Validation of two short questionnaires assessing physical activity in colorectal cancer patients

Validation of two short questionnaires assessing physical activity in colorectal cancer patients Background: In order to investigate the impact of adherence to recommendations of physical activity and sedentary time on health outcomes in clinical trials, there is a need for feasible tools such as questionnaires that can give representative estimates of these measures. The primary aim of the present study was to validate two such questionnaires and their ability to estimate adherence to the recommendations of physical activity defined as moderate-to- vigorous physical activity or moderate physical activity of at least 150 min/week in colorectal cancer patients. Secondarily, self-reported sedentary time from the HUNT-PAQ was also evaluated. Methods: Participants from 'The Norwegian dietary guidelines and colorectal cancer survival-study’ (CRC-NORDIET study) completed two short questionnaires; the NORDIET-FFQ (n = 78) and the HUNT-PAQ (n = 77). The physical activity monitor SenseWear Armband Mini was used as the reference method during seven consecutive days. Results: The NORDIET-FFQ provided better estimates of time in moderate-to- vigorous physical activity and moderate physical activity than the HUNT-PAQ. The NORDIET-FFQ was unable to rank individual time in moderate- to- vigorous physical activity and moderate physical activity (Spearman’s rho = 0.08, p = 0.509 and Spearman’s rho rho = 0.01, p = 0.402, respectively). All intensities were under-reported by the HUNT-PAQ, but ranking of individual time in moderate physical activity and sedentary time were acceptable among women only (Spearman’srho =0.37, p = 0.027 and Spearman’srho =0.36, p = 0.035, respectively). The HUNT-PAQ correctly classified 71% of those not meeting the recommendations (sensitivity), and the NORDIET-FFQ correctly classified 63% of those who met the recommendations (specificity). About 67% and 33% reported to meet the recommendation of moderate-to- vigorous physical activity with the NORDIET-FFQ and HUNT-PAQ, respectively, whereas 55% actually met the moderate-to- vigorous physical activity according to the SenseWear Armband Mini. Conclusions: The NORDIET-FFQ provided better specificity and better estimates of PA than the HUNT-PAQ. The HUNT- PAQ provided better sensitivity, and provided better ranking of PA and sedentary time among women than NORDIET- FFQ. It is important to be aware of the limitations documented in the present study. Trial registration: The study is registered on the National Institutes of Health Clinical Trials (Identifier: NCT01570010). Registered 4 April 2012. Keywords: Short questionnaire, Physical activity, Sedentary time, SenseWear armband mini, Physical activity recommendations * Correspondence: rune.blomhoff@medisin.uio.no Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway Department for Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 2 of 12 Background Although many previous questionnaires have been The preventive effect of physical activity (PA) on risk of successfully used to assess PA, there is no questionnaire colorectal cancer is well-established [1–3]. However, an specifically designed to assess adherence to the PA rec- increasing number of studies also examine beneficial ef- ommendations as defined in Norwegian FBDG. For a fects of PA during cancer treatment as well as in the clinical trial in colorectal cancer patients [38], a new posttreatment period [4–16], such as decreased all-cause short semi-quantitative questionnaire (NORDIET-FFQ) mortality, increased disease-free survival, improved was developed to measure adherence to the Norwegian physical function and quality of life [5, 6, 11–13, 17, 18]. FBDG. The NORDIET-FFQ includes two questions on Moreover, reduced sedentary time, such as sitting during PA related to intensity levels similar to MPA and VPA. daytime, may be associated with reduced mortality and Another short questionnaire, the HUNT-PAQ [39]has lower risk of recurrence in cancer patients [19–22]. been used in large healthy populations in Norway; how- The recommendations of PA for cancer patients and ever this questionnaire has not previously been validated survivors provided by the American Cancer Society [23] in a CRC population. emphasize that exercise is safe and feasible during can- Thus, the primary aim of the present study was to val- cer treatment, and improves outcomes such as physical idate the two short questionnaires and their ability to es- function, fatigue and completion of chemotherapy [23]. timate adherence to the PA recommendations according The American Cancer Society, the World Health to the Norwegian FBDG. Secondarily, self-reported sed- Organization and others [24–27] recommend at least entary time from the HUNT-PAQ was also evaluated. 150 min of moderate intensity PA (MPA) or 75 min of vigorous intensity PA (VPA) per week or an equivalent Methods combination. In 2011, the Norwegian Directorate of Subjects and study design Health published the Norwegian Food-Based Dietary The present validation study was a sub-study of the on- Guidelines (FBDG) which also includes similar recom- going CRC-NORDIET study, of which design and mendations on PA as well as for sedentary time [3]. methods have been published elsewhere [38]. In brief, In Norway, colorectal cancer (CRC) is the third most the aim of the CRC-NORDIET study is to investigate the common cancer type, and the incidence is among the effect of a diet similar to the Norwegian FBDG [3]on highest in Europe [28]. Implementing the recommenda- disease-free and overall survival among CRC patients tions of PA and incorporating specific exercises in the post-diagnosis [38]. The risk factors shown to be related clinical care may improve the health outcomes of CRC to CRC, i.e. diet and physical activity, are included in the patients [1–3, 24]. Norwegian FBDG [40]. The CRC-NORDIET study is a In order to estimate adherence to PA recommendations prospective randomised controlled intervention trial, according to the Norwegian FBDG in a Norwegian CRC randomising 500 CRC patients into one of two study population, a valid and accurate physical assessment tool groups (i.e. 250 to diet intervention group and 250 to is needed. Importantly, assessment of adherence to the PA the control group). All patients are invited to the Study recommendations is required in counselling and when centre 3 times during the intensive 1-year intervention evaluating effectiveness of intervention studies. The use of (i.e. at baseline 2–9 months post-surgery and at the two objective monitors to record PA has increased during re- visits 6- and 12 months after baseline), and subsequently cent decades and gives valid and reliable data on intensity followed up for 14 years. Both study groups are offered of PA and energy expenditure [29]. However, these activity equal recommendations on PA [38]. monitors are expensive and time consuming for the clin- All patients from both study groups in the CRC- ician and researcher, particularly when recording PA in NORDIET study, who attended the follow-up at 6 months larger populations. Therefore, less expensive and easier after baseline of intervention (i.e. 2–9months post- methods are required to measure adherence to PA surgery) from January 2014 to October 2015, were invited recommendations. to take part in the present validation study. The patients The most common self-reporting method to assess PA were men and women aged 50–80 years old, with a con- is the use of questionnaires [30, 31]. Over the past 2 or firmed CRC (ICD-10 C18–20), and staged I-III (i.e. locor- 3 decades, more than 30 PA questionnaires have been egional disease without metastasis) according to the TNM developed and validated [32]. Long questionnaires are staging system [41]. None of the patients included in the challenging to complete for cancer patients often experi- validation study underwent chemotherapy during the encing treatment and disease related side-effects such as time-frame covered by the physical assessment methods fatigue and functional decline [33–36]. Questionnaires used in the validation study (e.g. mean time from last which contains few and well-defined questions regarding chemotherapy injection to the start of the validation study the different intensities of PA may be more suitable for (i.e 6 months after baseline) was 155 days among the 15% this group of patients [37]. who received adjuvant treatment). During the 6-months Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 3 of 12 visit, the patients completed the self-administered were calculated by multiplying frequency (i.e. times NORDIET-FFQ and HUNT-PAQ. In addition, they re- per day) with duration (i.e. minutes each time). This ceived the SenseWear Armband Mini (SWA), which was resulted in variables of total-MPA and total-VPA, of returned by mail to the CRC-NORDIET-study at the end which all minutes within each intensity were included of the test period of 7 days. Exclusion criteria for the (Additional files 1 and 2). Additionally, categories of present study were pacemaker implantation, not com- 10-min bouts were computed and defined as ten or pleted questionnaires or not wearing the SWA. more consecutive minutes within each intensity level. This resulted in data on 10-min bouts of MPA and Characteristics of the participants VPA. To characterize the subjects, anthropometric measure- ments (weight, height, and hip-and waist circumference) HUNT (the Nord-Trøndelag health study) physical activity and physical tests (hand-grip strength and 30-s sit-to- questionnaire (HUNT-PAQ) stand test) were measured by the researchers of the The HUNT-PAQ was based on the questionnaire used CRC-NORDIET study during all visits at the Study in the HUNT 3-study [39]. Only the five questions about centre, as previously described elsewhere [38]. In PA as described in Kurtze et al. [43] were used. The addition, education level and smoking status were self- question about frequency contained the following re- reported by completion of questionnaires during the sponses: Never and Less than once a week, both coded as visits at the Study centre. Information about tumour 0, Once a week coded as 1, 2–3 times a week coded as 2. location status was retrieved from medical records in co- 5, and Almost every day coded as 7. The question about operation with the hospital personnel. Energy expend- duration of activity contained the following responses: iture (kJ/d) was estimated from the SWA. Less than 15 min coded as 12 (subtracted 20% from 15), 15–29 min coded as 22, 30–1h coded as 45 and more Short semi-quantitative frequency questionnaire than 1 h coded as 72 (added 20% to 60). The products (NORDIET-FFQ) of frequency and duration were weighed by intensity The NORDIET-FFQ (available upon request to corre- level, i.e. Low, Moderate or Vigorous coded as 1, 2 and 3, sponding author), was designed to report both dietary respectively. The low intensity level was not evaluated in intakes and PA in recent weeks (i.e. the last 1–2 months). the present study. Additionally, there was a question The validity of the dietary items of the NORDIET-FFQ about daily sedentary time in hours on a usual day (not has been published elsewhere [42]. Completion of the included sleeping