Patient-Reported Observance of a Mediterranean Diet and Physical Activity in Patients Living with Breast Cancer: Implications for Primary Care Providers

Abstract

Background:

Nutrition and physical activity are critical aspects of breast cancer care. Primary care is poised to be central to survivorship care as the number of breast cancer survivors increases. National cancer societies’ recommendations suggest optimizing diet and physical activity and reducing sedentary behavior.

Objective:

To evaluate adherence to a Mediterranean diet, levels of physical activity, and levels of sedentary behavior among a midwestern cohort of patients living with breast cancer, and to identify barriers to healthy eating.

Methods:

A survey consisting of the Mediterranean Diet Adherence Screener (MEDAS), a screener for physical activity and sedentary behavior screening, as well as barriers to healthy eating was administered to patients attending oncology visits at an academic medical center.

Results:

Results indicate a weak adherence to the Mediterranean diet. The MEDAS was correlated with minutes of moderate-intensity activity but not with vigorous activity or sedentary time. More than two thirds of patients reported at least 1 barrier to healthy eating, including unpredictable schedules, depression/low energy, and difficulty preparing meals for 1 to 2 people.

Conclusion:

The majority of patients living with breast cancer did not meet the minimal national recommendations. These findings underscore the need for further research to develop strategies to optimize nutrition and physical activity within oncology and primary care settings.

Keywords

breast cancer mediterranean diet physical activity healthy eating sedentary behavior

Introduction

Breast cancer accounts for approximately 31% of all new cancer diagnoses in women and is the leading non–skin cancer malignancy among women in the United States (US).^1,2 Based on current data, nearly 1 in 8 women will be diagnosed with a form of breast cancer during their lifetime.³ Fortunately, breast cancer survivorship is greatly improving. Currently, the overall 5-year relative survival rate is 99% for local disease, and 30% for advanced disease.⁴ There are nearly 4.3 million patients in the US living with breast cancer, and the number is projected to reach 5.3 million in the next decade.⁵ The role of primary care providers in managing patients with breast cancer is therefore evolving from routine screening and primary risk reduction to a broader scope that includes long-term cancer survivorship. Substantial transitions in the long-term delivery of care are likely to occur from oncology to primary care at an even higher rate in the future.^6,7 In addition, breast cancer survivors are known to be at an increased cardiometabolic risk, and for older women in particular, cardiovascular disease poses a greater mortality risk than breast cancer itself.⁸

Beyond established oncologic therapies, lifestyle behaviors including nutrition, physical activity, and sedentary behavior play a pivotal role across multiple dimensions of cancer care. Their influence extends beyond primary prevention and cancer risk reduction to encompass treatment efficacy, recurrence risk, long-term prognosis, overall quality of life, and survival outcomes.^9-11 National societies such as American Cancer Society (ACS) and the World Cancer Research Fund (WCRF) have produced similar guidelines and recommendations for physical activity and nutrition.^10,12 However, patients with cancer face significant barriers to a healthy lifestyle.^13,14 One study found that while patients thought they had no significant barriers to a healthy diet, their healthcare providers believed barriers included lack of knowledge, few resources, and low motivation.¹⁵ Other research indicated that breast cancer patients and the general population both face barriers to a healthy diet.¹⁶

The Mediterranean Diet is a dietary pattern rich in nutrient dense foods and has known cardiometabolic benefits.¹⁷ It is characterized by high consumption of fruits, vegetables, whole grains, legumes, fish, and olive oil, and has been associated with reduced cancer recurrence, especially in colorectal, breast, and gastric cancers.^18-20 These effects are primarily thought to be mediated by the diet’s high fruit, vegetable, and whole grain content, which are a significant source of antioxidants and anti-inflammatory nutrients.²¹ Studies have shown a lower risk of all-cause mortality with concordance with a Mediterranean dietary pattern.²²

In addition to nutrition, another pillar of lifestyle recommendations to optimize breast cancer care is physical activity.^23-25 Maintaining an active lifestyle is crucial for breast cancer survivors, as regular physical activity has been shown to reduce the risk of recurrence, improve overall cardiovascular health and survival, and enhance quality of life.^24,25 Current guidelines recommend at least 150 min of moderate-intensity or 75 min of vigorous-intensity aerobic exercise per week to optimize physical and mental health outcomes in this population.^10,23 A 2014 meta-analysis found that breast cancer survivors who engaged in 150 min of moderate physical activity or more per week had a 24% decreased total mortality risk.²⁶

