met benchmarks for feasibility. Additional research is needed to further understand the impact of virtually delivered PA interventions on older BC survivors.

Feasibility and Acceptability of an Active Video Game-Based Physical Activity Support Group (Pink Warrior) for Survivors of Breast Cancer: Randomized Controlled Pilot Trial

BACKGROUND

Survivors of breast cancer with functional limitations have a 40% higher mortality rate than those without. Despite the known benefits of physical activity (PA), <40% of survivors of breast cancer meet the recommendations for PA. The combination of active video games (AVGs) and group-based PA counseling may hold potential for motivating PA adoption and improving physical function. However, this method has not been widely studied in survivors of breast cancer.

OBJECTIVE

We aimed to determine the feasibility and acceptability of a group AVG-based multicomponent PA intervention and estimate its effect size and variability on PA and physical function in female survivors of breast cancer in a clinic setting.

METHODS

Female survivors of breast cancer (N=60) were recruited through the clinic and randomly assigned to the intervention group (12 weekly sessions) or the control group (existing support group). The intervention group received game-based pedometers and participated in weekly group AVG sessions, PA behavioral coaching, and survivorship navigation discussions. A participant manual with weekly reflection worksheets was provided to reinforce the coaching lessons and promote self-led PA. The control group received conventional pedometers and participated in an existing breast cancer support group. Feasibility was assessed by enrollment rate (≥50%), retention rate (≥80%), group attendance rate (75% attending ≥9 sessions [intervention group]), and the number of technological issues and adverse events. Acceptability was measured by participants' attitudes (from strongly disagree=1 to strongly agree=5) toward the use of AVGs and the overall program. The outcomes included PA (accelerometers) and physical function (Short Physical Performance Battery and gait speed). Analysis of covariance was used to determine differences in PA and physical function between the groups. The Cohen d and its 95% CI determined the effect size and variability, respectively. All the analyses followed the intention-to-treat principle.

RESULTS

Participants were an average of 57.4 (SD 10.5) years old, 70% (42/60) White, and 58% (35/60) off treatment. The enrollment rate was 55.9% (66/118). Despite substantial long-term hurricane-related disruptions, we achieved an 80% (48/60) retention. The intervention group's attendance rate was 78% (14/18), whereas the control group's attendance rate was 53% (9/17). Of the 26 game-based pedometers, 3 (12%) were damaged or lost. No study-related adverse events occurred. Acceptability items were highly rated. Steps (β=1621.64; P=.01; d=0.72), Short Physical Performance Battery (β=.47; P=.01; d=0.25), and gait speed (β=.12; P=.004; d=0.48) had a significant intervention effect.

CONCLUSIONS

The intervention was feasible and acceptable in this population despite the occurrence of a natural disaster. Pilot results indicate that group AVG sessions, PA coaching, and survivorship navigation produced moderate effects on PA and physical functioning. AVGs with PA counseling can potentially be used in existing breast cancer support groups to encourage PA and improve physical function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02750241; https://clinicaltrials.gov/ct2/show/NCT02750241.

Development of an Enhanced Recovery Program in Pediatric, Adolescent, and Young Adult Surgical Oncology Patients

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative treatment plans aimed at improving recovery time in patients following surgery using a multidisciplinary team approach. These protocols have been shown to optimize pain control, improve mobility, and decrease postoperative ileus and other surgical complications, thereby leading to a reduction in length of stay and readmission rates. To date, no ERAS-based protocols have been developed specifically for pediatric patients undergoing oncologic surgery. Our objective is to describe the development of a novel protocol for pediatric, adolescent, and young adult surgical oncology patients. Our protocol includes the following components: preoperative counseling, optimization of nutrition status, minimization of opioids, meticulous titration of fluids, and early mobilization. We describe the planning and implementation challenges and the successes of our protocol. The effectiveness of our program in improving perioperative outcomes in this surgical population could lead to the adaptation of such protocols for similar populations at other centers and would lend support to the use of ERAS in the pediatric population overall.

Non-pharmacological sleep interventions for pediatric cancer patients and survivors: a systematic review protocol

BACKGROUND

Sleep disturbances constitute a common complication in pediatric cancer patients and survivors and are frequently severe enough to warrant treatment. Suboptimal sleep has been associated with decreased emotional well-being and cognitive functioning and increased behavioral problems. Standardized guidelines for non-pharmacological sleep interventions for adults with cancer exist, but no standard of care intervention or standard guidelines are available to guide such intervention in pediatric cancer patients and survivors. Therefore, effective behavioral interventions for improving sleep quality need to be identified. The objective of the review is to evaluate the effect of non-pharmacological sleep interventions on sleep quality in pediatric cancer patients and survivors.