at night-time). The questionnaire gen- NORDIET-FFQ as well as protocol for data handling erated data on activities in bouts of 10 and more con- followed the same procedures as described in detail in secutive minutes for each intensity level, such as MPA Henriksen et al. [42]. In brief, the NORDIET-FFQ was and VPA. completed by the patients at the Study centre. The com- pleted questionnaires were scanned by trained researchers Objective physical activity measurement and the image files translated into data files using the The objective PA monitor SenseWear Armband Mini Cardiff Teleform 2006 Software (6.0) (Datascan). The last (SWA) (BodyMedia, Pittsburgh, Pennsylvania, USA) was two questions in the NORDIET-FFQ asked for PA with used to record daily PA and energy expenditure during two different intensities, MPA and VPA estimated in pre- seven consecutive days [44]. A priori, we defined a valid defined intervals of frequency per week and duration in day of recording if the wear time was ≥80% of a 24-h minutes. The explanatory texts for both PA questions in- sampling period. The SWA has previously been vali- cluded examples of typical activities: moderate intensity dated against double-labelled water [45], indirect calor- was exemplified by brisk walking, household chores or imetry [46] and other accelerometers [47] in adults and other activities resulting in slight breathlessness, and vig- cancer patients. It monitors physiological data such as orous intensity was exemplified by running, cross-country heat flux, galvanic skin response, 3-axis accelerometer skiing or other activities resulting in high breathlessness. and skin temperature. The SWA was pre-programmed The question about frequency contained different re- by the researcher with the co-predictors such as weight, sponses in times per week (time divided by seven) coded height, birth date, sex, smoking status (smoker/non- as follows: 0= 0, 1 = 0.14, 2 = 0.29, 3 = 0.43, 4 = 0.57, smoker) and whether the participant was left or right 5 = 0.71, 6–7 = 0.93 and 8+ = 1.37 (added 20% to 8 and handed, and placed around the triceps muscle halfway divided by7). Moreover theresponses of duration in on the upper non-dominant arm. The participants were minutes were coded as follows: 1–4= 2, 5–9= 7, instructed to continue their normal activity level while 10–15 = 12.5, 16–20 = 18, 21–30 = 25.5, 31–45 = 38, wearing the SWA. Water-based activities were not re- 46–60 = 53 and 60 + =72 (added 20% to 60). corded by the SWA because the monitor is not water- Amounts in minutes of PA per day for each intensity proof. Participants were asked to remove the SWA when Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 4 of 12 performing activities in water. All data were retrieved data. Bland-Altman plots with limits of agreements were from the SWA to a computer with the SenseWear used to explore the differences between the measure- Professional Software Version 7.0 BodyMedia Inc. ments from the two methods (i.e. questionnaire minus (Pittsburgh, Pennsylvania, USA). SWA) plotted against the average of the two measure- Activity intensities were integrated into algorithms, ments, for each individual subject, as well as to identify providing estimates of energy expenditure expressed in outliers [52, 53]. Systematic under- or over-reporting metabolic equivalents (METs). The definition of 1 MET was tested by linear regression with MVPA and MPA is the amount of oxygen consumed while sitting at rest from SWA as the independent variable and the differ- and is equal to 3.5 ml O per kg bodyweight per min ence between the questionnaires and SWA as the [48]. Moderate and vigorous intensities were defined as dependent variable. Ranking of individual time in PA 3–6 and > 6 METs, respectively, as calculated by and degree of association between the continuous vari- Ainsworth and coworkers [49, 50]. Sedentary time was ables from the two different methods were analysed by defined as all daily activities ≤1.5 METs, of which night- Spearman Rank Order Correlation (rho). The ability of time sleep was removed (a priori defined as from 12 the NORDIET-FFQ and the HUNT-PAQ to classify the midnight to 6.00 a.m.). All activities were calculated and individual’s activity intensity into the same category as expressed in minutes or hours per week (sedentary the SWA was estimated by the use of sensitivity and spe- time). cificity analysis. Sensitivity was defined as the number of The SWA records all intensities in 1-min intervals, subjects reported not to fulfil the MVPA with both ques- which were translated into different categories of data tionnaires and SWA as a percentage of those who had such as total-MPA and total-VPA. Furthermore, the data reported not to fulfil the MVPA with the SWA. Specifi- were also computed into 10-min intervals, which were city was defined as the number of subjects reported to defined as ten or more consecutive minutes within the fulfil the MVPA with both questionnaires and SWA as a relevant intensity level. The bouts of 10-min were calcu- percentage of those who had reported to fulfil the lated for the two intensity levels, which gave data on MVPA with the SWA. bouts of 10-min for MPA and VPA. Sample size Recommendations of physical activity In order to detect a Pearson correlation coefficient of 0.5 The CRC patients were advice to follow the recommen- or higher between the test-method (i.e. questionnaires) dations of moderate-to-vigorous intensity PA (MVPA), and the reference method (i.e. SWA), a sample size of 38 MPA and VPA. MVPA was defined as ‘MPA + (VPA*2)’ men and 38 women was required to achieve a signifi- [51] and the cut-off points for fulfilling recommenda- cance level of 5% and power of 90% [54]. With an ex- tions of MVPA and MPA were at least 150 min per pected consent rate of 90% and exclusion rate of week, and at least 75 min per week for VPA. The activ- maximum 5%, we aimed to invite 90 participants in ities should be in bouts of 10 and more consecutive order to include 76 participants to the present study. minutes. Statistical analysis Statistical analyses were performed by use of IBM SPSS Results Statistics, version 22. Results were considered significant Of the 88 invited participants, three were excluded with two-sided p-values below 0.05. Normal distribution due do pacemaker implantation and 7 declined to was checked for all data by inspection of histograms, nor- participate. Hence, 78 participants used the SWA and mal Q-Q-Plots and Kolmogorov-Smirnov test (p >0.05). completed the NORDIET-FFQ, whereas 77 of these All anthropometric measurements and other charac- also completed the HUNT-PAQ. General characteris- teristics of the study population were normally distrib- tics of the participants are presented in Table 1. uted and are presented as means with standard Mean age of the participants was 64.8 years, and did deviations (SD). The categorical data are presented as not differ significantly between men and women frequency with percentages and compared by the Fischer (Table 1). Mean time between surgery and baseline exact test and Pearson chi-square test. As most of the was 120.7 days ±41.4 days (mean ± SD) and between estimates of PA from the SWA, NORDIET-FFQ and baseline and 6-months visit was 184.4 ± 39.1 days HUNT-PAQ were not normally distributed, they are (mean ± SD). Total energy expenditure estimated presented as medians and 5th - and 95th percentile. from the SWA was 11.4 and 9.0 MJ for men and Statistical significant differences in median activity be- women, respectively. About 8% of the participants tween the two questionnaires compared to the SWA were smokers and 51% were highly educated (college/ were tested with Wilcoxon Signed-Rank test for paired university education) (Table 1). Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 5 of 12 Table 1 Characteristics of all participants in total and stratified by men and women (mean (SD)) Variables Total Men Women p (n = 78) (n = 42) (n = 36) Age, years, mean (SD) 64.8 (7) 65.2 (7.4) 64.3 (7.4) 0.590 Smokers, n (%) 6 (7.7%) 3 (7%) 3 (8%) 1.000 EE, kJ/d , mean (SD) 10,378 (1909) 11,496 (1474) 9074 (1488) < 0.001 Education, n (%) (total n = 78, men n = 42, women n = 36) Primary school 4 (5) 3 (7) 1 (3) 0.370 Lower secondary/High school 34 (44) 21 (50) 13 (36) College/University 40 (51) 18 (43) 22 (61) Anthropometry (mean, SD) (total n = 78, men n = 42, women n = 36) Weight, kg 79.2 (16.3) 87.0 (11.9) 70.0 (16.1) < 0.001 Height, m 1.73 (8.31) 1.77 (6.7) 1.66 (5.3) < 0.001 BMI, kg/m 26.1 (5) 27.5 (3.7) 25.2 (5.5) 0.030 Waist circumference 93.9 (13.7) 100.7 (9.6) 86.2 (13.8) < 0.001 Hip circumference 101.0 (9.2) 101.6 (6.9) 100.3 (11.4) 0.560 Tumor classification n (%) (total n = 70, men n = 36, women n = 34) TNM I 13 (17) 9 (25) 4 (12) 0.170 TNM II 33 (42) 18 (50) 15 (44) TNM III 24 (31) 9 (25) 15 (44) Physical performance (mean, SD) (total n = 78, men n = 42, women n = 36) Hand-grip strength right, kg 34.3 (9.5) 40.9 (6.6) 26.7 (5.9) < 0.001 Hand-grip strength left, kg 31.1 (9.7) 37.9 (7.1) 23.5 (5.7) < 0.001 Sit-to-stand test 17.3 (5.3) 17.9 (5.8) 16.5 (4.6) 0.220 TNM tumor node metastases, BMI body mass index, EE energy expenditure Continuously variables were tested with Student t-test. Categorical variables were tested by the Fischer exact test (two-sided) Estimated energy expenditure from the physical activity monitor SenseWear Armband Mini (BodyMedia, Pittsburgh, Pennsylvania, USA) (SWA) The maximal strength of hand grip (kg) was recorded. For women and men, a 40 kg- and 80 kg-spring was used, respectively Moderate-to-vigorous intensity physical activity recorded compared to SWA (mean difference and limits of agree- from the NORDIET-FFQ, HUNT- PAQ and SWA ment − 162 ± 576 min/week). Moreover, the Bland Participants wore the SWA monitors for 97.9 ± 3.8% Altman-plot for MVPA revealed an increase in the dif- (mean, ± SD) of the time during 6.2 ± 0.8 days (mean, ± ferences between both questionnaires and SWA with in- SD) of monitoring. creased PA level. Additionally, the differences were Median duration of PA estimated from the NORDIET- randomly and evenly distributed above and below the FFQ, HUNT-PAQ and the SWA is presented in Table 2. mean difference for both questionnaires compared to There was no significant difference between the SWA up to about 250 min/week (Fig. 1a and d). The NORDIET-FFQ and SWA for the measure for activity of slope of the linear regression was negative and signifi- moderate-to-vigorous intensity PA (MVPA), either for cant for both questionnaires (β = − 0.79, p < 0.001(NOR- the total population (p = 0.897) or when analyzing sexes DIET-FFQ) and β = − 0.85, p < 0.001 (HUNT-PAQ)), separately. The HUNT-PAQ, however, significantly mea- indicating under-reporting at higher levels of PA (MVPA sured MVPA differently on a group level compared to from SWA as independent variable). Removing of two SWA (p < 0.001). outliers shown in the Bland Altman plot (Fig. 1a) did Mean differences in PA measures (i.e. questionnaire not have any effect on the limits of agreement or the lin- minus SWA) with corresponding limits of agreements ear regression (data not shown). Therefore, they were in- between questionnaires and the SWA are shown in cluded in further analyses. The Spearman’s rho of the Bland Altman plots in Fig. 1. MVPA (Fig. 1a) was