Despite these established benefits, evidence suggests that nutrition and physical activity in breast cancer survivors are often suboptimal.²⁷ The ACS, which includes primary care physicians and oncologists, recommends that nutritional assessment and counseling should begin early in the cancer journey, and as soon as possible after being diagnosed.¹⁰ However, few studies have specifically examined lifestyle behaviors in patients who have been diagnosed with breast cancer in the midwestern US, a region with a high rate of physical inactivity as well as red meat and processed food consumption that is typically higher than national averages, potentially influencing diet-related health outcomes and cardiovascular health.^28,29 Examining nutrition intake and dietary patterns can be an arduous process. Many studies use the lengthy Healthy Eating Index,³⁰ a survey with a specialized scoring system that takes 30 min or longer to administer, making it unsuitable for a busy clinical practice. In addition, the Healthy Eating Index does not assess patient-reported barriers to healthy eating. Understanding these barriers enables a patient-centric approach to improving dietary patterns.³¹

There is a gap in the current knowledge regarding diet quality and physical activity in a midwestern population. A study of Midwestern patients diagnosed with breast cancer revealed that their average diet quality, as measured by the Rapid Eating Assessment for Participants-Shortened version, was lower than that of the average omnivorous US population.³² Almost 89% of Nebraskans meet federal guidelines for daily intake of fruit and 92% do not meet recommendations for vegetables.³³ Little information is available regarding Midwesterners’ adherence to the Mediterranean diet, which is one of the most validated and studied dietary patterns for cardiac and metabolic health.^17,20,34 The prevalence of physical inactivity outside of work is over 25% for Midwesterners²⁹ and only 21% of adult Nebraskans meet the US guidelines for physical activity.³⁵

The current study aims to characterize nutrition and physical activity behaviors among breast cancer survivors in a Midwestern clinical setting and to identify patient-reported barriers to healthy lifestyle practices, with the goal of informing strategies for future intervention development. Rather than using a longer instrument such as the Healthy Eating Index, we used a brief 14-item survey, the Mediterranean Diet Adherence Screener (MEDAS), which provides a score indicative of low, moderate, and high adherence and highlights the need for dietary counseling if scores are low or moderate.³⁴ Ideally, the information obtained will be used to optimize both cancer and noncancer outcomes as long-term patient care transitions to primary care. The specific aims of this study were: (1) to assess nutritional status, with emphasis on adherence to the Mediterranean dietary pattern, alongside physical activity, and sedentary behavior, (2) to assess the relationship between these lifestyle factors; and (3) to identify patient-reported barriers to healthy eating.

Methods

This cross-sectional study utilized a survey administered to patients at a National Cancer Institute–designated cancer center that is affiliated with an academic medical center in the midwestern US. This study was reviewed and approved by the Institutional Review Board (IRB #0255-24-EX).

Participants

Eligibility criteria included: (1) all adult patients (≥19 years) with a confirmed diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS), irrespective of histologic subtype, cancer stage, or treatment status; (2) the ability to provide informed consent; (3) the ability to read and respond to an English-language survey; and (4) ambulatory attendance at an oncology clinic from June through August 2024. The study was introduced to patients upon check-in to their regular clinic visit. Interested patients were referred to a medical student researcher, who explained the study, obtained informed consent, and administered the survey. Participation was voluntary, and refusals were documented.

Survey Instrument

The survey (Supplemental Material) contained 31 items:

Dietary Assessment: The validated 14-item Mediterranean Diet Adherence Screener (MEDAS) was used to assess adherence to Mediterranean Diet recommendations.³⁶ Scores range from 0 to 14, with higher scores indicating greater adherence. Scores less than 5 were categorized as weak adherence, 6 to 9 as moderate to fair adherence, and 10 or higher as good or very good adherence.³⁷

The survey included 1 question assessing whether the participant was vegan or vegetarian.

