Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women s Health, Bronx, NY, USA

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1 Women s Health, Issues and Care Research Article Association of Obesity with Transtheoretical Stage of Change and Self Efficacy for Diet and Exercise in Racially and Ethnically Diverse Women with Endometrial Cancer Kimberley Chiu 1, Anne Van Arsdale 1, Amerigo Rossi 3, Dennis Kuo 1, Devin Miller 1 and Nicole S. Nevadunsky 1,2 * 1 Montefiore Medical Center, Division of Gynecologic Oncology, Department of Obstetrics & Gynecology and Women s Health, Bronx, NY, USA 2 Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, NY, USA 3 Division of Athletic Training, Health and Exercise Science, Long Island University, Brooklyn, NY, USA Abstract Objectives: Exercise and lifestyle interventions may improve healthy weight, physical activity and quality of life of endometrial cancer survivors. Data on recruitment and retention to these programs suggest low acceptance and retention. A priori diet and exercise self-efficacy and transtheoretical stage may guide program development. Methods/Materials: After IRB approval 100 women were asked to complete a questionnaire including demographics, disease factors, comorbidities, Stages of Change Measure and Five Item self-perceived Measure. Associations were analyzed using Krusal Wallis and Anova Testing, performed with Stata version Results: Mean age of 99 responders was 69 years and BMI was 34.1 kg/m 2. 70% were obese, and race was 41% Black, 18% Hispanic, and 40% White. There was a moderate agreement between self-perceived weight and BMI (kg/m 2 ), weighted Kappa statistic =0.43 (SE 0.07). There was a difference in BMI between stages of transtheoretical stage of change for exercise, maintenance vs contemplation (29.2 vs 38.0, p<0.01) and between stages of change for diet (38.6 vs 31.4, p=0.04). Obesity (BMI>30) was associated with the action stage of change (p<0.01). Education level was associated with transtheoretical stage of change for diet (p=0.02). There was no association between obesity and self-efficacy for diet or exercise. Conclusions: In survivors of endometrial cancer, BMI was the only clinical/pathological factor associated with transtheoretical stage of change for exercise. Patient centered diet and exercise lifestyle programs structured on transtheoretical stage may improve recruitment and retention. Keywords: Exercise, Endometrial cancer, Self-efficacy, Trans- Theoretical stage of change, Obesity Background Endometrial cancers are the 7 th most common cancer in women worldwide and the 13 th most common cause of death from cancer [1]. Endometrial cancers can be subclassified into endometrioid (Type I) and non-endometrioid (Type II) based on histological classification. While Type I endometrial cancers have a lower mortality rate than Type II, they still account for the majority of deaths because over 80% of endometrial cancers are Type I [2]. Obesity has been associated with increased risk for both Type I and Type II endometrial cancers (Type I RR 2.72, Type II RR 1.94) [3,4]. The proposed mechanism of action is related to the production of estrogen in peripheral adipose tissue of obese patients. Excessive estrogen stimulation of the endometrium drives tumor production. Furthermore, obese women have lower levels of sex hormone binding globulin (SHBG) which leads to higher bioavailability of free estrogens [5]. There is data showing that weight loss interventions such as gastric bypass surgery reduce the incidence of endometrial