METHODS

The review will consider studies that include children and adolescents between 0 and 18 years diagnosed with cancer or who have a history of cancer who have non-respiratory sleep disturbance. We will include experimental and quasi-experimental studies evaluating non-pharmacological interventions such as psychological interventions, technical/device interventions, interventions targeting physical activity, and complementary and alternative medicine interventions (e.g., yoga, massage, music). Interventions involving medications, ingestible supplements, products purported to work through absorption, and medical devices will be excluded. Primary outcome will be sleep quality as measured by methods including retrospective ratings, daily sleep diary, and validated questionnaires. Secondary outcomes will include total sleep time, sleep onset latency, wake after sleep onset, daytime sleepiness, and daytime sleep duration (naps) as measured by retrospective ratings, daily sleep diary, validated questionnaires, and/or actigraphy. Databases will include MEDLINE (Ovid), EMBASE (Ovid), Cochrane Library, CINAHL (Ebsco), and PsycINFO (Ovid) and will be queried from database inception to present. Two reviewers will independently screen all citations, full-text articles, and extract data. The study methodological quality will be assessed using Joanna Briggs Institute (JBI) critical appraisal tools. Data will be extracted and findings pooled and synthesized using a meta-aggregation approach via the JBI System for the Unified Management, Assessment, and Review of Information (SUMARI). If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., methodological quality, study design, outcome measures).

DISCUSSION

This systematic review will synthesize and consolidate evidence on existing non-pharmacological interventions to improve sleep in pediatric cancer patients and survivors. Findings may help inform practitioners working with pediatric cancer patients and survivors experiencing sleep disturbances and is intended to identify gaps and opportunities to improve methodical quality of further non-pharmacological sleep intervention research in this population toward developing an eventual standard of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020200397 .

Use of active video games with or without videoconferencing on health outcomes in adolescent and young adult cancer survivors: a systematic review

PURPOSE

Adolescent and young adult (AYA) cancer survivors experience greater functional deficits compared to non-cancer peers or older survivors with a similar diagnosis. Physical activity (PA) is a key strategy for mitigating functional decline, and motivation and peer support are critical PA facilitators in AYA cancer survivors. Active video games (AVGs) may be a "gateway" method to promote PA. Further, integrating AVGs into group videoconferencing, a medium used by AYAs to socialize, can capitalize on peer support needed for PA motivation. Thus, we examined the use of AVGs and/or videoconferencing in PA interventions that included AYA survivors and the effect on physical function and health outcomes.

METHODS

Seven electronic databases were searched from incept to January 2020. Search terms included videoconferencing, video games, exercise, and cancer. The protocol is registered on PROSPERO: CRD42020163491. Two reviewers evaluated eligibility and methodological quality using Cochrane's risk of bias tools.

RESULTS

Six unique studies were included with 97% reviewer agreement. All used AVGs, none used videoconferencing alone, and one used both. Study designs and outcome measures were heterogeneous. Only one study solely targeted AYA survivors. Most were low to medium quality. Few showed significant improvements in quality of life (QOL) and fatigue (n=3), coordination/balance (n=2), and aerobic capacity (n=1).

CONCLUSIONS

PA interventions using AVGs and/or videoconferencing may improve QOL and fatigue, but evidence on function is lacking. Rigorous interventions targeting AYA survivors are needed.

IMPLICATIONS FOR CANCER SURVIVORS

Using AVGs and/or videoconferencing to facilitate PA may improve QOL and fatigue.

Effect of Electronic Activity Monitors and Pedometers on Health: Results from the TAME Health Pilot Randomized Pragmatic Trial

Background: Brief counseling and self-monitoring with a pedometer are common practice within primary care for physical activity promotion. It is unknown how high-tech electronic activity monitors compare to pedometers within this setting. This study aimed to investigate the outcomes, through effect size estimation, of an electronic activity monitor-based intervention to increase physical activity and decrease cardiovascular disease risk. Method: The pilot randomized controlled trial was pre-registered online at clinicaltrials.gov (NCT02554435). Forty overweight, sedentary participants 55–74 years of age were randomized to wear a pedometer or an electronic activity monitor for 12 weeks. Physical activity was measured objectively for 7 days at baseline and follow-up by a SenseWear monitor and cardiovascular disease risk was estimated by the Framingham risk calculator. Results: Effect sizes for behavioral and health outcomes ranged from small to medium. While these effect sizes were favorable to the intervention group for physical activity (PA) (d = 0.78) and general health (d = 0.39), they were not favorable for measures. Conclusion: The results of this pilot trial show promise for this low-intensity intervention strategy, but large-scale trials are needed to test its efficacy.