Barriers to Healthy Eating: We could not find a short, validated scale appropriate to be administered in a busy clinic setting. We therefore compiled a list of 9 common barriers to a healthy diet, along with a “none” option and an “other” option, was compiled by the researchers based upon previous studies and interactions with patients.^38-42

Physical Activity: 2 questions quantified weekly minutes of moderate and vigorous-intensity physical activity. Participants who acquired a minimum of 150 min of moderate and/or 75 min of vigorous activity were considered to have met the minimum recommendation for physical activity.^24,43

Sedentary Behavior: 1 question assessed the average daily minutes spent sitting.

Sociodemographic and Clinical Data: 12 questions captured clinic location, participant age, gender, ethnicity, race, self-reported height and weight, and cancer history.

Procedures

Paper surveys were distributed in person to eligible patients during oncology clinic visits by the study investigator. Participation was voluntary, and refusals were recorded. Returned surveys were entered into a secure database.

Data Analyses

Data were summarized using descriptive statistics (means and standard deviations for continuous variables; frequencies and percentages for categorical variables). Cronbach’s Alpha was calculated to determine internal consistency reliability for the MEDAS. Pearson’s correlation coefficients were calculated to examine associations between MEDAS scores and physical activity or sedentary behavior. Statistical significance was defined as P < .05. All analyses were conducted using SPSS v30.0.

Results

Of 105 patients approached, 79 agreed to participate in the study (75.2% completion rate). Of these, 71 had complete data and were included in the analyses. The sample was almost exclusively (98.6%) women, 94.4% were white, and 98.6% were non-Hispanic/Latina (Table 1). The mean age was 59.9 years (SD = 13.2). Most (78.9%) had a diagnosis of invasive breast cancer. The mean MEDAS score was 4.7 on a scale from 0 to 14 (SD = 2.2), with a Cronbach’s alpha of .60. Overall, 70.4% of participants demonstrated weak adherence to the Mediterranean diet. The mean BMI was 28.7 kg/m² (SD = 8.1). Only 36.6% of participants (n = 26) met the minimum recommendation of 150 min of moderate or 75 min of vigorous physical activity per week.

Table 1.

Participant Characteristics and Results of Survey (n = 71).

Gender, # (%)^a
Male	0 (0.0)
Female	70 (98.6)
Non-binary	1 (1.4)
Race, # (%)^a
White	67 (94.4)
Other	4 (5.6)
Ethnicity, # (%)
Hispanic or Latino/a	0 (0.0)
Non-Hispanic or Latino/a	70 (98.6)
Not disclosed	1 (1.4)
Age (in years), mean (SD)^b	59.9 (13.2)
Have you had a diagnosis of Invasive breast cancer or ductal carcinoma n situ? # (%)
Invasive breast cancer	56 (78.9)
Ductal carcinoma in situ	5 (7.0)
Both	10 (14.1)
How long ago were you diagnosed? # (%)
Less than 1 year	27 (38.0)
1-5 years	27 (38.0)
6-10 years	8 (11.3)
More than 10 years	8 (11.3)
Not disclosed	1 (1.4)
Total MEDAS score (Range 0-14), mean (SD)	4.7 (2.2)
MEDAS category^c
Weak adherence	50 (70.4)
Moderate to fair adherence	18 (25.4)
Good or very good adherence	3 (4.2)
Average BMI^d (kg/m²), mean (SD)	28.7 (8.1)
In an average week, how many minutes do you participate in moderate-intensity physical activity? mean (SD)	124.5 (155.7)
In an average week, how many minutes do you participate in vigorous physical activity? mean (SD)	28.9 (99.1)
Does participant meet minimum recommendations for physical activity? mean (SD)
No	45 (63.4%)
Yes	26 (36.6%)
How many minutes do you usually spend sitting on a typical day? mean (SD)	397.5 (221.6)

Categories with n < 5 responses were aggregated into “Other” categories or not reported.

SD = standard deviation.

MEDAS = Mediterranean Diet Adherence Screener.

BMI = Body Mass Index.

Associations Between Dietary Adherence and Physical Activity

A statistically significant positive correlation was observed between MEDAS scores and minutes of moderate-intensity physical activity per week (r = .435, P < .001; Figure 1). No significant associations were identified between MEDAS score and vigorous activity (r = .020, P = .872) or minutes per day of sitting time (r = −.270, P = .064).