and postmenopausal breast cancer [6]. However, bariatric surgery is not feasible for cancer prevention in the general population. It is unclear whether weight loss through diet and exercise can impact long-term survival in endometrial cancer patients from either tumor occurrence or mortality from co-morbidities such as cardiovascular disease and diabetes. Previous studies have shown feasibility of lifestyle interventions to impact weight loss and improve exercise and diet behaviors in endometrial cancer survivors, but also show low recruitment and retention rates [7,8]. A recent meta-analysis of eight lifestyle intervention trials for endometrial and ovarian cancer survivors showed improvements in physical functioning and self-efficacy, and reductions in fatigue and sleep dysfunction [9]. Self-efficacy has also been reported to be a significant factor in predicting exercise minutes for endometrial cancer survivors enrolled in an exercise lifestyle intervention [10]. Social cognitive *Corresponding author: Nicole S. Nevadunsky, Montefiore Medical Center, Albert Einstein College of Medicine, Department of Obstetrics, Gynecology and Women s Health, 3332 Rochambeau Ave Bronx, New York 10467, Tel: ; Fax: ; nnevadun@ montefiore.org Received: November 09, 2017; Accepted: December 12, 2017; Published: December 15,

2 exploration of beliefs about benefits of exercise for women with endometrial cancer suggest that women who exercise focus on the immediate and subjective results of exercise such as quality of life and weight loss and not long term health benefits [11]. The goal of this study was to report on current dietary and exercise practices of a diverse patient population in a social cognitive framework, the Transtheoretical Model (Stages of Change) [12,13]. Additionally, this study aimed to identify patient specific factors related to self-efficacy and the relationship of self-efficacy to Transtheoretical Stage of Change for diet and exercise. Methods After IRB approval 100 consecutive women who had completed therapy for endometrial cancer and had no evidence of disease, were asked by a trained study co-coordinator at the time of their usual gynecologic oncology follow-up appointment to complete a questionnaire including demographics, disease factors and co-morbidities (Appendix I.) Transtheoretical Stage of Change was assessed for both diet and exercise using the validated Stages of Change Measure 10. Self-efficacy for both Diet and Exercise were assessed using the validated Five Item Self Efficacy Measure. Self-efficacy scores from 0-35 were generated by the assignment of 0 points for not at all confident, 1 point for somewhat confident, and 2 points for very confident. Frequency and percentages as well as means and ranges were presented in a descriptive fashion. The association of demographic and clinical pathological factors with Transtheoretical stage of change for Diet and Exercise was analyzed using pairwise comparisons with Tukey correction for multiple testing. Weighted Kappa statistics were utilized to compare association of perceived with actual BMI. Nonparametric testing was utilized to evaluate association of demographic clinical variables with median self-efficacy scores as stratified by obese (patients with BMI > 30) and non-obese patients (BMI<30). Associations between transtheoretical stage of change and self-efficacy were evaluated using Krusal Wallis and Anova Testing, performed with Stata version 13.0 (StataCorp, College Station, TX). Results Mean age of 99 responders was 69 years and BMI was 34.1 kg/m 2 (Table 1). One patient refused to complete questionnaire after consenting for study. 