We observed four distinct patterns of health behavior co-occurrence among a nationally representative sample of cancer survivors and informal cancer caregivers. In general, respondents who reported greater FVI also reported greater MVPA and sleep duration. Likewise, participants reporting lower FVI had lower MVPA and sleep duration. Approximately 20% of the sample was in the Highly Engaged profile, indicating that more than 80% warrant some degree of intervention to support dietary quality, physical activity, and/or sleep behaviors. We also identified that role, cancer type, self-efficacy, age, alcohol use, and educational attainment were associated with profile membership. This information could help identify which individuals may require more or less intensive health behavior intervention for maximum benefit.
Our results were similar to Olson and colleagues’ (Olson et al., 2023) finding that most survivors had problems with physical activity and diet, with or without sleep difficulties, and that those with these challenges were less likely to report high health-related quality of life. Our results are also consistent with their finding that the most engaged were younger and had a lower BMI. However, unlike these authors, we found that MVPA had the greatest variance across profiles while they identified sleep as the key differentiating behavior. This difference may be due to their categorization of variables prior to analysis, or because their profiles were also indicated by smoking status. Although Olson and colleagues did not evaluate ethnicity or rurality, we found that rural-dwelling respondents were least likely to be in the Moderately Engaged profile. This is consistent with the broader cancer survivorship literature, suggesting that greater efforts may be required to promote health behavior engagement among rural-dwelling cancer survivors (Werts et al., 2023).
Regarding inclusion of informal cancer caregivers, qualitative evidence has suggested that including an informal caregiver in interventions may help survivors engage in healthful behaviors (Skiba et al., 2022). However, dyadic health behavior interventions developed specifically with the well-being of both the cancer survivor and the informal caregiver in mind remain limited (Bisht et al., 2023). To date, most of this work has focused on physical activity (Song et al., 2023), diet (Xu et al., 2023), weight-loss (Demark-Wahnefried et al., 2023), or symptom management (Crane et al., 2021), or has excluded non-spousal caregivers (Carmack et al., 2021; Kim et al., 2023; Winters-Stone KM, 2016). Given the demonstrated interrelationship between survivor-caregiver health behaviors (Badr et al., 2019; Kiecolt-Glaser & Wilson, 2017), more interventional research is warranted that includes diverse cancer survivor-caregiving relationship dynamics and targets multiple health behaviors.
Previous studies have identified patterns and correlates of health behaviors respective to current recommendations (Fong et al., 2023; Glasgow et al., 2022; Olson et al., 2023). Such an approach is important, as higher adherence to health behavior guidelines is associated with lower cancer incidence and mortality (Kohler et al., 2016). However, simply categorizing behaviors as adherent or non-adherent runs the risk of missing individuals who are close to the cut-off but may need just a little more support to cross the threshold into adherence. Our use of a person-centered analysis that considered three behaviors on a continuous scale allowed for the inclusion of this information. For example, we found that those in the Moderately Engaged profile were, on average, consuming one less serving of fruits and vegetables and engaging in eight fewer minutes of MVPA per day than guidelines recommend. Although these individuals may benefit from health behavior intervention, they are likely to need much less intensive intervention than the participants in either of the Least Engaged profiles. Had we categorized behaviors as adherent and non-adherent prior to analysis, we would not have identified this pattern, and in turn our conclusions may have encouraged inefficient application of health behavior support.