A Pilot Study of a Culturally Tailored Lifestyle Intervention for Chinese American Cancer Survivors

Although Asian Americans generally have the lowest cancer incidence rates and mortality rates, cancer is the leading cause of death among Asian Americans. The goal of this pilot study was to engage Chinese American cancer survivors (CACS) in systematic changes toward desired health behaviors through a healthy lifestyle intervention delivered by a community-based organization. The Reach out to ENhanceE Wellness (RENEW) program workbook was translated into Mandarin Chinese with additional physical activity (PA) and dietary information that are culturally appropriate (RENEW-C). Fifty-five Chinese cancer survivors were recruited from the greater Houston area to participate in this 50-week program and 50 of them completed both the baseline and postintervention surveys in 2013 and 2014, respectively. Paired sample t tests were used to assess changes in 5 groups of outcomes: (1) patient knowledge (measured by Health Education Impact Questionnaire [heiQ]), (2) dietary intake (Automated Self-Administered 24-Hour [ASA24] Dietary Assessment Tool), (3) PA (Community Healthy Activities Model Program for Seniors [CHAMPS]), (4) body mass index, and (5) quality of life (36-item Short-Form Survey [SF-36]). Compared with the baseline, participants reported significantly higher consumption of vegetables and higher frequency of PAs at the postintervention survey. They also showed improved mental health and lower limitation in doing their work or other activities due to physical health or emotional problems. Despite the small sample size, this pilot study demonstrated the effectiveness of using a community-based participatory approach in a healthy lifestyle intervention tailored for CACS.

A Retrospective Study of Administrative Data to Identify Factors Associated with Future Disability Status among Older Colorectal Cancer Survivors

Disability is associated with loss of independence and early mortality. Currently, only 1–2% of cancer survivors who reported physical limitations received rehabilitation services. It is critical to identify factors associated with the development of disability to guide clinical practice given treatment changes. We aimed to 1) identify demographic and cancer-related characteristics associated with future disability status among older colorectal cancer survivors, and 2) compared the future disability status among cancer and matched non-cancer cohorts. Methods: We conducted a retrospective cohort study using the Texas Cancer Registry-national Medicare linked database. The cancer cohort included Medicare beneficiaries with a primary colorectal cancer diagnosis between 2005 and 2013 (n = 13,229). The non-cancer cohort was identified from a 5% sample of Medicare beneficiaries (n = 11,416). Diagnosis dates from the cancer cohort were used as the index date for the non-cancer cohort. Cohorts were matched 1:1 based on index date, age, and gender. Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals. Disability status was defined according to Davidoff and colleagues using inpatient, outpatient and durable medical equipment claims files, and assessed monthly, beginning 1 month after cancer diagnosis (or index date), continuing until disability, death, end of Medicare continuous enrollment, or end of study. Results: Factors that were significantly associated with disability status in the cancer cohort were age (HR = 3.50 for &gt;80 years old), female gender (HR = 1.50), race/ethnicity (HR = 1.34 for Hispanic and 1.21 for Black), stage (HR = 2.26 for distant stage), comorbidity (HR = 2.18 for &gt;1), and radiation (HR = 1.21). When compared to the non-cancer cohort, having a cancer diagnosis (HR = 1.07) and comorbidity (HR = 2.09 for &gt;1) were associated with developing disability. Conclusions: Colorectal diagnosis is an independent risk for disability status. Beyond well-known risk factors “age and mortality” subsets of survivors (Hispanic and Black survivors and those with comorbidity) are found to be at higher risk for developing disability. This warrants further investigation and may indicate targeted intervention to prevent future disability.

A Narrative Review on the Potential of Red Beetroot as an Adjuvant Strategy to Counter Fatigue in Children with Cancer

Cancer-related fatigue (CRF) is a debilitating adverse effect among children with cancer and a significant barrier to physical activity (PA) participation. PA interventions are effective at reducing fatigue and improving both quality of life (QOL) and functional outcomes in children with cancer. However, 50-70% of children with cancer do not meet PA guidelines. Thus, adjuvant methods are needed to increase PA participation. Given the growing interest in the use of beetroot juice to reduce exercise-induced fatigue, our narrative review evaluated the potential use of beetroot to improve PA participation to counter CRF and improve QOL. Our review of 249 articles showed a lack of published clinical trials of beetroot in children and adults with cancer. Trials of beetroot use had been conducted in a noncancer population (n = 198), and anticancer studies were primarily in the preclinical phase (n = 40). Although results are promising, with beetroot juice shown to counter exercise-induced fatigue in a variety of athletic and patient populations, its use to counter CRF in children with cancer is inconclusive. Pilot and feasibility studies are needed to examine the potential benefits of beetroot to counter CRF, increase PA participation, and improve QOL in children with cancer.

Social Support Patterns of Middle-Aged and Older Adults Within a Physical Activity App: Secondary Mixed Method Analysis

Background

Physical activity (PA) is critical for maintaining independence and delaying mobility disability in aging adults. However, 27 to 44% of older adults in the United States are meeting the recommended PA level. Activity trackers are proving to be a promising tool to promote PA adherence through activity tracking and enhanced social interaction features. Although social support has been known to be an influential behavior change technique to promote PA, how middle-aged and older adults use the social interaction feature of mobile apps to provide virtual support to promote PA engagement remains mostly underexplored.