re- MVPA was insignificant and weak (rho = 0.08, p =0.509) ported only 4% differently with the NORDIET-FFQ for the NORDIET-FFQ, indicating that the questionnaire compared to the SWA (mean difference and limits of was not able to rank individual time in MVPA. Likewise, agreement − 12 ± 624 min/week). The under-estimation in the HUNT-PAQ, ranking of individual time in MVPA of MVPA (Fig. 1d) with the HUNT-PAQ was 58% was also poor (Spearman’s rho of 0.14, p =0.238).The Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 6 of 12 Table 2 Physical activities and sedentary time, all participants in total and stratified by sex Physical activity NORDIET-FFQ SWA NORDIET-FFQ/SWA a b (min/week) p-values Total (n = 78) Men (n = 42) Women (n = 36) Total (n = 78) Men (n = 42) Women (n = 36) p p p tot male female Median Median Median Median Median Median (P ,P ) (P ,P ) (P ,P ) (P ,P ) (P ,P ) (P ,P ) 5 95 5 95 5 95 5 95 5 95 5 95 MVPA 247 (0,691) 226 (0,812) 247 (0,641) 187 (12,881) 200 (2,1342) 169 (24,615) 0.897 0.759 0.838 MPA 152 (0,469) 159 (0,469) 152 (0,469) 187 (12,691) 200 (2872) 169 (11,615) 0.007 0.050 0.090 VPA 0 (0,219) 0 (0,256) 0 (0,236) 0 (0,42) 0 (0,44) 0 (0,43) < 0.001 0.011 0.005 HUNT-PAQ SWA HUNT-PAQ/SWA p-values Total (n = 77) Men (n = 42) Women (n = 35) Total (n = 77) Men (n = 42) Women (n = 35) p p p tot male female MVPA 72 (0,504) 38 (0,504) 113 (0,389) 182 (11,881) 200 (2,1342) 156 (23,618) < 0.001 < 0.001 0.001 MPA 55 (0,504) 38 (0,504) 113 (0,353) 182 (11,696) 200 (2872) 156 (11,618) < 0.001 < 0.001 0.002 Sedentary time (h/day) 6 (0,12) 6 (0,13) 7 (0,12) 13 (10,15) 13 (10,15) 13 (10,15) < 0.001 < 0.001 < 0.001 NORDIET-FFQ Norwegian Dietary Guidelines Food Frequency Questionnaire, HUNT-PAQ HUNT Physical Activity Questionnaire, SWA SenseWear Armband, MVPA (moderate intensity physical activity 10 min bouts + (vigorous intensity physical activity 10 min bouts*2)); bouts of 10 min = sum of at least 10 consecutive minutes of activity and above, MPA moderate intensity physical activity in bouts of 10 min, VPA vigorous intensity physical activity in bouts of 10 min Physical activity levels based on Norwegian Food Based Dietary Guidelines Wilcoxon signed rank test, p-values for median physical activity from NORDIET-FFQ, HUNT-PAQ and SWA, both total and between sex NORDIET-FFQ captured 63% individuals fulfilling the HUNT-PAQ captured 74% of individuals not fulfilling recommendation of MVPA (specificity), whereas only the recommendation of MPA (sensitivity), but only 29% of those in need of PA counselling (sensitivity) 36% of those who did (specificity). Both sensitivity (Table 3). The HUNT-PAQ was better at capturing and specificity for MPA were low with the individuals not fulfilling the recommendation of NORDIET-FFQ (Table 3). MVPA (sensitivity of 71%), but worse in identifying those who did (specificity of 36%). Vigorous intensity physical activity recorded from the NORDIET-FFQ, HUNT- PAQ and SWA Moderate intensity physical activity recorded from the Median time in activity at vigorous intensity PA NORDIET-FFQ, HUNT- PAQ and SWA (VPA) was reported significantly differently between Time spent in activity of moderate intensity PA (MPA) both questionnaires and SWA. The Bland Altman did not differ significantly by sex between the plot for VPA revealed an over-reporting of NORDIET-FFQ and SWA, whereas in HUNT-PAQ time 36 ± 176 min/week (mean difference ± limits of in MPA was measured significantly different from SWA agreement) with the NORDIET-FFQ, which increased on group level (Table 2). with increased activity (Fig. 1c). Sinceonlyonepar- MPA was under-reported in both questionnaires as ticipant reported VPA with the HUNT-PAQ, data shown by the mean differences and limits of agreement from this activity are not presented. Moreover, the from the Bland-Altman plots of − 83 ± 512 min/week NORDIET-FFQ identified 75% of the individuals not and − 153 ± 523 min/week from the NORDIET-FFQ fulfilling VPA. and HUNT-PAQ, respectively (Fig. 1b and e). The differ- ences of MPA were randomly and evenly distributed above and below the mean difference for both question- naires compared to SWA up to about 250 and 200 min/ Sedentary time recorded from the HUNT- PAQ and SWA week with the NORDIET-FFQ and HUNT-PAQ, re- Amount of sedentary time was only measured in the spectively (Fig. 1b and e). Linear regression also revealed HUNT-PAQ. Median time in sedentary intensity was a significant systematic under-reporting at higher levels significantly different between the questionnaire and of PA (MPA from SWA as independent variable) in both SWA (Table 2). The Bland Altman plot revealed a questionnaires (β = − 0.78, p < 0.001(NORDIET-FFQ) high under-reporting of about 52% (6.5 h/day) com- and β = − 0.83, p < 0.001 (HUNT-PAQ)). pared to SWA, which decreased with increased seden- Ranking of individual time in MPA was fair among tary time (Fig. 1f). However, the questionnaire was women only (Spearman’s rho = 0.37, p = 0.027) with the able to rank individuals according to sedentary time HUNT-PAQ, but weak and insignificant with the among women (r = 0.36. p = 0.035), but not among NORDIET-FFQ (Spearman’s rho = 0.01, p = 0.402). The men or all participants in total. Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 7 of 12 Fig. 1 Bland-Altman plots depicting mean differences of the questionnaires minus SWA for physical activity; a MVPA minutes/week, NORDIET-FFQ, b moderate intensity physical activity in bouts of 10 min/week, NORDIET-FFQ; c vigorous intensity physical activity in bouts of 10 min per week, NORDIET-FFQ; d MVPA minutes per week, HUNT-PAQ; e moderate intensity physical activity in bouts of 10 min/week, HUNT-PAQ; f Sedentary time in hours/day, HUNT- PAQ. The solid line represents the mean, and the dashed lines represent the 1.96 SDs of the observations. Females denoted as ♀ and males denoted as ♂ Adherence to the recommendations of physical activity were 66% and 33% with the NORDIET-FFQ and HUNT- recorded from the NORDIET-FFQ, HUNT- PAQ and SWA PAQ, respectively. However, only 55% of the participants Looking at each method separately, participants who re- actually met this recommendation according to the ported to fulfil the MVPA of at least 150 min per week SWA (Table 4). Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 8 of 12 Table 3 Sensitivity and specificity of the questionnaires in detecting adherence to the recommendations of physical activity a b Sensitivity n (%) Specificity n (%) Physical activity intensity NORDIET-FFQ HUNT-PAQ NORDIET-FFQ HUNT-PAQ MVPA> 150 min/week 10 (29) 25 (71) 27 (63) 15 (36) MPA > 150 min/week 16 (46) 26 (74) 22 (51) 15 (36) VPA > 75 min/week 57 (75) – 0 (0) 0 (0) NORDIET-FFQ NORDIET Food Frequency Questionnaire, HUNT-PAQ HUNT Physical Activity Questionnaire, SWA SenseWear Armband, MVPA = (moderate physical activity 10 min bouts + (vigorous physical activity 10 min bouts*2)); bouts = sum of at least 10 consecutive minutes of activity and above, MPA moderate physical activity in bouts of 10 min, VPA vigorous physical activity in bouts of 10 min subjects reported not fulfilling the recommendations for both the NORDIET-FFQ/HUNT-PAQ and SWA subjects reported fulfilling the recommendations for both the NORDIET-FFQ/HUNT-PAQ and SWA Discussion physical activities used by the two methods. All activities In the present study, we evaluated the ability of the are recorded by the SWA within a 24 h day, whereas the questionnaires, NORDIET-FFQ and HUNT-PAQ, to es- questionnaires rely on the participant’s memory and sub- timate adherence to PA recommendations among CRC jective evaluation of activity while responding to just a patients participating in the ongoing intervention, CRC- few questions [60]. NORDIET study [38]. Thirdly, the degree of under-reporting of MVPA and Generally, self-reported measures tend to over-report MPA was higher with the HUNT-PAQ than with the both duration and level of PA compared to objective NORDIET-FFQ. This might be due to the restricted op- methods [55], but under-reporting has also frequently portunity for the participants to report both MPA and been documented [55, 56] which may have several differ- VPA in the HUNT-PAQ, which is possible with the ent explanations. A review of studies focusing on the NORDIET-FFQ. Moreover, under-reporting may also be comparison of objective measures versus self-reporting explained by the different reporting intervals of frequen- of PA was performed by Prince et al. [55]. They found cies in the responses; the NORDIET-FFQ contained re- that self-reported measures of PA were higher than the sponses for activities lasting both less than and above objective measure when accelerometers were used. How- 10-min intervals, while the HUNT-PAQ only asked for ever, in the present study MVPA (only HUNT-PAQ) and activities lasting more than 10-min intervals. Therefore, MPA were under-reported with the questionnaires com- increased accuracy in reporting of intensities was pos- pared to SWA. This may be for several reasons; firstly, sible with the NORDIET-FFQ compared to the HUNT- the intensity level of MPA was defined as activities PAQ, since intensities performed for less than 10 min resulting in slight breathlessness. Cancer patients under- were not recorded with the HUNT-PAQ. going disease-related treatment and in a recovery phase Bias in reporting of intensity seems to be influenced post-surgery might experience breathlessness at lighter by the amount of questions for a specific activity within intensity than before, due to treatment effects and co- a questionnaire, i.e. whether it contains a single-item morbidities such as anaemia, chronic obstructive pul- question or domain-item questions [61–64]. The self- monary disease, and physical deconditioning [57, 58]. reported sedentary time in the present study was based Breathlessness may result in over-reporting of higher in- on a single-item question and was greatly under- tensity (VPA) and under-reporting of MPA. Slightly re- reported by the HUNT-PAQ compared to SWA, an ef- duced physical function, measured by handgrip-strength fect supported by other studies [61, 64]. Since the and 30-s sit-to-stand test, was observed in the CRC pa- HUNT-PAQ asked for sedentary time during day-time, a tients participating in the present study as compared to general definition of a day in the SWA was performed healthy individuals in Norway (Table 1)[59]. by removing night-hours between midnight and 6 am. Secondly, the under-reporting of MPA might also be Consequently, sedentary time during day-time recorded explained by the different techniques in recording by the SWA was calculated from 6 am to midnight. Table 4 Proportion of participants (n (%)) fulfilling the recommendations of physical activity with each measuring method Recommendations of physical activity intensity NORDIET-FFQ HUNT-PAQ SWA (n = 78) (n = 77) (n = 78) MVPA > 150 min/week 52 (66.7%) 25 (32.5%) 43 (55.1%) MPA > 150 min/week 41 (52.6%) 24 (31.2%) 43 (55.1%) NORDIET-FFQ NORDIET Food Frequency Questionnaire, HUNT-PAQ HUNT Physical Activity Questionnaire, SWA SenseWear Armband Mini, MVPA = (moderate intensity physical activity 10 min bouts + (vigorous intensity physical activity 10 min bouts*2)); bouts = sum of at least 10 consecutive minutes of activity and above, MPA moderate intensity physical activity