70% of women had BMI greater then 30 kg/m 2, and self-identified racial/ethnic distribution was 41% Black, 18% Hispanic, and 40% White. Eighty-seven percent were Stage 1-2, and 75% had been diagnosed in the past 10 years. Fifty-nine percent of patients had hypertension, and 33% had diabetes. Seventy percent of patients had Grade 1 or 2 tumors. There was a moderate degree of agreement between selfperceived weight and measured BMI (kg/m 2 ), weighted Kappa statistic =0.43 (SE 0.07) (Table 2). All patients with BMI <25 identified as average, slightly underweight or underweight. Only 7% of obese patients believed that they were of average weight. There was a difference in BMI between stages of transtheoretical stage of change for exercise. In particular patients in maintenance had lower BMI (29.2 kg/m 2 vs 38.0 kg/ m 2, p<0.01) when compared to women in the contemplation stage of exercise (Table 3). There was a borderline significance Table 1. Clinical and demographic characteristics of study cohort. Characteristic N (%) Mean (SD) Age (years) 69.4 (10.1) BMI (kg/m 2 ) 34.1 (7.6) BMI (30.0) >30 70 (70.0) Race/ethnicity AA/Black 41 (41.0) Hispanic 18 (18.0) White 40 (40.0) Asian/PI 1 (1.0) Eduction MS or less 5 (5.0) Some HS 8 (8.0) HS grad 19 (19.0) Some college 7 (7.0) College grad 5 (5.0) Professional 8 (8.0) Missing 48 (48.0) HLD No 58 (58.0) Yes 42 (42.0) Hypertension No 40 (40.0) Yes 59 (59.0) Missing 1 (1.0) Diabetes No 66 (66.0) Yes 33 (33.0) Missing 1 (1.0) Stage 1/2 87 (87.0) 3/4 8 (8.0) Other 5 (5.0) Grade 1 50 (53.2) 2 16 (17.0) 3 28 (29.8) Years since diagnosis <10 75 (75.0) (25.0) between BMI and maintenance versus precontemplation (29.2 kg/m 2 vs kg/m 2, p=0.07) and maintenance versus action (29.2 kg/m 2 vs kg/m 2, p=0.09). When BMI was considered as a categorical variable defined as non-obese (BMI <30 kg/ m 2 ) versus obese (BMI > 30), there was a higher proportion of patients in the maintenance phase in the non-obese category. There was no association of transtheoretical stage of change for exercise and age. There was a difference in median BMI between women in transtheoretical stage of change for diet in action versus precontemplation (38.6 vs 31.4, p=0.04) (Table 4). Education of more than high school level was associated with transtheoretical stage of change for diet (0.02). When stratified to obese patients only, self-efficacy for exercise was of borderline association with self-identified race (p=0.08) (Table 5). There were no clinical or demographic variables associated with self-efficacy to diet. When self-efficacy 2

3 Table 2. Self-perceived weight categorization of women with history of endometrial cancer. *p<0.001 (Fisher s Exact test). BMI Kg/m 2 Underweight Slightly Underweight Average Slightly Overweight Very Overweight (10.0) 1 (10.0) 8 (80.0) 0 (0.0) 0 (0.0) (0.0) 2 (11.8) 7 (41.1) 6 (35.3) 2 (11.8) (0.0) 0 (0.0) 4 (13.8) 12 (41.4) 13 (44.8) (0.0) 0 (0.0) 3 (11.1) 7 (25.9) 17 (63.0) 40 0 (0.0) 0 (0.0) 0 (0.0) 3 (17.7) 14 (82.3) Table 3. Association of Transtheoretical Stage of Change for exercise with clinical/demographic variables by pairwise comparisons with Tukey correction for multiple testing. Variable Precontemplation N=11 Contemplation N=24 Preparation N=30 Action N=11 Maintenance N=23 Median Age (years) 74.3 (9.4) 68.5 (6.1) 69.1 (10.8) 66.5 (11.2) 69.0 (11.8) 0.45 Median BMI (kg/m 2 ) 35.8 (5.6) 38.0 (7.0) 33.7 (7.3) 35.7 (5.2) 29.2 (7.9) BMI (3.5) 2 (6.9) 10 (34.5) 2 (6.9) 