Objective

This study aimed to describe the social support patterns of middle-aged and older adults using a mobile app as part of a behavioral PA intervention.

Methods

Data from 35 participants (mean age 61.66 [SD 6] years) in a 12-week, home-based activity intervention were used for this secondary mixed method analysis. Participants were provided with a Jawbone Up24 activity monitor and an Apple iPad Mini installed with the UP app to facilitate self-monitoring and social interaction. All participants were given an anonymous account and encouraged to interact with other participants using the app. Social support features included comments and likes. Thematic coding was used to identify the type of social support provided within the UP app and characterize the levels of engagement from users. Participants were categorized as superusers or contributors, and passive participants were categorized as lurkers based on the literature.

Results

Over the 12-week intervention, participants provided a total of 3153 likes and 1759 comments. Most participants (n=25) were contributors, with 4 categorized as superusers and 6 categorized as lurkers. Comments were coded as emotional support, informational support, instrumental support, self-talk, and other, with emotional support being the most prevalent type.

Conclusions

Our cohort of middle-aged and older adults was willing to use the social network feature in an activity app to communicate with anonymous peers. Most of our participants were contributors. In addition, the social support provided through the activity app followed social support constructs. In sum, PA apps are a promising tool for delivering virtual social support to enhance PA engagement and have the potential to make a widespread impact on PA promotion.

Trial Registration

ClinicalTrials.gov NCT01869348; https://clinicaltrials.gov/ct2/show/NCT01869348

Brief Report: Active Ingredients for Adherence to a Tracker-Based Physical Activity Intervention in Older Adults

OBJECTIVES

To identify factors associated with weekly adherence to a 12-week tracker-based activity intervention in older adults.

METHOD

Using generalized linear mixed models in a secondary analysis ( N = 35), we examined factors associated with weekly adherence (defined as wore the Jawbone Up24 tracker for ≥5 days and completed weekly calls). Factors examined included individual characteristics, gave and received virtual support, achieved step goals, barrier and task self-efficacy, and self-comment.

RESULTS

Participants' ( M_age = 61.7, SD_age = 5.7) adherence changed from 86% (Week 1) to 74% (Week 12). Achieved the previous week's goal (β = 1.13, p = .01) and received virtual support (β = 0.01, p = .02) significantly increased the odds of weekly adherence.

DISCUSSION

Achieved step goals and received virtual support were associated with improved adherence to our tracker-based activity intervention, which has promising potential to be translated into the clinical setting to promote active lifestyles.

Physical activity and exercise self-regulation in cancer survivors: A qualitative study

OBJECTIVE

Despite the benefits of physical activity, many cancer survivors do not adhere to clinically recommended levels. This qualitative study investigated factors of self-regulation contributing to survivor physical activity patterns.

METHODS

Participants attended focus groups with prompts on exercise habits and self-regulation on the basis of social cognitive theory, self-determination theory, and self-regulation theory. Content analysis with a priori codes was conducted to identify emergent themes.

RESULTS

Participants (n = 35) were predominately older (63.7 y ± 10.8), female (69%), white (71%), and breast cancer (60%) survivors, with 41% not meeting activity guidelines. Emergent themes included exercise goal development, selection, and attainment; exercise planning; and self-reward. Participants tended to develop values-based, general goals rather than action-based, measurable goals. Goal attainment success emerged as a facilitator of future goal performance; completing a current goal facilitated subsequent goal attainment, while failure hindered future goal completion. Rather than having deliberate intentions to schedule exercise, participants exercised if expedient in the context of normal daily activities. Food consumption emerged as a major mechanism for self-reward.

CONCLUSIONS

Our findings suggest that values-based goals, unplanned activity, influence from previous goal attempts, and self-reward were important factors related to self-regulation. Interventions designed to improve self-regulation may consider facilitating development of autonomous, value-based goals, assisting in development of strategies for future goals if current goals are not met, endorsing exercise as a scheduled activity, and introducing healthy self-reward alternatives.

Effect of Home- and Community-Based Physical Activity Interventions on Physical Function Among Cancer Survivors: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the effect of home- and community-based physical activity interventions on physical functioning among cancer survivors based on the most prevalent physical function measures, randomized trials were reviewed.

DATA SOURCES

Five electronic databases-Medline Ovid, PubMed, CINAHL, Web of Science, and PsycINFO-were searched from inception to March 2016 for relevant articles.

STUDY SELECTION

Search terms included community-based interventions, physical functioning, and cancer survivors. A reference librarian trained in systematic reviews conducted the final search.

DATA EXTRACTION

Four reviewers evaluated eligibility and 2 reviewers evaluated methodological quality. Data were abstracted from studies that used the most prevalent physical function measurement tools-Medical Outcomes Study 36-Item Short-Form Health Survey, Late-Life Function and Disability Instrument, European Organisation for the Research and Treatment of Cancer Quality-of-Life Questionnaire, and 6-minute walk test. Random- or fixed-effects models were conducted to obtain overall effect size per physical function measure.