in bouts of 10 min, VPA vigorous intensity physical activity in bouts of 10 min Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 9 of 12 However, this definition may be challenged in cancer pa- Hence, the NORDIET-FFQ was able to measure inten- tients facing several disease- and treatment side-effects sities up to about 250 min/week (i.e. including the PA influencing sleeping pattern due to increased need for recommendation of at least 150 min/week), but the resting time [65]. A diary report from each participant HUNT-PAQ was less well suited to measure the corre- would probably improve the definition of night-time sponding intensities. resulting in higher precision in reporting sedentary time Studies including physical activities categorized in during day-time. terms of different levels of exertion (light, moderate, vig- Vassbakk- Brovold et al. [34]documentedanover- orous) tend to result in more outliers, with VPA contrib- reporting of 366% of MVPA recommendation with uting the most outliers [55]. The present study reported the short form International Physical Activity Ques- more outliers at higher levels of all intensities, of which tionnaire (IPAQ-sf) compared to the SWA among the more extreme differences in reporting tended to be cancer patients undergoing chemotherapy. The IPAQ- among males. Importantly, there were few observations sf contains 9 questions on PA [66], whereas the with high amounts of PA, indicating high uncertainty NORDIET-FFQ and HUNT-PAQ contains 2 and 4 and low interpretation of those data. questions on PA, respectively. Both questionnaires in Previous studies differ in degrees of correlation be- the present study contained few detailed question tween self-reported methods and objective measure- about type of PA activities. Thus, under-reporting of ments of PA [55], with no specific trend. In the present the activities may be due to decreased precision in study, there were poor correlations for all variables be- reporting different kinds of activities during a day. tween the NORDIET-FFQ and SWA, whereas fair corre- However, the number of questions depends on the ra- lations were found between the HUNT-PAQ and SWA tionale of the questionnaire. In the present study, the for MPA and sedentary time among women only. Rank- aim was to estimate adherence to the PA recommen- ing of individuals according to time in MPA and seden- dations based on the Norwegian FBDG. In clinical tary time were thus fairly good with the HUNT-PAQ. practice as well as intervention studies, it is advanta- NORDIET-FFQ identified 63% of individuals fulfilling geous to have a short and easy PA assessment tool to the MVPA (specificity), but was not able to identify be used when monitoring adherence to the PA those in need of PA counselling (sensitivity). However, recommendations. the HUNT-PAQ was able to identify 71% not fulfilling A small mean difference of only 4% was revealed for the MVPA and 36% of those who did. Hence, the MVPA by the NORDIET-FFQ, whereas HUNT-PAQ NORDIET-FFQ provided a fairly specific measure of PA, under-estimated by 58% compared to the SWA. This is but limited sensitivity to correctly classify individuals comparable with previous studies, which have reported not fulfilling the MVPA. Thus, NORDIET-FFQ should mean differences around 44% (ranging from − 78% to be used with care in a clinical setting. In contrast, the 500%) [55]. Evenly distributed differences above and HUNT-PAQ was able to identify those in need of PA below the mean difference in the Bland Altman plots in- counselling, but limited in identifying those who fulfilled dicated no systematic bias of activities in any of the the PA recommendations. questionnaires. However, linear regression revealed a About 66% reported meeting the recommended level systematic bias as shown by the significant negative of MVPA with the NORDIET-FFQ (i.e. 150 min/week) slope for both questionnaires, indicating a trend towards whereas 55% actually met the MVPA according to the more under-reporting with increased amount of PA. As SWA. This is comparable with Vassbakk- Brovold et al. can be seen from the Bland Altman plots, this negative [34] who also documented a higher proportion (i.e. 90%) trend seems to be accounted for by intensities higher of cancer patients perceiving themselves as meeting the than 250 and 200 min/week with the NORDIET-FFQ MVPA recommendation of 150 min/week, while less and HUNT-PAQ, respectively. than 50% actually met the PA recommendations re- The limits of agreements were wide for both question- corded with SWA. This compares with a normal adult naires, indicating weak ability to assess MVPA and MPA population in Norway, in which one in five met the na- on an individual level. This has been supported by tional PA recommendations (i.e. 30 min/day) [21]. Im- Ekelund et al. [67] and by Vassbakk- Brovold et al. [34], portantly, the physical activity assessment method used who validated the short form of the International Phys- in the normal Norwegian population survey was differ- ical Activity Questionnaire (IPAQ-s) against an objective ent from the one used in the present study and the study monitor among healthy Swedish adults and adult cancer of Vassbakk-Brovold et al. [34]. Several barriers to meet patients, respectively. In the present study, limits of PA recommendations among cancer survivors have been agreement were smaller at 150 min/week for MVPA and documented, of which treatment and disease-related fac- MPA for both questionnaires (about 500 min/week) than tors are dominant [68, 69]. Consequently, cancer pa- at higher levels of PA. tients may feel breathlessness at lighter intensities than Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 10 of 12 normal, as abovementioned, resulting in over-reporting MET: Metabolic equivalent; MPA: Moderate intensity physical activity; MVPA: Moderate-to-vigorous intensity physical activity; NORDIET- of PA. Thus, these considerations are important to bear FFQ: Norwegian dietary guidelines food frequency questionnaire; in mind when using self-reported data on PA in cancer PA: Physical activity; SWA: SenseWear Armband Mini; TNM: Tumor node patients. metastasis; VPA: Vigorous intensity physical activity The main strength in the present study was the use of Acknowledgements SWA as the objective reference method in evaluating We would like to thank the patients for their valuable contribution to this self-reported PA from the two questionnaires. Addition- study. We would also like to thank Torgrim Langleite, Karoline Borg, Magnhild Håskjold, Stine Fallingen Ødegaard, Jonas Grenne, Hanna Ræder, ally, there was high compliance with the protocols for Siv Åshild Billington and Ane Sørlie Kværner for their contributions to data both self-reporting PA and wearing time of SWA. The collection and study administration. NORDIET-FFQ and the HUNT-PAQ asked for PA in re- cent weeks (i.e. the previous 1–2 months), whereas the Funding This project has received funding from Research Council of Norway, Throne SWA recorded PA the subsequent week. Since none of Holst Foundation of Nutrition Research, Norwegian Cancer Society and the patients in the present study underwent chemother- South Eastern Norway Regional Health Authority. The funder had no role in apy during the validation period (i.e. mean time since the design of the study, no role in collection, analysis, and interpretation of data, and no role in writing the manuscript. last treatment of 155 days), less variation due to treat- ment effect on physical activity was therefore assumed. Availability of data and materials The limitation in our study was the use of different cut- Anonymized data resulting from this study may be available upon request off points defining frequency and duration of PA, which by corresponding author. might have caused misclassification into MVPA, MPA Authors’ contributions and VPA activities between the questionnaires and HBH had the main responsibility for writing the manuscript. HBH, SB, IP, MZ, SWA. This is supported by other studies, of which one AJS, SKB, CH, SS, MHC and RB contributed to the conception and the design should be aware of the different qualities in measuring of the study, analysis and interpretation of the data and drafting of the manuscript. HBH, SB, IP, AJS and SKB contributed to acquisition of data. All levels of PA between methods [21, 66]. authors contributed to the writing and approval of the final manuscript. Conclusions Ethics approval and consent to participate The CRC-NORDIET study is carried out in accordance with the Helsinki There are many inherent limitations in using short ques- Declaration and informed consent was obtained from all participants. tionnaires to assess PA as compared to objective moni- The study was approved by the Norwegian Regional Committees for tors. In the present study we observed that the Medical and Health Research Ethics, Protocol Approval 2011/836, and by the data protection officials at Oslo University Hospital and Akershus NORDIET-FFQ provided better specificity and better es- University Hospital. The study is registered on the National Institutes of timates of PA than the HUNT-PAQ in CRC patients. Health Clinical Trials (http://www.clinicaltrials.gov; Identifier: The HUNT-PAQ provided better sensitivity, and pro- NCT01570010). Registered 4 April 2012. All participants provided in- formed written consent prior to participation. vided better ranking of PA and sedentary time among women than NORDIET-FFQ. However, it is important Competing interests to be aware of the limitations when interpreting the re- The authors declare that they have no competing interests. sults from these questionnaires. An objective monitor should be considered to be used when more accurate in- Publisher’sNote dividual data on PA and sedentary time are needed. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Additional files Author details Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway. Faculty of Health and Sports Science, University of Additional file 1: Physical activity, all participants in total and stratified Agder, Kristiansand, Norway. Norwegian Advisory Unit on Disease-Related by sex. Physical activity levels based on Norwegian Food Based Dietary Malnutrition, Division of Cancer Medicine, Oslo University Hospital, Oslo, Guideline (i.e. moderate intensity physical activity and vigorous Norway. Department of Biostatistics, Oslo Centre for Biostatistics and intensity physical activity) are presented in minutes per week as both Epidemiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, self-reported by NORDIET-FFQ and objectively measured by SenseWear Norway. Department for Clinical Service, Division of Cancer Medicine, Oslo Armband (SWA). (DOCX 18 kb) University Hospital, Oslo, Norway. Institute of Clinical Medicine University of Additional file 2: Bland-Altman plots depicting the mean differences Oslo, Oslo, Norway. (NORDIET-FFQ minus SenseWear Armband (SWA)) for physical activity in minutes per week; A. total-moderate intensity physical activity in minutes/ Received: 29 June 2017 Accepted: 25 April 2018 week, B. total-vigorous intensity physical activity, minutes/week. The solid line represents the mean, and the dashed lines represent the 1.96 SDs of the observations. Females denoted as ♀ and males denoted as ♂.(TIF 1133 kb) References 1. 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Abstract