14 (48.2) >30 10 (14.3) 22 (31.4) 20 (28.5) 9 (12.9) 9 (12.9) Race/ethnicity 0.26 Black 2 (4.8) 10 (24.4) 17 (41.5) 4 (9.8) 8 (19.5) Hispanic 1 (5.6) 5 (27.8) 4 (22.2) 4 (22.2) 4 (22.2) White 8 (20.5) 9 (23.1) 8 (20.5) 3 (7.7) 11 (28.1) Asian/PI 0 (0.0) 0 (0.0) 1 (100.0) 0 (0.0) (0.0) Education 0.78 Middle School or Less 1 (20.0) 1 (20.0) 2 (40.0) 0 (0.0) 2 (20.0) Some High School 1 (12.5) 0 (0.0) 2 (25.0) 1 (12.5) 4 (50.0) High School Graduate 3 (15.8) 6 (31.6) 5 (26.3) 2 (10.5) 3 (15.8) Some College 0 (0.0) 2 (28.6) 2 (28.6) 2 (28.6) 1 (14.2) College Graduate 0 (0.0) 3 (60.0) 0 (0.0) 0 (0.0) 2 (40.0) Post Colllege 1 (12.5) 4 (50.0) 1 (12.5) 1 (12.5) 1 (12.5) Hyperlipidemia 0.66 No 6 (10.3) 11 (19.0) 19 (32.8) 7 (12.0) 15 (25.9) Yes 5 (12.2) 13 (31.7) 11 (26.8) 4 (9.8) 8 (19.5) Hypertension 0.09 No 4 (10.0) 5 (12.5) 12 (30.0) 5 (12.5) 14 (35.0) Yes 7 (11.9) 19 (32.2) 18 (30.5) 6 (10.2) 9 (15.3) Diabetes 0.55 No 5 (7.6) 17 (25.8) 22 (33.3) 7 (10.6) 15 (22.7) Yes 6 (18.2) 7 (21.2) 8 (24.2) 4 (12.1) 8 (24.2) Stage 0.07 ½ 7 (8.1) 21 (24.4) 28 (32.6) 9 (10.5) 21 (24.4) ¾ 2 (25.0) 2 (25.0) 2 (25.0) 0 (0.0) 2 (25.0) Other 2 (40.0) 1 (20.0) 0 (0.0) 2 (40.0) 0 (0.0) Grade (6.0) 10 (20.0) 18 (36.0) 7 (14.0) 12 (24.0) 2 1 (6.25) 6 (37.5) 4 (25.0) 1 (6.25) 4 (25.0) 3 5 (18.5) 7 (25.9) 7 (25.9) 1 (3.7) 7 (25.9) Years since diagnosis 0.42 <10 8 (10.7) 19 (25.3) 25 (33.3) 6 (8.0) 17 (22.7) 10 3 (12.4) 5 (20.8) 5 (20.8) 5 (20.8) 6 (25.0) scores were compared to transtheoretical stage of change, selfefficacy for exercise was of borderline significance (p=0.08) with a median self-efficacy score of 19.1 for contemplation of exercise and 25.5 for maintenance of exercise (Table 6). There was no association between self-efficacy score and transtheoretical stage of change for diet. Discussion In survivors of endometrial cancer, BMI was the only clinical/ pathological factor associated with transtheoretical stage of change for exercise and diet. "Education as stratified to less than or high school and more was associated with transtheoretical 3

4 Table 4. Association of Transtheoretical Stage of Change for diet with clinical/demographic variables by pairwise comparisons with Tukey correction for multiple testing. Variable Precontemplation N=29 Contemplation N=17 Preparation N=20 Action N=11 Maintenance N=23 Age (years) 72.1 (10.4) 68.0 (7.5) 70.0 (11.6) 66.0 (10.7) 68.1 (9.6) 0.40 BMI (kg/m 2 ) 31.4 (8.0) 37.8 (7.1) 34.6 (7.7) 38.6 (5.5) 32.1 (6.4) BMI (46.7) 1 (3.3) 7 (23.3) 0 (0.0) 8 (26.7) >30 15 (21.4) 16 (22.9) 13 (18.6) 11 (15.7) 15 (21.4) Race/ethnicity 0.87 Black 11 (26.8) 6 (14.6) 9 (22.0) 6 (14.6) 9 (22.0) Hispanic 7 (38.9) 5 (27.8) 2 (11.1) 1 (5.6) 3 (16.7) White 10 (25.0) 6 (15.0) 9 (22.5) 4 (10.0) 11 (27.5) Asian/PI 1 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) (0.0) Education 0.28 Middle School or less 2 (40.0) 2 (40.0) 1 (20.0) 0 (0.0) 0 (0.0) Some High School 6 (75.0) 1 (12.5) 0 (0.0) 0 (0.0) 1 (12.5) High School Graduate 8 (42.1) 3 (15.8) 2 (10.5) 3 (15.8) 3 (15.8) Some College 1 (14.3) 1 (14.3) 0 (0.0) 2 (28.6) 3 (42.9) College Graduate 0 (0.0) 1 (20.0) 1 (20.0) 2 (40.0) 1 (20.0) Post College 1 (12.5) 1 (12.5) 2 (25.0) 1 (12.5) 3 (37.5) Hyperlipidemia 0.26 No 19 (32.8) 7 (12.1) 9 (15.5) 8 (13.8) 15 (25.9) Yes 10 (23.8) 10 (23.8) 11 (26.2) 3 (7.1) 8 (19.1) Hypertension 0.55 No 14 (34.2) 5 (12.2) 6 (14.6) 5 (12.2) 11 (26.8) Yes 15 (25.4) 12 (20.3) 14 (23.7) 6 (10.2) 12 (20.3) Diabetes 0.25 No 23 (34.9) 12 (18.2) 9 (13.6) 7 (10.6) 15 (22.7) Yes 6 (18.2) 5 (15.2) 10 (30.3) 4 (12.1) 8 (24.2) Stage 0.86 ½ 