DATA SYNTHESIS

Fourteen studies met inclusion criteria and were used to compute standardized mean differences using the inverse variance statistical method. The median sample size was 83 participants. Most of the studies (n=7) were conducted among breast cancer survivors. The interventions produced short-term positive effects on physical functioning, with overall effect sizes ranging from small (.17; 95% confidence interval [CI], .07-.27) to medium (.45; 95% CI, .23-.67). Community-based interventions that met in groups and used behavioral change strategies produced the largest effect sizes.

CONCLUSIONS

Home and community-based physical activity interventions may be a potential tool to combat functional deterioration among aging cancer survivors. More studies are needed among other cancer types using clinically relevant objective functional measures (eg, gait speed) to accelerate translation into the community and clinical practice.

Feasibility and Acceptability of a Wearable Technology Physical Activity Intervention With Telephone Counseling for Mid-Aged and Older Adults: A Randomized Controlled Pilot Trial

Background

As adults age, their physical activity decreases and sedentary behavior increases, leading to increased risk of negative health outcomes. Wearable electronic activity monitors have shown promise for delivering effective behavior change techniques. However, little is known about the feasibility and acceptability of non-Fitbit wearables (Fitbit, Inc, San Francisco, California) combined with telephone counseling among adults aged more than 55 years.

Objective

The purpose of our study was to determine the feasibility, acceptability, and effect on physical activity of an intervention combining a wearable physical activity monitor, tablet device, and telephone counseling among adults aged 55-79 years.

Methods

Adults (N=40, aged 55-79 years, body mass index=25-35, <60 min of activity per week) were randomized to receive a 12-week intervention or to a wait list control. Intervention participants received a Jawbone Up24 monitor, a tablet with the Jawbone Up app installed, and brief weekly telephone counseling. Participants set daily and weekly step goals and used the monitor’s idle alert to notify them when they were sedentary for more than 1 h. Interventionists provided brief counseling once per week by telephone. Feasibility was measured using observation and study records, and acceptability was measured by self-report using validated items. Physical activity and sedentary time were measured using ActivPAL monitors following standard protocols. Body composition was measured using dual-energy x-ray absorptiometry scans, and fitness was measured using a 6-min walk test.

Results

Participants were 61.48 years old (SD 5.60), 85% (34/40) female, 65% (26/40) white. Average activity monitor wear time was 81.85 (SD 3.73) of 90 days. Of the 20 Up24 monitors, 5 were reported broken and 1 lost. No related adverse events were reported. Acceptability items were rated at least 4 on a scale of 1-5. Effect sizes for most outcomes were small, including stepping time per day (d=0.35), steps per day (d=0.26), sitting time per day (d=0.21), body fat (d=0.17), and weight (d=0.33).

Conclusions

The intervention was feasible and acceptable in this population. Effect sizes were similar to the sizes found using other wearable electronic activity monitors, indicating that when combined with telephone counseling, wearable activity monitors are a potentially effective tool for increasing physical activity and decreasing sedentary behavior.

Trial registration

Clinicaltrials.gov NCT01869348; https://clinicaltrials.gov/ct2/show/NCT01869348 (Archived by WebCite at http://www.webcitation.org/6odlIolqy)

A randomized nutrition counseling intervention in pediatric leukemia patients receiving steroids results in reduced caloric intake

BACKGROUND

Quality of life in survivors of pediatric acute lymphocytic leukemia (ALL) can be compromised by chronic diseases including increased risk of second cancers, cardiovascular disease, and diabetes. Overweight or obesity further increases these risks. Steroids are a component of chemotherapy for ALL, and weight gain is a common side effect. To impact behaviors associated with weight gain, we conducted a randomized nutrition counseling intervention in ALL patients on treatment.

PROCEDURE

ALL patients on a steroid-based treatment regimen at the MD Anderson Children's Cancer Hospital were recruited and randomized into control or intervention groups. The control group received standard care and nutrition education materials. The intervention group received monthly one-on-one nutrition counseling sessions, consisting of a baseline and 12 follow-up visits. Anthropometrics, dietary intake (3-day 24-hr dietary recalls) and oxidative stress measures were collected at baseline, 6 months, and postintervention. Dietary recall data were analyzed using the Nutrition Data System for Research.

RESULTS

Twenty-two patients (median age 11.5 years), all in the maintenance phase of treatment, were recruited. The intervention group (n = 12) reported significantly lower calorie intake from baseline to 12-month follow-up and significant changes in glutamic acid and selenium intake (P < 0.05). Waist circumference was significantly associated with calorie, vitamin E, glutamic acid, and selenium intake.

CONCLUSIONS

A year-long dietary intervention was effective at reducing caloric intake in pediatric ALL patients receiving steroid-based chemotherapy, indicating that this is a modality that can be built upon for obesity prevention and management.

Mobile Health Physical Activity Intervention Preferences in Cancer Survivors: A Qualitative Study

Background

Cancer survivors are at an elevated risk for several negative health outcomes, but physical activity (PA) can decrease those risks. Unfortunately, adherence to PA recommendations among survivors is low. Fitness mobile apps have been shown to facilitate the adoption of PA in the general population, but there are limited apps specifically designed for cancer survivors. This population has unique needs and barriers to PA, and most existing PA apps do not address these issues. Moreover, incorporating user preferences has been identified as an important priority for technology-based PA interventions, but at present there is limited literature that serves to establish these preferences in cancer survivors. This is especially problematic given the high cost of app development and because the majority of downloaded apps fail to engage users over the long term.

Objective

The aim of this study was to take a qualitative approach to provide practical insight regarding this population’s preferences for the features and messages of an app to increase PA.

Methods

A total of 35 cancer survivors each attended 2 focus groups; a moderator presented slide shows on potential app features and messages and asked open-ended questions to elicit participant preferences. All sessions were audio recorded and transcribed verbatim. Three reviewers independently conducted thematic content analysis on all transcripts, then organized and consolidated findings to identify salient themes.

Results

Participants (mean age 63.7, SD 10.8, years) were mostly female (24/35, 69%) and mostly white (25/35, 71%). Participants generally had access to technology and were receptive to engaging with an app to increase PA. Themes identified included preferences for (1) a casual, concise, and positive tone, (2) tools for personal goal attainment, (3) a prescription for PA, and (4) an experience that is tailored to the user. Participants reported wanting extensive background data collection with low data entry burden and to have a trustworthy source translate their personal data into individualized PA recommendations. They expressed a desire for app functions that could facilitate goal achievement and articulated a preference for a more private social experience. Finally, results indicated that PA goals might be best established in the context of personally held priorities and values.

Conclusions

Many of the desired features identified are compatible with both empirically supported methods of behavior change and the relative strengths of an app as a delivery vehicle for behavioral intervention. Participating cancer survivors’ preferences contrasted with many current standard practices for mobile app development, including value-based rather than numeric goals, private socialization in small groups rather than sharing with broader social networks, and interpretation of PA data rather than merely providing numerical data. Taken together, these insights may help increase the acceptability of theory-based mHealth PA interventions in cancer survivors.

Testing Activity Monitors' Effect on Health: Study Protocol for a Randomized Controlled Trial Among Older Primary Care Patients

BACKGROUND

Cardiovascular disease is the leading cause of mortality in the United States. Maintaining healthy levels of physical activity is critical to cardiovascular health, but many older adults are inactive. There is a growing body of evidence linking low motivation and inactivity. Standard behavioral counseling techniques used within the primary care setting strive to increase motivation, but often do not emphasize the key component of self-control. The addition of electronic activity monitors (EAMs) to counseling protocols may provide more effective behavior change and increase overall motivation for exercise through interactive self-monitoring, feedback, and social support from other users.

OBJECTIVE

The objective of the study is to conduct a three month intervention trial that will test the feasibility of adding an EAM system to brief counseling within a primary care setting. Participants (n=40) will be randomized to receive evidence-based brief counseling plus either an EAM or a pedometer.

METHODS

Throughout the intervention, we will test its feasibility and acceptability, the change in primary outcomes (cardiovascular risk and physical activity), and the change in secondary outcomes (adherence, weight and body composition, health status, motivation, physical function, psychological feelings, and self-regulation). Upon completion of the intervention, we will also conduct focus groups with the participants and with primary care stakeholders.

RESULTS

The study started recruitment in October 2015 and is scheduled to be completed by October 2016.

CONCLUSIONS

This project will lay the groundwork and establish the infrastructure for intervention refinement and ultimately translation within the primary care setting in order to prevent cardiovascular disease on a population level.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02554435; https://clinicaltrials.gov/ct2/show/NCT02554435 (Archived by WebCite at http://www.webcitation/6fUlW5tdT).

Psychometric Analysis of the Three-Factor Eating Questionnaire-R18V2 in Adolescent and Young Adult-Aged Central Nervous System Tumor Survivors

PURPOSE

Adolescent and young adult (AYA)-aged central nervous system (CNS) tumor survivors are an understudied population that is at risk of developing adverse health outcomes, such as obesity. Long-term follow-up guidelines recommend monitoring those at risk of obesity, thus motivating the need for an eating behavior questionnaire. An abbreviated online version of the Three-Factor Eating Questionnaire (TFEQ-R18v2) has been developed, but its applicability to this population is not yet known. This study investigated the instrument's factor structure and reliability in this population.