Background: In order to investigate the impact of adherence to recommendations of physical activity and sedentary time on health outcomes in clinical trials, there is a need for feasible tools such as questionnaires that can give representative estimates of these measures. The primary aim of the present study was to validate two such questionnaires and their ability to estimate adherence to the recommendations of physical activity defined as moderate-to- vigorous physical activity or moderate physical activity of at least 150 min/week in colorectal cancer patients. Secondarily, self-reported sedentary time from the HUNT-PAQ was also evaluated. Methods: Participants from 'The Norwegian dietary guidelines and colorectal cancer survival-study’ (CRC-NORDIET study) completed two short questionnaires; the NORDIET-FFQ (n = 78) and the HUNT-PAQ (n = 77). The physical activity monitor SenseWear Armband Mini was used as the reference method during seven consecutive days. Results: The NORDIET-FFQ provided better estimates of time in moderate-to- vigorous physical activity and moderate physical activity than the HUNT-PAQ. The NORDIET-FFQ was unable to rank individual time in moderate- to- vigorous physical activity and moderate physical activity (Spearman’s rho = 0.08, p = 0.509 and Spearman’s rho rho = 0.01, p = 0.402, respectively). All intensities were under-reported by the HUNT-PAQ, but ranking of individual time in moderate physical activity and sedentary time were acceptable among women only (Spearman’srho =0.37, p = 0.027 and Spearman’srho =0.36, p = 0.035, respectively). The HUNT-PAQ correctly classified 71% of those not meeting the recommendations (sensitivity), and the NORDIET-FFQ correctly classified 63% of those who met the recommendations (specificity). About 67% and 33% reported to meet the recommendation of moderate-to- vigorous physical activity with the NORDIET-FFQ and HUNT-PAQ, respectively, whereas 55% actually met the moderate-to- vigorous physical activity according to the SenseWear Armband Mini. Conclusions: The NORDIET-FFQ provided better specificity and better estimates of PA than the HUNT-PAQ. The HUNT- PAQ provided better sensitivity, and provided better ranking of PA and sedentary time among women than NORDIET- FFQ. It is important to be aware of the limitations documented in the present study. Trial registration: The study is registered on the National Institutes of Health Clinical Trials (Identifier: NCT01570010). Registered 4 April 2012. Keywords: Short questionnaire, Physical activity, Sedentary time, SenseWear armband mini, Physical activity recommendations * Correspondence: rune.blomhoff@medisin.uio.no Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway Department for Clinical Service, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 2 of 12 Background Although many previous questionnaires have been The preventive effect of physical activity (PA) on risk of successfully used to assess PA, there is no questionnaire colorectal cancer is well-established [1–3]. However, an specifically designed to assess adherence to the PA rec- increasing number of studies also examine beneficial ef- ommendations as defined in Norwegian FBDG. For a fects of PA during cancer treatment as well as in the clinical trial in colorectal cancer patients [38], a new posttreatment period [4–16], such as decreased all-cause short semi-quantitative questionnaire (NORDIET-FFQ) mortality, increased disease-free survival, improved was developed to measure adherence to the Norwegian physical function and quality of life [5, 6, 11–13, 17, 18]. FBDG. The NORDIET-FFQ includes two questions on Moreover, reduced sedentary time, such as sitting during PA related to intensity levels similar to MPA and VPA. daytime, may be associated with reduced mortality and Another short questionnaire, the HUNT-PAQ [39]has lower risk of recurrence in cancer patients [19–22]. been used in large healthy populations in Norway; how- The recommendations of PA for cancer patients and ever this questionnaire has not previously been validated survivors provided by the American Cancer Society [23] in a CRC population. emphasize that exercise is safe and feasible during can- Thus, the primary aim of the present study was to val- cer treatment, and improves outcomes such as physical idate the two short questionnaires and their ability to es- function, fatigue and completion of chemotherapy [23]. timate adherence to the PA recommendations according The American Cancer Society, the World Health to the Norwegian FBDG. Secondarily, self-reported sed- Organization and others [24–27] recommend at least entary time from the HUNT-PAQ was also evaluated. 150 min of moderate intensity PA (MPA) or 75 min of vigorous intensity PA (VPA) per week or an equivalent Methods combination. In 2011, the Norwegian Directorate of Subjects and study design Health published the Norwegian Food-Based Dietary The present validation study was a sub-study of the on- Guidelines (FBDG) which also includes similar recom- going CRC-NORDIET study, of which design and mendations on PA as well as for sedentary time [3]. methods have been published elsewhere [38]. In brief, In Norway, colorectal cancer (CRC) is the third most the aim of the CRC-NORDIET study is to investigate the common cancer type, and the incidence is among the effect of a diet similar to the Norwegian FBDG [3]on highest in Europe [28]. Implementing the recommenda- disease-free and overall survival among CRC patients tions of PA and incorporating specific exercises in the post-diagnosis [38]. The risk factors shown to be related clinical care may improve the health outcomes of CRC to CRC, i.e. diet and physical activity, are included in the patients [1–3, 24]. Norwegian FBDG [40]. The CRC-NORDIET study is a In order to estimate adherence to PA recommendations prospective randomised controlled intervention trial, according to the Norwegian FBDG in a Norwegian CRC randomising 500 CRC patients into one of two study population, a valid and accurate physical assessment tool groups (i.e. 250 to diet intervention group and 250 to is needed. Importantly, assessment of adherence to the PA the control group). All patients are invited to the Study recommendations is required in counselling and when centre 3 times during the intensive 1-year intervention evaluating effectiveness of intervention studies. The use of (i.e. at baseline 2–9 months post-surgery and at the two objective monitors to record PA has increased during re- visits 6- and 12 months after baseline), and subsequently cent decades and gives valid and reliable data on intensity followed up for 14 years. Both study groups are offered of PA and energy expenditure [29]. However, these activity equal recommendations on PA [38]. monitors are expensive and time consuming for the clin- All patients from both study groups in the CRC- ician and researcher, particularly when recording PA in NORDIET study, who attended the follow-up at 6 months larger populations. Therefore, less expensive and easier after baseline of intervention (i.e. 2–9months post- methods are required to measure adherence to PA surgery) from January 2014 to October 2015, were invited recommendations. to take part in the present validation study. The patients The most common self-reporting method to assess PA were men and women aged 50–80 years old, with a con- is the use of questionnaires [30, 31]. Over the past 2 or firmed CRC (ICD-10 C18–20), and staged I-III (i.e. locor- 3 decades, more than 30 PA questionnaires have been egional disease without metastasis) according to the TNM developed and validated [32]. Long questionnaires are staging system [41]. None of the patients included in the challenging to complete for cancer patients often experi- validation study underwent chemotherapy during the encing treatment and disease related side-effects such as time-frame covered by the physical assessment methods fatigue and functional decline [33–36]. Questionnaires used in the validation study (e.g. mean time from last which contains few and well-defined questions regarding chemotherapy injection to the start of the validation study the different intensities of PA may be more suitable for (i.e 6 months after baseline) was 155 days among the 15% this group of patients [37]. who received adjuvant treatment). During the 6-months Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 3 of 12 visit, the patients completed the self-administered were calculated by multiplying frequency (i.e. times NORDIET-FFQ and HUNT-PAQ. In addition, they re- per day) with duration (i.e. minutes each time). This ceived the SenseWear Armband Mini (SWA), which was resulted in variables of total-MPA and total-VPA, of returned by mail to the CRC-NORDIET-study at the end which all minutes within each intensity were included of the test period of 7 days. Exclusion criteria for the (Additional files 1 and 2). Additionally, categories of present study were pacemaker implantation, not com- 10-min bouts were computed and defined as ten or pleted questionnaires or not wearing the SWA. more consecutive minutes within each intensity level. This resulted in data on 10-min bouts of MPA and Characteristics of the participants VPA. To characterize the subjects, anthropometric measure- ments (weight, height, and hip-and waist circumference) HUNT (the Nord-Trøndelag health study) physical activity and physical tests (hand-grip strength and 30-s sit-to- questionnaire (HUNT-PAQ) stand test) were measured by the researchers of the The HUNT-PAQ was based on the questionnaire used CRC-NORDIET study during all visits at the Study in the HUNT 3-study [39]. Only the five questions about centre, as previously described elsewhere [38]. In PA as described in Kurtze et al. [43] were used. The addition, education level and smoking status were self- question about frequency contained the following re- reported by completion of questionnaires during the sponses: Never and Less than once a week, both coded as visits at the Study centre. Information about tumour 0, Once a week coded as 1, 2–3 times a week coded as 2. location status was retrieved from medical records in co- 5, and Almost every day coded as 7. The question about operation with the hospital personnel. Energy expend- duration of activity contained the following responses: iture (kJ/d) was estimated from the SWA. Less than 15 min coded as 12 (subtracted 20% from 15), 15–29 min coded as 22, 30–1h coded as 45 and more Short semi-quantitative frequency questionnaire than 1 h coded as 72 (added 20% to 60). The products (NORDIET-FFQ) of frequency and duration were weighed by intensity The NORDIET-FFQ (available upon request to corre- level, i.e. Low, Moderate or Vigorous coded as 1, 2 and 3, sponding author), was designed to report both dietary respectively. The low intensity level was not evaluated in intakes and PA in recent weeks (i.e. the last 1–2 months). the present study. Additionally, there was a question The validity of the dietary items of the NORDIET-FFQ about daily sedentary time in hours on a usual day (not has been published elsewhere [42]. Completion of the included sleeping at night-time). The questionnaire gen- NORDIET-FFQ as well as protocol for data handling erated