25 (28.7) 16 (18.4) 17 (19.5) 10 (11.5) 19 (21.8) ¾ 3 (37.5) 0 (0.0) 1 (12.5) 1 (12.5) 3 (37.5) Other 1 (20.0) 1 (20.0) 2 (40.0) 0 (0.0) 1 (20.0) Grade (24.0) 9 (18.0) 8 (16.0) 9 (18.0) 12 (24.0) 2 5 (31.2) 3 (18.8) 2 (12.5) 2 (12.5) 4 (25.0) 3 11 (39.3) 4 (14.3) 7 (25.0) 0 (0.0) 6 (21.4) Years since diagnosis 0.06 <10 22 (29.3) 16 (21.3) 12 (16.0) 6 (8.0) 19 (25.3) 10 7 (28.0) 1 (4.0) 8 (32.0) 5 (20.0) 4 (16.0) stage of change for diet". Higher self-efficacy scores for exercise were borderline associated with Hispanic ethnicity. There was a borderline association of transtheoretical stage of change and self-efficacy scores for exercise. As diet and lifestyle interventions have often demonstrated poor recruitment, strategies to engage patients may include consideration of transtheoretical stage of change and BMI. Programs may additionally consider education history and self-identified race/ethnicity when designing patient centered lifestyle modification programs. There was not an association between transtheoretical stage of change and selfefficacy for dieting which may indicate different barriers between patient acceptance of exercise versus diet based programs. Associations between patient BMI and attitude toward exercise within the framework of social cognitive theory were similar between our study and previous reports. As reported by Lukowski, et al. patients who identified as active exercisers had lower BMI then women who did not exercise 31.6+/- 1.2 vs /-1.2 (p<0.01) (14). Similarly patients in our study who were in the action stage of exercise had lower average BMI then patients in the contemplative stage of change. A priori self-efficacy to diet and exercise was of borderline association to transtheoretical stage of change, consistent with previously reported studies on patients without cancer [9]. This may inform the design of lifestyle modifications to address patients at their particular stage of change. For example, it may be inappropriate to educate patients who are in the pre-contemplative stage on the optimal exercise technique, and efforts may be better focused on improving self-efficacy and health awareness of the potential benefits of exercise. This study was unique from other studies of lifestyle modification in that the majority of patients were of black and Hispanic ethnicity/race. Previous studies included only 5-10% of black and Hispanic women [8]. Additionally, this is the first study to our knowledge to consider the association of clinical demographic characteristics with social cognitive theory constructs (stage of transtheoretical stage of change and selfefficacy) regarding diet in endometrial survivors. Social cognitive theory constructs have been reported to explain 40-71% of the 4

5 Table 5. Self-efficacy for exercise and diet as correlated with demographic/clinical variables and stratified by obesity. Variable BMI <30 ANOVA Non-par BMI >=30 Exercise Mean (SD) Median [Range] Mean (SD) Median [Range] ANOVA Age (years) < (10.2) 22 [0-31.5] 22.6 (8.6) 22 [5-35] > (7.5) 22 [ ] 20.4 (9.5) 21 [0-35] Race/Ethnicity Black 21.7 (8.5) 23.8 [ ] 22.2 (7.7) 22 [5-35] Hispanic 17.9 (11.1) 22 [0-31.5] 26.4 (8.0) 28 [ ] White 21.7 (9.2) 25 [0-31.5] 19.0 (10.0) 18.5 [0-35] Asian/PI 12.5 (--) 10 [--] 0 0 Education High School or less 16.6 (12.4) 22 [0-31.5] 23.6 (9.8) 25.5 [0-35] College or more 22.4 (6.4) 22.8 [ ] 21.3 (10.6) 23.3 [0-35] Hyperlipidemia No 8.6 (6.7) 8 [1-35] 8.8 (7.5) 7.5 [0-35] Yes 11.6 (10.0) 7 [5-35] 7.4 (3.6) 7 [0-18] Hypertension No 7.9 (3.4) 8 [1-14] 6.7 (4.4) 7 [0-20] Yes 