Although we included three health behaviors as indicators of profile membership in our analysis, cancer-specific guidelines were available for only two. This is likely because, historically, sleep has been underrepresented in cancer survivorship research relative to dietary quality and physical activity. Interestingly, we also found that sleep had the lowest variance across profiles. However, even this low variance corresponded to a 33 minute per night difference in sleep duration between the profile with the lowest average sleep (Moderately Engaged) compared to highest (Highly Engaged). The clinical relevance of this difference is substantial, as just a few minutes of additional sleep per night is related to improvements in population-level resting heart rate and decreased cardiometabolic risk (Rezaei & Grandner, 2021). Adult survivors of cancer have significantly heightened risk for cardiovascular disease relative to those with no history of cancer (Florido et al., 2022), and findings from the National Health Interview Survey have shown that survivors have lower odds of obtaining adequate sleep compared to cancer-free controls (Boyd et al., 2020). Therefore, despite the lack of cancer-specific sleep recommendations, our results highlight the criticality of including sleep when developing multiple health behavior interventions for cancer survivors.
An important consideration when looking at co-occurrence of multiple health behaviors is that these behaviors are mutually time exclusive. An individual typically is not physically active or eating while sleeping. Instead, dietary intake, physical activity, and sleep may happen sequentially and in a rhythm throughout each 24-hour period. This phenomenon has been documented outside of cancer populations. For the average American in 2022, during each 24-hour period an estimated 1.23 hours were spent eating or drinking with another 0.65 hours spent on food preparation and clean up, 0.29 hours were spent participating in recreational physical activity, and 9.02 hours were spent sleeping (U.S. Bureau of Labor Statistics, 2023). In recognition of this relationship, reducing the emphasis on guideline adherence and focusing instead on balancing multiple health behaviors may promote greater behavior change.
Strengths and Limitations
This study provides early evidence of the co-occurrence of multiple synergistic cancer preventive health behaviors in a sample of cancer survivors and informal cancer caregivers. Unique to this analysis, we pooled together cancer survivors and informal cancer caregivers and found they had similar health behavior profiles. Data were evaluated on a continuous scale, providing greater granularity. The utilization of HINTS data provided a nationally representative sample, increasing the generalizability of our findings to cancer survivors and informal cancer caregivers across the United States. Moreover, the methodology employed by HINTS reduced the risk of sampling bias through random sampling and nonresponse bias through applying weights (Maitland et al., 2017).
There is a potential for recall bias, as HINTS data are self-reported health behaviors and the selected behaviors come from singular survey items. There may also be measurement error in reporting or potential overestimation of FVI due to the response scale on which the original data were collected and our subsequent recoding to enable evaluation on a continuum. The evaluation of sleep duration as a continuous variable did not account for the documented curvilinear relationship between sleep and health (Hoogland et al., 2019), with both short and long sleep linked to poor outcomes. Weighted ranges in our sample demonstrated that most long-sleepers (i.e., ≥9 hours per night) were in the Least Engaged–Sedentary profile, further supporting the potential utility of health behavior intervention for this group. Data included in this analysis were collected prior to the COVID-19 pandemic, which may have changed population engagement in health behaviors, although this remains unclear (Cole et al., 2023; Donzella et al., 2021; Ye & Ren, 2022). Finally, the temporality of the relationships examined and changes over time cannot be determined in this cross-sectional study.
Implications and Future Research
In 2021, HINTS fielded a cancer survivor specific survey that did not capture sleep (Blake et al., 2023). Given the co-occurrence of behaviors we observed in the present analysis and the clinical relevance of sleep for cancer outcomes, it is important that future surveys measuring health behaviors include assessment of sleep. Developing interventions that focus on promoting multiple health behaviors, rather than a singular behavior, remains a priority to address the deleterious effects cancer treatment and cancer caregiving can have on health outcomes (Carroll et al., 2022; Guida et al., 2021). Multiple studies promote diet and physical activity together and sleep separately in cancer survivors (Fox et al., 2022; Rodrigues et al., 2023; Squires et al., 2022; Thomson et al., 2023), but little work has championed all three simultaneously. Theoretically informed behavior change interventions can support strategic selection of techniques (Abraham & Michie, 2008). Additionally, due to the concordant tendencies of behaviors within survivor-caregiver dyads, future research should consider dyadic dynamics in the design, assessment, and interpretation of health behavior promotion interventions (Badr et al., 2019).