METHODS

AYA-aged CNS tumor survivors (n = 114) aged 15-39 years completed the TFEQ-R18V2 questionnaire online. Confirmatory factor analysis was used to examine the fit of the three-factor structure (uncontrollable eating, cognitive restraint, and emotional eating [EE]) and reliability (internal consistency of the TFEQ-R18v2). Associations between the three factors and body mass index (BMI) were assessed by linear regression.

RESULTS

The theorized three-factor structure was supported in our population (RMSEA = 0.056 and CFI = 0.98) and demonstrated good reliability (α of 0.81-0.93). EE (β = 0.07, 95% CI 0.02-0.13) was positively associated with BMI, whereas the other two subscale scores were not.

CONCLUSION

The TFEQ-R18v2 instrument holds promise for research and clinical use among AYA-aged CNS tumor survivors. The instrument may be a useful tool for researchers to develop tailored weight management strategies. It also may be a valuable tool for clinicians to monitor survivors who are at risk of obesity and to facilitate referral. Our results also suggest that EE in this population should be further investigated as a potential target for intervention.

Testing the effects of narrative and play on physical activity among breast cancer survivors using mobile apps: study protocol for a randomized controlled trial

Background

Physical activity reduces risk for numerous negative health outcomes, but postmenopausal breast cancer survivors do not reach recommended levels. Many interventions encourage self-monitoring of steps, which can increase physical activity in the short term. However, these interventions appear insufficient to increase motivation for sustained change. There is a need for innovative strategies to increase physical activity motivation in this population. Narratives are uniquely persuasive, and video games show promise for increasing motivation. This study will determine the effectiveness of an intervention that combines narrative and gaming to encourage sustained physical activity.

Methods/Design

SMARTGOAL (Self-Monitoring Activity: a Randomized Trial of Game-Oriented AppLications) is a randomized controlled intervention trial. The intervention period is six months, followed by a six month maintenance period. Participants (overweight, sedentary postmenopausal breast cancer survivors aged 45–75) will be randomized to a self-monitoring group or an enhanced narrative game group. The self-monitoring group will be encouraged to use a mobile application for self-monitoring and feedback and will receive 15 counseling phone calls emphasizing self-regulation. The narrative game group will be encouraged to use a mobile application that includes self-monitoring and feedback as well as a narrative-based active video game. The 15 calls for this group will emphasize concepts related to the game storyline. Counseling calls in both groups will occur weekly in months 1 – 3 and monthly in months 4 – 6. No counseling calls will occur after month 6, but both groups will be encouraged to continue using their apps. The primary outcome of the study is minutes of moderate to vigorous physical activity at six months. Other objectively measured outcomes include fitness and physical function. Self-reported outcomes include quality of life, depression, and motivation.

Discussion

This protocol will result in implementation and evaluation of two technology-based physical activity interventions among breast cancer survivors. Both interventions hold promise for broad dissemination. Understanding the potential benefit of adding narrative and game elements to interventions will provide critical information to interventionists, researchers, clinicians, and policymakers. This study is uniquely suited to investigate not just whether but how and why game elements may improve breast cancer survivors’ health.

Trial registration

clinicaltrials.gov NCT02341235 (January 9, 2015)

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2244-y) contains supplementary material, which is available to authorized users.

What's the Point?: A Review of Reward Systems Implemented in Gamification Interventions

Rewards are commonly used in interventions to change behavior, but they can inhibit development of intrinsic motivation, which is associated with long-term behavior maintenance. Gamification is a novel intervention strategy that may target intrinsic motivation through fun and enjoyment. Before the effects of gamified interventions on motivation can be determined, there must be an understanding of how gamified interventions operationalize rewards, such as point systems. The purpose of this review is to determine the prevalence of different reward types, specifically point systems, within gamified interventions. Electronic databases were searched for relevant articles. Data sources included Medline OVID, Medline PubMed, Web of Science, CINAHL, Cochrane Central, and PsycINFO. Out of the 21 articles retrieved, 18 studies described a reward system and were included in this review. Gamified interventions were designed to target a myriad of clinical outcomes across diverse populations. Rewards included points (n = 14), achievements/badges/medals (n = 7), tangible rewards (n = 7), currency (n = 4), other unspecified rewards (n = 3), likes (n = 2), animated feedback (n = 1), and kudos (n = 1). Rewards, and points in particular, appear to be a foundational component of gamified interventions. Despite their prevalence, authors seldom described the use of noncontingent rewards or how the rewards interacted with other game features. The reward systems relying on tangible rewards and currency may have been limited by inhibited intrinsic motivation. As gamification proliferates, future research should explicitly describe how rewards were operationalized in the intervention and evaluate the effects of gamified rewards on motivation across populations and research outcomes.