11.7 (11.2) 7.5 [2-35] 8.8 (6.5) 7.5 [0-35] Diabetes No 8.9 (6.4) 8 [1-35] 8.5 (6.9) 8 [0-35] Yes 11.7 (12.0) 7.5 [2-35] 7.4 (4.0) 7 [0-18] Stage ½ 10.4 (8.6) 8 [1-35] 8.3 (6.1) 7 [0-35] ¾ 7.2 (2.1) 8 [4-9] 7.5 (3.5) 7.5 [5-10] Other 2 (--) 2 [--] 5.8 (4.2) 6.5 [0-10] Grade (8.2) 9 [6-35] 8.2 (5.7) 7 [0-35] (3.5) 7 [3-10] 8.0 (4.6) 8 [0-18] (8.2) 8 [1-35] 8.7 (8.1) 7 [2-35] Years since diagnosis < (8.2) 8 [3-35] 8.3 (6.6) 7 [0-35] (4.4) 6 [1-13] 7.6 (3.8) 8 [0-14] Diet Age (years) < (10.9) 9 [3-35] 7.8 (2.8) 8 [0-13] > (6.8) 8.5 [1-28] 10.5 (9.1) 8 [0-35] Race/ethnicity Black 7.4 (2.8) 8.5 [1-13] 8.8 (6.3) 8 [0-35] Hispanic 14.5 (13.5) 7.5 [3-35] 8.9 (3.6) 9 [3-18] White 13.8 (11.4) 9 [5-35] 9.4 (8.0) 8 [0-35] Asian/PI 12.0 (--) 12 [--] 0 0 Education MS or less 9 (--) 9 (--) 7.5 (7.6) 6 [0-18] Some HS 15.2 (15.2) 6 [1-35] 9.5 (0.7) 9.5 [9-10] HS grad 19 (22.6) 19 [3-35] 9.5 (6.8) 9 [5-35] Some college 7 (--) 7 (--) 11.5 (12.1) 8.5 [0-35] College grad 8.5 (0.7) 8.5 [8-9] 10.3 (2.5) 10 [8-13] Professional 7.0 (5.3) 5 [3-13] 12.4 (12.7) 7 [6-35] Missing 10.5 (7.3) 9 [3-35] 7.9 (4.2) 7.5 [0-20] Hyperlipidemia No 10.3 (8.8) 9 [1-35] 10.0 (8.5) 8 [0-35] Yes 13.8 (11.4) 8.5 [5-35] 8.0 (3.5) 8 [0-18] Hypertension No 9.5 (7.4) 9 [1-35] 7.7 (4.3) 7.5 [0-20] Yes 13.7 (11.8) 8.5 [3-35] 9.7 (7.5) 8 [0-35] Non-par 5

6 Diabetes No 11.1 (9.1) 9 [1-35] 9.0 (6.8) 8 [0-35] Yes 11.8 (11.9) 7.5 [3-35] 9.1 (6.5) 8 [0-35] Stage ½ 11.3 (9.4) 9 [1-35] 9.3 (6.8) 8 [0-35] ¾ 12.5 (11.1) 8.5 [5-35] 8.0 (2.8) 8 [6-10] Other 3 (--) 3 [--] 5.8 (4.2) 6.5 [0-10] Grade (8.2) 9 [6-35] 9.5 (6.9) 8 [0-35] (3.8) 9 [3-10] 8.5 (4.5) 9 [0-18] (11.7) 9 [1-35] 9.3 (8.4) 8 [1-35] Table 6. Correlation of self-efficacy for exercise and diet by transtheorectical stage. *Oneway ANOVA: F(4,93)=1.77, p=0.14, Krusal-Wallis Χ 4 = 8.635, p=0.07 **Oneway ANOVA: F(4,93)=0.44, p=0.78 Krusal-Wallis Χ 4 = 2.490, p=0.65 Stage Frequency (%) Self-Efficacy Score Exercise Mean (SD)* Precontemplation 11 (11.1) 19.1 (10.0) Contemplation 24 (24.2) 21.0 (8.6) Preparation 30 (30.3) 19.4 (9.0) Action 11 (11.1) 20.8 (8.1) Maintenance 23 (23.2) 25.5 (8.8) Diet Mean (SD)** Precontemplation 29 (29.0) 20.3 (11.0) Contemplation 17 (17.0) 22.1 (9.8) Preparation 20 (20.0) 20.7 (8.5) Action 11 (11.0) 23.0 (9.4) Maintenance 23 (23.0) 23.7 (11.8) variance in physical activity behavior in adults and 14-61% of the variance in dietary behavior in adults [14,15]. Self- efficacy is thought to be the central construct of social cognitive theory by directly influencing behavior through belief in ability, outcome expectations, barriers and facilitators [16]. For diet and exercise there was an association of BMI to transtheoretical stage of change. However, higher BMI s in the action stage of change (38kg/m 2 ) for diet then contemplation (31.4kg/m 2 ) were unexpected and the opposite direction from exercise. While patients in the action stage of change for exercise had lower BMI then patients in the precontemplative stage, patients who reported active dieting had higher BMIs then patients in the precontemplative stage for dieting. Unlike self-efficacy to exercise there was no association between self-efficacy to diet and transtheoretical stage of change. While lifestyle modification programs addressing self-efficacy have reported in exercise, the same approach may not apply to diet [12]. Shortcomings of our study included inability to measure whether patients were dieting and exercising as reported. Additionally we did not follow patients over time to see if Transtheoretical Stage of Change