Figure 1.

Relationships of MEDAS scores with moderate and vigorous physical activity and sitting time.

Barriers to Healthy Eating

Reported barriers to healthy eating are detailed in Table 2. Nearly half (49.3%) of participants indicated that they typically eat a healthy diet and do not face any barriers. Of those who indicated barriers, the most cited challenges included unpredictable schedules, depression/low energy, and difficulty preparing meals for small households.

Table 2.

Patient-reported barriers to healthy eating.

Which of the following impact your ability to eat a healthy diet? (Please check all that apply)	# (%)
None – I usually eat a healthy diet	34 (47.9)
Unpredictable schedule	21 (29.6)
Depression/low energy	18 (25.4)
Difficult to prepare meals for 1 or 2 people	14 (19.7)
Not enough time	12 (16.9)
Money/cost of food	10 (14.1)
Dietary restrictions/allergies	9 (12.7)
Family obligations	7 (9.9)
Physically unable to spend time cooking	5 (7.0)
Poor cooking skills	3 (4.2)
Other*	6 (8.5)

Other responses included: bad habits/junk food, celiac disease, chemotherapy-related nausea or loss of appetite, denture use, avoidant/restrictive food intake disorder, lack of desire to eat, poor appetite, and altered taste.

Discussion

In this single cohort study of patients in the midwestern US, we report that patient-reported lifestyle factors of nutrition and physical activity did not meet minimal national guidelines in the majority of patients living with breast cancer. Less than one-third of participants met recommendations regarding nutrition and just over one-third met recommendations for physical activity. A number of barriers to healthy living were reported by about half of the study population. Overall, adherence to the Mediterranean diet was weak in nearly three quarters of the study population.

Our findings suggest that key principles of the Mediterranean diet are not being followed. Given the health advantages of this type of diet, patients may benefit from dietary counseling that emphasizes its key components: (1) the use of monounsaturated oil as the primary culinary fat, (2) increased consumption of fruits, vegetables, fish, and nuts, and (3) reduced intake of red meat and processed foods.²⁰ Additionally, findings regarding physical activity levels varied, but moderate-intensity activity was modest and vigorous activity was absent for the majority of the study population. Over one quarter of respondents reported no participation in moderate or vigorous physical activity, a finding of concern, yet consistent with trends observed within the midwestern population. The overall evaluation of physical activity in this cohort underscores the need for coordinated approaches by multidisciplinary healthcare teams to actively promote and support regular physical activity. Achieving sustainable, long-term engagement by patients could further require community-based initiatives and targeted outreach efforts.¹⁰

The significant positive association between MEDAS scores and moderate physical activity suggests a clustering of health-promoting behaviors in certain patients, consistent with previous findings that better nutrition and increased levels of physical activity often co-occur.^44,45 This may be important for guiding community-based initiatives to develop interventions that address both dietary and physical activity behaviors. However, vigorous activity and sedentary time were not associated with diet quality, which may reflect the lower prevalence of high-intensity exercise among cancer survivors, possibly due to treatment-related fatigue, comorbidities, or lack of exercise guidance.⁴⁶ Sedentary behavior was prevalent. While the guidelines are much clearer on nutrition and physical activity, sedentary behavior is increasingly recognized as a modifiable lifestyle factor. “Walking more and sitting less” is a key recommendation from the American Institute for Cancer Research/World Cancer Research Fund and this approach is endorsed by the American Cancer Society as part of their evidence-based guidelines for reducing cancer risk.^12,43

Patient-reported barriers in this study underscore a multifactorial challenge; psychosocial factors (eg, depression, low energy), logistical barriers (eg, unpredictable schedules, difficulty preparing meals for small households), and cancer-related effects (eg, loss of appetite, altered taste from chemotherapy) all contributed to reported dietary challenges in this population. However, although over 70% of our study sample reported a weak adherence to a Mediterranean diet, about half indicated that they faced no barriers to healthy eating. It seems apparent that our study sample considered a “healthy diet” to be something beyond the boundaries of a Mediterranean diet. Typically, cancer-related barriers are more commonly reported than in our study.¹⁵ Our findings are consistent with patterns observed in research comparing breast cancer populations to the general population indicating persistent barriers in both populations.¹⁶ Our study cohort did not indicate lack of knowledge as a barrier, and this significant deficit could be viewed as a “teachable moment” for clinicians involved in after-cancer care for promoting healthy behavior change.