Recommendations for the Optimal Design of Exergame Interventions for Persons with Disabilities: Challenges, Best Practices, and Future Research

A group discussion of individuals with expertise working in the field of exergaming and rehabilitation focused on the issue of designing exergames for persons with disabilities as well as appropriate interventions using exergames. The purpose of these discussions was to develop recommendations for the design, evaluation, and application of exergames in therapy serving as potential guidelines for researchers, developers, and therapists. The following key issues were addressed: (1) Challenges in exergame design for persons with disabilities, (2) adaptation of exergames for persons with disabilities, (3) exergame interventions, and (4) future research directions. It is the hope of the group that the results of these recommendations will help improve the quality of exergame design and interventions and thereby increase opportunities for persons with disabilities to engage sustainably in exergaming.

Fit4Life: a weight loss intervention for children who have survived childhood leukemia

BACKGROUND

Children surviving acute lymphoblastic leukemia (ALL) are at increased risk for overweight and obesity over that of the general population. Whether a generic or tailored approach to weight management is needed for cancer survivors has yet to be tested.

PROCEDURE

Thirty-eight youth 8-18 years with BMI ≥ 85% who had survived ALL were recruited for a randomized clinical trial evaluating a weight management intervention (WMI) tailored for childhood ALL survivors (Fit4Life). Fit4Life recipients received a 4-month web, phone, and text message-delivered WMI tailored for cancer survivorship. Controls received a general WMI delivered via phone and mail. Assessments were performed at baseline and 4 months. Outcome data were analyzed according to assigned treatment condition over time.

RESULTS

Most (80%, (70%, 100%) [median (IQR)]) of the assigned curriculum was received by Fit4Life participants as compared to 50% (40%, 65%) among controls. Fit4Life recipients ≥ 14 years demonstrated less weight gain (P = 0.05) and increased moderate-to-vigorous physical activity (P < 0.01) while all Fit4Life recipients reported reduced negative mood (P < 0.05) over time as compared to control counterparts.

CONCLUSIONS

We demonstrated acceptable feasibility of a WMI tailored for overweight and obese children surviving ALL utilizing a multimodal technology approach. Improved weight, weight-related behavior, and psychological outcomes were demonstrated among Fit4Life intervention as compared to youth receiving a generic WMI. Data from this pilot trial may be used to design a larger trial to determine whether youth of all ages also can derive a benefit from a cancer survivor-tailored WMI and whether short-term outcomes translate into improved long-term outcomes for childhood ALL survivors.

Response to an exercise intervention after endometrial cancer: differences between obese and non-obese survivors

OBJECTIVE

The objective of this paper is to describe baseline differences between obese and non-obese endometrial cancer survivor in anthropometrics, exercise behavior, fitness, heart rate and blood pressure, and quality of life, and to analyze whether the effect of a home-based exercise intervention on these outcomes differed for obese and non-obese participants.

METHODS

One hundred post-treatment Stage I-IIIa endometrial cancer survivors participated in a single arm 6month study in which they received a home-based exercise intervention. Cardiorespiratory fitness, anthropometrics, and exercise behavior were measured every two months, and quality of life (QOL) and psychological distress were measured at baseline and 6months.

RESULTS

Adjusting for potential confounders, at baseline obese survivors had poorer cardiorespiratory fitness (p=.002), higher systolic blood pressure (p=.018), and lower physical functioning (p<.001) and ratings of general health (p=.002), and more pain (p=.037) and somatization (.002). Significant improvements were seen in exercise behavior, resting heart rate, systolic blood pressure, and multiple QOL domains over the course of the intervention. Obese survivors had less improvement in exercise behavior and cardiorespiratory fitness than non-obese survivors, but there were no differences with regard to improvements in QOL and stress.

CONCLUSIONS

Home based exercise interventions are beneficial to endometrial cancer survivors, including those whose BMI is in the obese range. While obese survivors have lower levels of physical activity and fitness, they experienced similar activity, fitness, quality of life and mental health benefits. Exercise should be encouraged in endometrial cancer survivors, including those who are obese.

Exploring Parental Factors Related to Weight Management in Survivors of Childhood Central Nervous System Tumors

Childhood central nervous system tumor survivors (CCNSTS) are at risk for adverse health issues. Little research has been conducted to explore the role of parental factors in weight management to mitigate adverse health outcomes. We conducted 9 group interviews (n = 20) with CCNSTS, their parents, and health care providers to ascertain parental factors that may influence weight management practices in CCNSTS. Three main themes were identified: parenting style, parent–child connectedness, and food and physical activity (PA) environment. Although most parents adopted an authoritative parenting style related to diet and PA practices, some adopted a permissive parenting style. Participants expressed high levels of connection that may hinder the development of peer relationships and described the food and PA environments that promote or hinder weight management through parental modeling of healthy eating and PA and access to healthy food and activities. Weight management interventions for CCNSTS may experience greater benefit from using a family-focused approach, promoting positive food and PA environments, parental modeling of healthy eating and exercise, and partnering with youth to adopt weight management behaviors.