resulted in action or decreased BMI, nor did we assess how long a patient had been in a particular stage of change. Patients may also have biased answers to reflect more diet and exercise to the interviewer because it was a face to face encounter. In conclusion, the relationship of patients transtheoretical stage of change for exercise and diet seems to be most closely related to obesity. Self-efficacy for exercise was associated with a trend in transtheoretical stage of change, however a similar relationship was not seen for self-efficacy as related to diet. In design of future lifestyle interventions, real-time feedback by way of technology including wearable technology may impact self-efficacy and could present an opportunity to improve transtheoretical stage of change for exercise. It is unclear how education effects transtheoretical stage of change for dieting and additional research may be needed to address this complex topic. References 1. Parkin DM, Bray F, Ferlay J, et al. (2005) Global cancer statistics, CA Cancer J Clin 55: [Pubmed] 2. Kaaks R, Lukanova A, Kurzer M (2001) Obesity, endogenous hormones, and endometrial cancer risk a synthetic review. Cancer Epidemiol Biomarkers Prev 11: Borge T, Engelend A, Treli S, et al. (2006) Body size in relation to cancer of the uterine corpus in 1 million Norwegian women. Int J Cancer 120: McCullough M, Patel A, Patel R, et al. (2008) Body mass and endometrial cancer risk by hormone replacement therapy and cancer subtype. Cancer Epidemiol Biomarkers Prev 17: Kaaks R, Lukanova A, Kurzer MS (2002) Obesity, endogenous hormones, and endometrial cancer risk: a synthetic review. Cancer Epidemiol Biomark Prev 11: McCawley GM, Ferriss JS, Geffel D, et al. (2009) Cancer in obese women: potential protective impact of bariatric surgery. J Am Coll Surg 208: [Pubmed] 7. Rossi A, Moadel-Robblee A, Garber CE, et al. (2015) Physical activity for an ethnically diverse sample of endometrial cancer survivors: a needs assessment and pilot intervention. J Gynecol Oncol 26: Von Gruenigen V, Frasure H, Grandon M, et al. (2008) Feasibility and effectiveness of a lifestyle intervention program in obese and endometrial cancer patients. Gynecol Oncol 109: Smits A, Lopes A, Das N, et al. (2015) The effect of lifestyle interventions on the quality of life of gynaecological cancer survivors: A systematic review and meta-analysis. Gynecol Oncol 139: Basen-Enquist K, Carmack C, Li Y, et al. (2013) Social cognitive theory predictors of exercise behavior in endometrial cancer survivors. Health Psychol 32: Lukowski J, Gil K, Jenison E, et al. (2012) Endometrial cancer survivors assessment of the benefits of exercise. Gynecol Oncol 124: Marcus BH, Selby VC, Niaura RS, Rossi JS (1992) Self-efficacy and the stages of exercise behavior change. Res Q Exerc Sport 63: [Pubmed] 13. Prochaska JO, Butterworth S, Redding CA, Burden, et al. (2008) Initial efficacy of MI, TTM tailoring and HRI's with multiple behaviors for employee health promotion. Prev Med 46: Stacey F, James E, Chapman K, et al. (2015) A systematic review and meta-analysis of social cognitive theory-based physical activity and/ or nutrition behavior change interventions for cancer survivors. J Cancer Surviv

7 15. Phillips S, McAuley E (2012) Social cognitive influences on physical activity participation in long-term breast cancer survivors. Psychooncology 22: Bandura A (1998) Health promotion from the perspective of social cognitive theory. Psychol Health 13: Copyright: 2017 Chiu K. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 7