data on activities in bouts of 10 and more con- followed the same procedures as described in detail in secutive minutes for each intensity level, such as MPA Henriksen et al. [42]. In brief, the NORDIET-FFQ was and VPA. completed by the patients at the Study centre. The com- pleted questionnaires were scanned by trained researchers Objective physical activity measurement and the image files translated into data files using the The objective PA monitor SenseWear Armband Mini Cardiff Teleform 2006 Software (6.0) (Datascan). The last (SWA) (BodyMedia, Pittsburgh, Pennsylvania, USA) was two questions in the NORDIET-FFQ asked for PA with used to record daily PA and energy expenditure during two different intensities, MPA and VPA estimated in pre- seven consecutive days [44]. A priori, we defined a valid defined intervals of frequency per week and duration in day of recording if the wear time was ≥80% of a 24-h minutes. The explanatory texts for both PA questions in- sampling period. The SWA has previously been vali- cluded examples of typical activities: moderate intensity dated against double-labelled water [45], indirect calor- was exemplified by brisk walking, household chores or imetry [46] and other accelerometers [47] in adults and other activities resulting in slight breathlessness, and vig- cancer patients. It monitors physiological data such as orous intensity was exemplified by running, cross-country heat flux, galvanic skin response, 3-axis accelerometer skiing or other activities resulting in high breathlessness. and skin temperature. The SWA was pre-programmed The question about frequency contained different re- by the researcher with the co-predictors such as weight, sponses in times per week (time divided by seven) coded height, birth date, sex, smoking status (smoker/non- as follows: 0= 0, 1 = 0.14, 2 = 0.29, 3 = 0.43, 4 = 0.57, smoker) and whether the participant was left or right 5 = 0.71, 6–7 = 0.93 and 8+ = 1.37 (added 20% to 8 and handed, and placed around the triceps muscle halfway divided by7). Moreover theresponses of duration in on the upper non-dominant arm. The participants were minutes were coded as follows: 1–4= 2, 5–9= 7, instructed to continue their normal activity level while 10–15 = 12.5, 16–20 = 18, 21–30 = 25.5, 31–45 = 38, wearing the SWA. Water-based activities were not re- 46–60 = 53 and 60 + =72 (added 20% to 60). corded by the SWA because the monitor is not water- Amounts in minutes of PA per day for each intensity proof. Participants were asked to remove the SWA when Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 4 of 12 performing activities in water. All data were retrieved data. Bland-Altman plots with limits of agreements were from the SWA to a computer with the SenseWear used to explore the differences between the measure- Professional Software Version 7.0 BodyMedia Inc. ments from the two methods (i.e. questionnaire minus (Pittsburgh, Pennsylvania, USA). SWA) plotted against the average of the two measure- Activity intensities were integrated into algorithms, ments, for each individual subject, as well as to identify providing estimates of energy expenditure expressed in outliers [52, 53]. Systematic under- or over-reporting metabolic equivalents (METs). The definition of 1 MET was tested by linear regression with MVPA and MPA is the amount of oxygen consumed while sitting at rest from SWA as the independent variable and the differ- and is equal to 3.5 ml O per kg bodyweight per min ence between the questionnaires and SWA as the [48]. Moderate and vigorous intensities were defined as dependent variable. Ranking of individual time in PA 3–6 and > 6 METs, respectively, as calculated by and degree of association between the continuous vari- Ainsworth and coworkers [49, 50]. Sedentary time was ables from the two different methods were analysed by defined as all daily activities ≤1.5 METs, of which night- Spearman Rank Order Correlation (rho). The ability of time sleep was removed (a priori defined as from 12 the NORDIET-FFQ and the HUNT-PAQ to classify the midnight to 6.00 a.m.). All activities were calculated and individual’s activity intensity into the same category as expressed in minutes or hours per week (sedentary the SWA was estimated by the use of sensitivity and spe- time). cificity analysis. Sensitivity was defined as the number of The SWA records all intensities in 1-min intervals, subjects reported not to fulfil the MVPA with both ques- which were translated into different categories of data tionnaires and SWA as a percentage of those who had such as total-MPA and total-VPA. Furthermore, the data reported not to fulfil the MVPA with the SWA. Specifi- were also computed into 10-min intervals, which were city was defined as the number of subjects reported to defined as ten or more consecutive minutes within the fulfil the MVPA with both questionnaires and SWA as a relevant intensity level. The bouts of 10-min were calcu- percentage of those who had reported to fulfil the lated for the two intensity levels, which gave data on MVPA with the SWA. bouts of 10-min for MPA and VPA. Sample size Recommendations of physical activity In order to detect a Pearson correlation coefficient of 0.5 The CRC patients were advice to follow the recommen- or higher between the test-method (i.e. questionnaires) dations of moderate-to-vigorous intensity PA (MVPA), and the reference method (i.e. SWA), a sample size of 38 MPA and VPA. MVPA was defined as ‘MPA + (VPA*2)’ men and 38 women was required to achieve a signifi- [51] and the cut-off points for fulfilling recommenda- cance level of 5% and power of 90% [54]. With an ex- tions of MVPA and MPA were at least 150 min per pected consent rate of 90% and exclusion rate of week, and at least 75 min per week for VPA. The activ- maximum 5%, we aimed to invite 90 participants in ities should be in bouts of 10 and more consecutive order to include 76 participants to the present study. minutes. Statistical analysis Statistical analyses were performed by use of IBM SPSS Results Statistics, version 22. Results were considered significant Of the 88 invited participants, three were excluded with two-sided p-values below 0.05. Normal distribution due do pacemaker implantation and 7 declined to was checked for all data by inspection of histograms, nor- participate. Hence, 78 participants used the SWA and mal Q-Q-Plots and Kolmogorov-Smirnov test (p >0.05). completed the NORDIET-FFQ, whereas 77 of these All anthropometric measurements and other charac- also completed the HUNT-PAQ. General characteris- teristics of the study population were normally distrib- tics of the participants are presented in Table 1. uted and are presented as means with standard Mean age of the participants was 64.8 years, and did deviations (SD). The categorical data are presented as not differ significantly between men and women frequency with percentages and compared by the Fischer (Table 1). Mean time between surgery and baseline exact test and Pearson chi-square test. As most of the was 120.7 days ±41.4 days (mean ± SD) and between estimates of PA from the SWA, NORDIET-FFQ and baseline and 6-months visit was 184.4 ± 39.1 days HUNT-PAQ were not normally distributed, they are (mean ± SD). Total energy expenditure estimated presented as medians and 5th - and 95th percentile. from the SWA was 11.4 and 9.0 MJ for men and Statistical significant differences in median activity be- women, respectively. About 8% of the participants tween the two questionnaires compared to the SWA were smokers and 51% were highly educated (college/ were tested with Wilcoxon Signed-Rank test for paired university education) (Table 1). Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 5 of 12 Table 1 Characteristics of all participants in total and stratified by men and women (mean (SD)) Variables Total Men Women p (n = 78) (n = 42) (n = 36) Age, years, mean (SD) 64.8 (7) 65.2 (7.4) 64.3 (7.4) 0.590 Smokers, n (%) 6 (7.7%) 3 (7%) 3 (8%) 1.000 EE, kJ/d , mean (SD) 10,378 (1909) 11,496 (1474) 9074 (1488) < 0.001 Education, n (%) (total n = 78, men n = 42, women n = 36) Primary school 4 (5) 3 (7) 1 (3) 0.370 Lower secondary/High school 34 (44) 21 (50) 13 (36) College/University 40 (51) 18 (43) 22 (61) Anthropometry (mean, SD) (total n = 78, men n = 42, women n = 36) Weight, kg 79.2 (16.3) 87.0 (11.9) 70.0 (16.1) < 0.001 Height, m 1.73 (8.31) 1.77 (6.7) 1.66 (5.3) < 0.001 BMI, kg/m 26.1 (5) 27.5 (3.7) 25.2 (5.5) 0.030 Waist circumference 93.9 (13.7) 100.7 (9.6) 86.2 (13.8) < 0.001 Hip circumference 101.0 (9.2) 101.6 (6.9) 100.3 (11.4) 0.560 Tumor classification n (%) (total n = 70, men n = 36, women n = 34) TNM I 13 (17) 9 (25) 4 (12) 0.170 TNM II 33 (42) 18 (50) 15 (44) TNM III 24 (31) 9 (25) 15 (44) Physical performance (mean, SD) (total n = 78, men n = 42, women n = 36) Hand-grip strength right, kg 34.3 (9.5) 40.9 (6.6) 26.7 (5.9) < 0.001 Hand-grip strength left, kg 31.1 (9.7) 37.9 (7.1) 23.5 (5.7) < 0.001 Sit-to-stand test 17.3 (5.3) 17.9 (5.8) 16.5 (4.6) 0.220 TNM tumor node metastases, BMI body mass index, EE energy expenditure Continuously variables were tested with Student t-test. Categorical variables were tested by the Fischer exact test (two-sided) Estimated energy expenditure from the physical activity monitor SenseWear Armband Mini (BodyMedia, Pittsburgh, Pennsylvania, USA) (SWA) The maximal strength of hand grip (kg) was recorded. For women and men, a 40 kg- and 80 kg-spring was used, respectively Moderate-to-vigorous intensity physical activity recorded compared to SWA (mean difference and limits of agree- from the NORDIET-FFQ, HUNT- PAQ and SWA ment − 162 ± 576 min/week). Moreover, the Bland Participants wore the SWA monitors for 97.9 ± 3.8% Altman-plot for MVPA revealed an increase in the dif- (mean, ± SD) of the time during 6.2 ± 0.8 days (mean, ± ferences between both questionnaires and SWA with in- SD) of monitoring. creased PA level. Additionally, the differences were Median duration of PA estimated from the NORDIET- randomly and evenly distributed above and below the FFQ, HUNT-PAQ and the SWA is presented in Table 2. mean difference for both questionnaires compared to There was no significant difference between the SWA up to about 250 min/week (Fig. 1a and d). The NORDIET-FFQ and SWA for the measure for activity of slope of the linear regression was negative and signifi- moderate-to-vigorous intensity PA (MVPA), either for cant for both questionnaires (β = − 0.79, p < 0.001(NOR- the total population (p = 0.897) or when analyzing sexes DIET-FFQ) and β = − 0.85, p < 0.001 (HUNT-PAQ)), separately. The HUNT-PAQ, however, significantly mea- indicating under-reporting at higher levels of PA (MVPA sured MVPA differently on a group level compared to from SWA as independent variable). Removing of two SWA (p < 0.001). outliers shown in the Bland Altman plot (Fig. 1a) did Mean differences in PA measures (i.e. questionnaire not have any effect on the limits of agreement or the lin- minus SWA) with corresponding limits of agreements ear regression (data not shown). Therefore, they were in- between questionnaires and the SWA are shown in cluded in further analyses. The Spearman’s rho of the Bland Altman plots in Fig. 1. MVPA (Fig. 1a) was re- MVPA was insignificant and weak (rho = 0.08, p =0.509) ported only 4% differently with the NORDIET-FFQ for the NORDIET-FFQ, indicating that the questionnaire compared to the SWA (mean difference and limits of was not able to rank individual time in MVPA. Likewise, agreement − 12 ± 624 min/week). The under-estimation in the HUNT-PAQ, ranking of individual time in MVPA of MVPA (Fig. 1d) with the HUNT-PAQ was 58% was also poor (Spearman’s rho of 0.14, p =0.238).The Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 6 of 12 Table 2 Physical activities and sedentary time, all participants in total and stratified by sex Physical activity NORDIET-FFQ SWA NORDIET-FFQ/SWA a b (min/week) p-values Total (n = 78) Men (n = 42) Women (n = 36) Total (n = 78) Men (n = 42) Women (n = 36) p p p tot male female Median Median Median Median Median Median (P ,P ) (P ,P ) (P ,P ) (P ,P ) (P ,P ) (P ,P ) 5 95 5 95 5 95 5 95 5 95 5 95 MVPA 247 (0,691) 226 (0,812) 247 (0,641) 187 (12,881) 200 (2,1342) 169 (24,615) 0.897 0.759 0.838 MPA 152 (0,469) 159 (0,469) 152 (0,469) 187 (12,691) 200 (2872) 169 (11,615) 0.007 0.050 0.090 VPA 0 (0,219) 0 (0,256) 0 (0,236) 0 (0,42) 0 (0,44) 0 (0,43) < 0.001 0.011 0.005 HUNT-PAQ SWA HUNT-PAQ/SWA p-values Total (n = 77) Men (n = 42) Women (n = 35) Total (n = 77) Men (n = 42) Women (n = 35) p p p tot male female MVPA 72 (0,504) 38 (0,504) 113 (0,389) 182 (11,881) 200 (2,1342) 156 (23,618) < 0.001 < 0.001 0.001 MPA 55 (0,504) 38 (0,504) 113 (0,353) 182 (11,696) 200 (2872) 156 (11,618) < 0.001 < 0.001 0.002 Sedentary time (h/day) 6 (0,12) 6 (0,13) 7 (0,12) 13 (10,15) 13 (10,15) 13 (10,15) < 0.001 < 0.001 < 0.001 NORDIET-FFQ Norwegian Dietary Guidelines Food Frequency Questionnaire, HUNT-PAQ HUNT Physical Activity Questionnaire, SWA SenseWear Armband, MVPA (moderate intensity physical activity 10 min bouts + (vigorous intensity physical activity 10 min bouts*2)); bouts of 10 min = sum of at least 10 consecutive minutes of activity and above, MPA moderate intensity physical activity in bouts of 10 min, VPA vigorous intensity physical activity in bouts of 10 min Physical activity levels based on Norwegian Food Based Dietary Guidelines Wilcoxon signed rank test, p-values for median physical activity from NORDIET-FFQ, HUNT-PAQ and SWA, both total and between sex NORDIET-FFQ captured 63% individuals fulfilling the HUNT-PAQ captured 74% of individuals not fulfilling recommendation of MVPA (specificity), whereas only the recommendation of MPA (sensitivity), but only 29% of those in need of PA counselling (sensitivity) 36% of those who did (specificity). Both sensitivity (Table 3). The HUNT-PAQ was better at capturing and specificity for MPA were low with the individuals not fulfilling the recommendation of NORDIET-FFQ (Table 3). MVPA (sensitivity of 71%), but worse in identifying those who did (specificity of 36%). Vigorous intensity physical activity recorded from the NORDIET-FFQ, HUNT- PAQ and SWA Moderate intensity physical activity recorded from the Median time in activity at vigorous intensity PA NORDIET-FFQ, HUNT- PAQ and SWA (VPA) was reported significantly differently between Time spent in activity of moderate intensity PA (MPA) both questionnaires and SWA. The Bland Altman did not differ significantly by sex between the plot for VPA revealed an over-reporting of NORDIET-FFQ and SWA, whereas in HUNT-PAQ time 36 ± 176 min/week (mean difference ± limits of in MPA was measured significantly different from SWA agreement) with the NORDIET-FFQ, which increased on group level (Table 2). with increased activity (Fig. 1c). Sinceonlyonepar- MPA was under-reported in both questionnaires as ticipant reported VPA with the HUNT-PAQ, data shown by the mean differences and limits of agreement from this activity are not presented. Moreover, the from the Bland-Altman plots of − 83 ± 512 min/week NORDIET-FFQ identified 75% of the individuals not and − 153 ± 523 min/week from the NORDIET-FFQ fulfilling VPA. and HUNT-PAQ, respectively (Fig. 1b and e). The differ- ences of MPA were randomly and evenly distributed above and below the mean difference for both question- naires compared to SWA up to about 250 and 200 min/ Sedentary time recorded from the HUNT- PAQ and SWA week with the NORDIET-FFQ and HUNT-PAQ, re- Amount of sedentary time was only measured in the spectively (Fig. 1b and e). Linear regression also revealed HUNT-PAQ. Median time in sedentary intensity was a significant systematic under-reporting at higher levels significantly different between the questionnaire and of PA (MPA from SWA as independent variable) in both SWA (Table 2). The Bland Altman plot revealed a questionnaires (β = − 0.78, p < 0.001(NORDIET-FFQ) high under-reporting of about 52% (6.5 h/day) com- and β = − 0.83, p < 0.001 (HUNT-PAQ)). pared to SWA, which decreased with increased seden- Ranking of individual time in MPA was fair among tary time (Fig. 1f). However, the questionnaire was women only (Spearman’s rho = 0.37, p = 0.027) with the able to rank individuals according to sedentary time HUNT-PAQ, but weak and insignificant with the among women (r = 0.36. p = 0.035), but not among NORDIET-FFQ (Spearman’s rho = 0.01, p = 0.402). The men or all participants in total. Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 7 of 12 Fig. 1 Bland-Altman plots depicting mean differences of the questionnaires minus SWA for physical activity; a MVPA minutes/week, NORDIET-FFQ, b moderate intensity physical activity in bouts of 10 min/week, NORDIET-FFQ; c vigorous intensity physical activity in bouts of 10 min per week, NORDIET-FFQ; d MVPA minutes per week, HUNT-PAQ; e moderate intensity physical activity in bouts of 10 min/week, HUNT-PAQ; f Sedentary time in hours/day, HUNT- PAQ. The solid line represents the mean, and the dashed lines represent the 1.96 SDs of the observations. Females denoted as ♀ and males denoted as ♂ Adherence to the recommendations of physical activity were 66% and 33% with the NORDIET-FFQ and HUNT- recorded from the NORDIET-FFQ, HUNT- PAQ and SWA PAQ, respectively. However, only 55% of the participants Looking at each method separately, participants who re- actually met this recommendation according to the ported to fulfil the MVPA of at least 150 min per week SWA (Table 4). Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 8 of 12 Table 3 Sensitivity and specificity of the questionnaires in detecting adherence to the recommendations of physical activity a b Sensitivity n (%) Specificity n (%) Physical activity intensity NORDIET-FFQ HUNT-PAQ NORDIET-FFQ HUNT-PAQ MVPA> 150 min/week 10 (29) 25 (71) 27 (63) 15 (36) MPA > 150 min/week 16 (46) 26 (74) 22 (51) 15 (36) VPA > 75 min/week 57 (75) – 0 (0) 0 (0) NORDIET-FFQ NORDIET Food Frequency Questionnaire, HUNT-PAQ HUNT Physical Activity Questionnaire, SWA SenseWear Armband, MVPA = (moderate physical activity 10 min bouts + (vigorous physical activity 10 min bouts*2)); bouts = sum of at least 10 consecutive minutes of activity and above, MPA moderate physical activity in bouts of 10 min, VPA vigorous physical activity in bouts of 10 min subjects reported not fulfilling the recommendations for both the NORDIET-FFQ/HUNT-PAQ and SWA subjects reported fulfilling the recommendations for both the NORDIET-FFQ/HUNT-PAQ and SWA Discussion physical activities used by the two methods. All activities In the present study, we evaluated the ability of the are recorded by the SWA within a 24 h day, whereas the questionnaires, NORDIET-FFQ and HUNT-PAQ, to es- questionnaires rely on the participant’s memory and sub- timate adherence to PA recommendations among CRC jective evaluation of activity while responding to just a patients participating in the ongoing intervention, CRC- few questions [60]. NORDIET study [38]. Thirdly, the degree of under-reporting of MVPA and Generally, self-reported measures tend to over-report MPA was higher with the HUNT-PAQ than with the both duration and level of PA compared to objective NORDIET-FFQ. This might be due to the restricted op- methods [55], but under-reporting has also frequently portunity for the participants to report both MPA and been documented [55, 56] which may have several differ- VPA in the HUNT-PAQ, which is possible with the ent explanations. A review of studies focusing on the NORDIET-FFQ. Moreover, under-reporting may also be comparison of objective measures versus self-reporting explained by the different reporting intervals of frequen- of PA was performed by Prince et al. [55]. They found cies in the responses; the NORDIET-FFQ contained re- that self-reported measures of PA were higher than the sponses for activities lasting both less than and above objective measure when accelerometers were used. How- 10-min intervals, while the HUNT-PAQ only asked for ever, in the present study MVPA (only HUNT-PAQ) and activities lasting more than 10-min intervals. Therefore, MPA were under-reported with the questionnaires com- increased accuracy in reporting of intensities was pos- pared to SWA. This may be for several reasons; firstly, sible with the NORDIET-FFQ compared to the HUNT- the intensity level of MPA was defined as activities PAQ, since intensities performed for less than 10 min resulting in slight breathlessness. Cancer patients under- were not recorded with the HUNT-PAQ. going disease-related treatment and in a recovery phase Bias in reporting of intensity seems to be influenced post-surgery might experience breathlessness at lighter by the amount of questions for a specific activity within intensity than before, due to treatment effects and co- a questionnaire, i.e. whether it contains a single-item morbidities such as anaemia, chronic obstructive pul- question or domain-item questions [61–64]. The self- monary disease, and physical deconditioning [57, 58]. reported sedentary time in the present study was based Breathlessness may result in over-reporting of higher in- on a single-item question and was greatly under- tensity (VPA) and under-reporting of MPA. Slightly re- reported by the HUNT-PAQ compared to SWA, an ef- duced physical function, measured by handgrip-strength fect supported by other studies [61, 64]. Since the and 30-s sit-to-stand test, was observed in the CRC pa- HUNT-PAQ asked for sedentary time during day-time, a tients participating in the present study as compared to general definition of a day in the SWA was performed healthy individuals in Norway (Table 1)[59]. by removing night-hours between midnight and 6 am. Secondly, the under-reporting of MPA might also be Consequently, sedentary time during day-time recorded explained by the different techniques in recording by the SWA was calculated from 6 am to midnight. Table 4 Proportion of participants (n (%)) fulfilling the recommendations of physical activity with each measuring method Recommendations of physical activity intensity NORDIET-FFQ HUNT-PAQ SWA (n = 78) (n = 77) (n = 78) MVPA > 150 min/week 52 (66.7%) 25 (32.5%) 43 (55.1%) MPA > 150 min/week 41 (52.6%) 24 (31.2%) 43 (55.1%) NORDIET-FFQ NORDIET Food Frequency Questionnaire, HUNT-PAQ HUNT Physical Activity Questionnaire, SWA SenseWear Armband Mini, MVPA = (moderate intensity physical activity 10 min bouts + (vigorous intensity physical activity 10 min bouts*2)); bouts = sum of at least 10 consecutive minutes of activity and above, MPA moderate intensity physical activity in bouts of 10 min, VPA vigorous intensity physical activity in bouts of 10 min Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 9 of 12 However, this definition may be challenged in cancer pa- Hence, the NORDIET-FFQ was able to measure inten- tients facing several disease- and treatment side-effects sities up to about 250 min/week (i.e. including the PA influencing sleeping pattern due to increased need for recommendation of at least 150 min/week), but the resting time [65]. A diary report from each participant HUNT-PAQ was less well suited to measure the corre- would probably improve the definition of night-time sponding intensities. resulting in higher precision in reporting sedentary time Studies including physical activities categorized in during day-time. terms of different levels of exertion (light, moderate, vig- Vassbakk- Brovold et al. [34]documentedanover- orous) tend to result in more outliers, with VPA contrib- reporting of 366% of MVPA recommendation with uting the most outliers [55]. The present study reported the short form International Physical Activity Ques- more outliers at higher levels of all intensities, of which tionnaire (IPAQ-sf) compared to the SWA among the more extreme differences in reporting tended to be cancer patients undergoing chemotherapy. The IPAQ- among males. Importantly, there were few observations sf contains 9 questions on PA [66], whereas the with high amounts of PA, indicating high uncertainty NORDIET-FFQ and HUNT-PAQ contains 2 and 4 and low interpretation of those data. questions on PA, respectively. Both questionnaires in Previous studies differ in degrees of correlation be- the present study contained few detailed question tween self-reported methods and objective measure- about type of PA activities. Thus, under-reporting of ments of PA [55], with no specific trend. In the present the activities may be due to decreased precision in study, there were poor correlations for all variables be- reporting different kinds of activities during a day. tween the NORDIET-FFQ and SWA, whereas fair corre- However, the number of questions depends on the ra- lations were found between the HUNT-PAQ and SWA tionale of the questionnaire. In the present study, the for MPA and sedentary time among women only. Rank- aim was to estimate adherence to the PA recommen- ing of individuals according to time in MPA and seden- dations based on the Norwegian FBDG. In clinical tary time were thus fairly good with the HUNT-PAQ. practice as well as intervention studies, it is advanta- NORDIET-FFQ identified 63% of individuals fulfilling geous to have a short and easy PA assessment tool to the MVPA (specificity), but was not able to identify be used when monitoring adherence to the PA those in need of PA counselling (sensitivity). However, recommendations. the HUNT-PAQ was able to identify 71% not fulfilling A small mean difference of only 4% was revealed for the MVPA and 36% of those who did. Hence, the MVPA by the NORDIET-FFQ, whereas HUNT-PAQ NORDIET-FFQ provided a fairly specific measure of PA, under-estimated by 58% compared to the SWA. This is but limited sensitivity to correctly classify individuals comparable with previous studies, which have reported not fulfilling the MVPA. Thus, NORDIET-FFQ should mean differences around 44% (ranging from − 78% to be used with care in a clinical setting. In contrast, the 500%) [55]. Evenly distributed differences above and HUNT-PAQ was able to identify those in need of PA below the mean difference in the Bland Altman plots in- counselling, but limited in identifying those who fulfilled dicated no systematic bias of activities in any of the the PA recommendations. questionnaires. However, linear regression revealed a About 66% reported meeting the recommended level systematic bias as shown by the significant negative of MVPA with the NORDIET-FFQ (i.e. 150 min/week) slope for both questionnaires, indicating a trend towards whereas 55% actually met the MVPA according to the more under-reporting with increased amount of PA. As SWA. This is comparable with Vassbakk- Brovold et al. can be seen from the Bland Altman plots, this negative [34] who also documented a higher proportion (i.e. 90%) trend seems to be accounted for by intensities higher of cancer patients perceiving themselves as meeting the than 250 and 200 min/week with the NORDIET-FFQ MVPA recommendation of 150 min/week, while less and HUNT-PAQ, respectively. than 50% actually met the PA recommendations re- The limits of agreements were wide for both question- corded with SWA. This compares with a normal adult naires, indicating weak ability to assess MVPA and MPA population in Norway, in which one in five met the na- on an individual level. This has been supported by tional PA recommendations (i.e. 30 min/day) [21]. Im- Ekelund et al. [67] and by Vassbakk- Brovold et al. [34], portantly, the physical activity assessment method used who validated the short form of the International Phys- in the normal Norwegian population survey was differ- ical Activity Questionnaire (IPAQ-s) against an objective ent from the one used in the present study and the study monitor among healthy Swedish adults and adult cancer of Vassbakk-Brovold et al. [34]. Several barriers to meet patients, respectively. In the present study, limits of PA recommendations among cancer survivors have been agreement were smaller at 150 min/week for MVPA and documented, of which treatment and disease-related fac- MPA for both questionnaires (about 500 min/week) than tors are dominant [68, 69]. Consequently, cancer pa- at higher levels of PA. tients may feel breathlessness at lighter intensities than Henriksen et al. BMC Sports Science, Medicine and Rehabilitation (2018) 10:8 Page 10 of 12 normal, as abovementioned, resulting in over-reporting MET: Metabolic equivalent; MPA: Moderate intensity physical activity; MVPA: Moderate-to-vigorous intensity physical activity; NORDIET- of PA. Thus, these considerations are important to bear FFQ: Norwegian dietary guidelines food frequency questionnaire; in mind when using self-reported data on PA in cancer PA: Physical activity; SWA: SenseWear Armband Mini; TNM: Tumor node patients. metastasis; VPA: Vigorous intensity physical activity The main strength in the present study was the use of Acknowledgements SWA as the objective reference method in evaluating We would like to thank the patients for their valuable contribution to this self-reported PA from the two questionnaires. Addition- study. We would also like to thank Torgrim Langleite, Karoline Borg, Magnhild Håskjold, Stine Fallingen Ødegaard, Jonas Grenne, Hanna Ræder, ally, there was high compliance with the protocols for Siv Åshild Billington and Ane Sørlie Kværner for their contributions to data both self-reporting PA and wearing time of SWA. The collection and study administration. NORDIET-FFQ and the HUNT-PAQ asked for PA in re- cent weeks (i.e. the previous 1–2 months), whereas the Funding This project has received funding from Research Council of Norway, Throne SWA recorded PA the subsequent week. Since none of Holst Foundation of Nutrition Research, Norwegian Cancer Society and the patients in the present study underwent chemother- South Eastern Norway Regional Health Authority. The funder had no role in apy during the validation period (i.e. mean time since the design of the study, no role in collection, analysis, and interpretation of data, and no role in writing the manuscript. last treatment of 155 days), less variation due to treat- ment effect on physical activity was therefore assumed. Availability of data and materials The limitation in our study was the use of different cut- Anonymized data resulting from this study may be available upon request off points defining frequency and duration of PA, which by corresponding author. might have caused misclassification into MVPA, MPA Authors’ contributions and VPA activities between the questionnaires and HBH had the main responsibility for writing the manuscript. HBH, SB, IP, MZ, SWA. This is supported by other studies, of which one AJS, SKB, CH, SS, MHC and RB contributed to the conception and the design should be aware of the different qualities in measuring of the study, analysis and interpretation of the data and drafting of the manuscript. HBH, SB, IP, AJS and SKB contributed to acquisition of data. All levels of PA between methods [21, 66]. authors contributed to the writing and approval of the final manuscript. Conclusions Ethics approval and consent to participate The CRC-NORDIET study is carried out in accordance with the Helsinki There are many inherent limitations in using short ques- Declaration and informed consent was obtained from all participants. tionnaires to assess PA as compared to objective moni- The study was approved by the Norwegian Regional Committees for tors. In the present study we observed that the Medical and Health Research Ethics, Protocol Approval 2011/836, and by the data protection officials at Oslo University Hospital and Akershus NORDIET-FFQ provided better specificity and better es- University Hospital. The study is registered on the National Institutes of timates of PA than the HUNT-PAQ in CRC patients. Health Clinical Trials (http://www.clinicaltrials.gov; Identifier: The HUNT-PAQ provided better sensitivity, and pro- NCT01570010). Registered 4 April 2012. All participants provided in- formed written consent prior to participation. vided better ranking of PA and sedentary time among women than NORDIET-FFQ. However, it is important Competing interests to be aware of the limitations when interpreting the re- The authors declare that they have no competing interests. sults from these questionnaires. An objective monitor should be considered to be used when more accurate in- Publisher’sNote dividual data on PA and sedentary time are needed. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Additional files Author details Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway. Faculty of Health and Sports Science, University of Additional file 1: Physical activity, all participants in total and stratified Agder, Kristiansand, Norway. Norwegian Advisory Unit on Disease-Related by sex. Physical activity levels based on Norwegian Food Based Dietary Malnutrition, Division of Cancer Medicine, Oslo University Hospital, Oslo, Guideline (i.e. moderate intensity physical activity and vigorous Norway. Department of Biostatistics, Oslo Centre for Biostatistics and intensity physical activity) are presented in minutes per week as both Epidemiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, self-reported by NORDIET-FFQ and objectively measured by SenseWear Norway. Department for Clinical Service, Division of Cancer Medicine, Oslo Armband (SWA). (DOCX 18 kb) University Hospital, Oslo, Norway. Institute of Clinical Medicine University of Additional file 2: Bland-Altman plots depicting the mean differences Oslo, Oslo, Norway. (NORDIET-FFQ minus SenseWear Armband (SWA)) for physical activity in minutes per week; A. total-moderate intensity physical activity in minutes/ Received: 29 June 2017 Accepted: 25 April 2018 week, B. total-vigorous intensity physical activity, minutes/week. The solid line represents the mean, and the dashed lines represent the 1.96 SDs of the observations. Females denoted as ♀ and males denoted as ♂.(TIF 1133 kb) References 1. 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