Failure to address these suboptimal behaviors may have serious long-term consequences for patient outcomes, given the well-established benefits of better nutrition and regular physical activity in cancer survivorship.^17,19-21,25 Our study findings underscore the need for targeted lifestyle counseling and tailored interventions in primary care settings in all populations, but especially those who may be at increased cardiovascular risk.¹⁶ One effort to address this gap comes from the American Cancer Society, which has developed the Nutrition and Physical Activity After Cancer guide.⁴⁷

Although our study focused on patients diagnosed with breast cancer, existing systematic reviews and meta-analyses have examined the effects of the Mediterranean diet and associated lifestyle for not only breast cancer risk and survivorship, but also for quality of life across diverse populations.^21,48 Future research should explore the use of a patient-centered educational brochure or teaching that synthesizes evidence-based recommendations on diet and physical activity specifically for use during clinical encounters to promote adequate nutritional habits and regular physical activity among this population.^10,43

Limitations

This study has several limitations, particularly those inherent to a cross-sectional observational self-reported study with recall and self-selection bias.⁴⁹ The survey was conducted with a small sample of patients from a single health system in the midwestern US, which may limit generalizability to broader populations of breast cancer patients or community settings. In addition, the Mediterranean Diet Adherence Screener (MEDAS) provides a validated but brief measure of nutrition. The internal consistency reliability (Cronbach’s Alpha) in our sample was lower than expected and was lower than those found in studies from other countries, which ranged from .62 to .85.^50-53 This may indicate cultural differences in dietary habits reflected in this questionnaire. Due to time and resource constraints, factors that may be related to physical activity and/or diet quality, such as education level, marital status, meal source, and employment circumstances, were not included in the survey, Future research should examine the effect of these factors on diet and activity levels.

Conclusions

Nutrition and physical activity in a midwestern US population of patients living with breast cancer did not meet national cancer survivor guideline recommendations in the majority of survey participants. The increasing proportion of breast cancer survivors transitioning to long-term management within primary care settings reflects a need for evolving care delivery models. Such models ideally will integrate lifestyle counseling into routine care while addressing barriers to a healthy diet.

Supplemental Material

sj-pdf-1-jpc-10.1177_21501319251406845 – Supplemental material for Patient-Reported Observance of a Mediterranean Diet and Physical Activity in Patients Living with Breast Cancer: Implications for Primary Care Providers

Supplemental material, sj-pdf-1-jpc-10.1177_21501319251406845 for Patient-Reported Observance of a Mediterranean Diet and Physical Activity in Patients Living with Breast Cancer: Implications for Primary Care Providers by Lydia Hesseltine, Jenenne Geske, Meghana Kesireddy and Birgit Khandalavala in Journal of Primary Care & Community Health

Footnotes

Acknowledgements

The authors gratefully acknowledge Dr. Jairam Krishnamurthy and Dr. Amulya Yellala for their assistance in facilitating patient participation and permitting administration of the survey within their clinical practices. We also acknowledge the study participants for their time, and to Mary Beth Steele for manuscript preparation.

Author Note

Grammar and sentence structure were refined using Grammarly software.

ORCID iD

Birgit Khandalavala

Ethical Considerations

This study was reviewed and approved by the Institutional Review Board of the University of Nebraska Medical Center (IRB #0255-24-EX).

Consent to Participate

Eligibility criteria included: (1) adult patients (≥19 years) with a confirmed diagnosis of breast cancer, irrespective of cancer stage or treatment status; (2) ability to provide informed consent; (3) ability to read and respond to an English-language survey; and (4) attendance at one of the three specified oncology clinics during the study period. Participation was voluntary, and verbal consent was obtained prior to survey administration.

Consent for Publication

All authors have approved paper for publication.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Raw data were generated at University of Nebraska. Derived data supporting the findings of this study are available from the author JG upon request.

Supplemental Material

Supplemental material for this article is available online.

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