Temporal profiles of physical activity and energy expenditure in cancer in-patients

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Temporal profiles of physical activityand energy expenditure in cancer in-patientsSaba Taj a , Vivek Choudhary b & Arti Parganiha aa School of Life Sciences, Pt. Ravishankar Shukla University,Raipur, 492010, Indiab Regional Cancer Center, Pt. J.N.M. Medical College, Dr. B.R.Ambedkar Hospital, Raipur, 492001, India

Available online: 21 Feb 2012

To cite this article: Saba Taj, Vivek Choudhary & Arti Parganiha (2012): Temporal profiles ofphysical activity and energy expenditure in cancer in-patients, Biological Rhythm Research,DOI:10.1080/09291016.2012.667979

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Temporal profiles of physical activity and energy expenditure in cancer

in-patients

Saba Taja, Vivek Choudharyb and Arti Parganihaa*

aSchool of Life Sciences, Pt. Ravishankar Shukla University, Raipur 492010, India; bRegionalCancer Center, Pt. J.N.M. Medical College, Dr. B.R. Ambedkar Hospital, Raipur 492001, India

(Received 25 December 2011; final version received 8 February 2012)

Fifty-three cancer in-patients (37 males and 16 females) were randomly selectedfrom the Regional Cancer Center, Pt. J.N.M. College, Dr. B.R. AmbedkarHospital, Raipur, India. Rhythms in physical activity (PA) and energyexpenditure (EE) were studied non-invasively using Actical (Mini Mitter Co.Inc., USA) and compared with 24 apparently healthy subjects (11 males and 13females). Data were gathered at 1-min epoch length for at least three to fourconsecutive days and were analyzed using several statistical techniques, such asCosinor rhythmometry, ANOVA, Duncan’s multiple-range test, and t-test. Mostof the cancer in-patients and all control subjects exhibited a statisticallysignificant circadian rhythm in PA and EE. However, the rhythm detection ratiowas low among cancer in-patients. Patients had significantly lower 24-h average,lower amplitude, and an earlier acrophase in PA and EE rhythms. Further,significant effect of factor disease was discerned on total activity count (TAC) andtotal energy expenditure (TEE). TAC and TEE were significantly lower in cancerin-patients as compared to control subjects, irrespective of gender. In addition, agradual decrement in PA intensity levels from sedentary to vigorous was validatedin patients. From the present findings, it can be concluded that the factor diseasemight alter the temporal profiles of the PA and EE. However, further intensivestudies involving more patients are required to reinforce the above conclusion.

Keywords: Actical; physical activity; energy expenditure; circadian rhythm; cancerin-patients; PA intensity level

1. Introduction

The cancer patients showed altered temporal organization along the 24 h-time scale.The rhythm characteristics of a number of variables, such as melatonin, cortisol,lymphocytes, and rest-activity undergo alterations in cancer patients (Mormont et al.2002; Pati et al. 2006, 2007). The changes involve: (1) lowering of 24-h average andamplitude; (2) phase advance/delay of the peak; and (3) suppression of one or morecircadian outputs (Touitou et al. 1995; Mormont and Levi 1997; Pati et al. 2006,2007). The disruption of the circadian timing system (CTS) accelerates cancer growthin tumor-bearing rodents (Filipski et al. 2002, 2004) and dampens circadian rest-activity rhythm in patients with metastatic colorectal cancer (Levi 1997, 2001;

*Corresponding author. Email: [email protected]

Biological Rhythm Research

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Mormont et al. 2000, 2002; Mormont and Levi 2003; Rich et al. 2005; Innominatoet al. 2009; Levi et al. 2010). The chances of survival were found to be poor inmetastatic colorectal cancer patients with altered circadian rhythm in rest-activity(Innominato et al. 2007). In humans, the rest–activity rhythm is considered as aconfirmed biomarker of the central pacemaker (Mormont and Levi 2003). Mormontand Waterhouse (2002) suggested that the rest–activity rhythm could be an indicatorof quality of life (QoL) in cancer patients. In recent times, this biomarker is widelyused as a reference for administration of chronotherapeutics in cancer patients.

Further, it has been documented that the physical activity (PA) is associated withlower risk of cancer (Lee 2003). Reduction in the incidence of specific cancer, i.e.colon, rectum, breast, prostate, and lung was found to be associated with routine PA(Shephard and Futcher 1997; Lee 2003; Warburton et al. 2006). However, theseeffects can vary according to the intensity, mode, and duration of PA. It has beendocumented that the PA enhances the dose–response in physically active cancerpatients as compared to sedentary patients (Lee 2003). Physical activity may reducethe probability of tumor recurrence, reduce fatigue, and increase survival of cancerpatients (Godlee 2000).

Moreover, knowledge of energy expenditure (EE) is paramount for severaldiseases, like cancer, diabetes, and obesity. It may be helpful in understanding of thepathophysiology of wasting associated with disease (Nelson et al. 1994; Elia 1995).Presently, the techniques used to assess total EE are either quite expensive andrequire huge place (doubly labeled water and indirect calorimetry) or inaccurate(prediction equations or questionnaires). Thus, the use of activity monitors, i.e.Actical, is useful to estimate the EE. Such estimation can be useful for the patients toprovide nutritional support. A proper nutrition management can be provided on thebasis of studies and the energy wasted in a disease condition can be compensated(Nelson et al. 1994; Elia 1995).

In India, information on circadian rhythms in PA and EE in cancer patients aremeager. In this study, therefore, we examined the CTS of PA and EE in cancer in-patients who were admitted to receive chemotherapy.

2. Materials and methods

2.1. Subjects

Fifty-three cancer patients (median age: 33 years; range: 18–65 years) consisting of37 males and 16 females were selected randomly from the indoor cancer ward of theRegional Cancer Center, Pt. J.N.M. Medical College, B.R. Ambedkar Hospital,Raipur, Chhattisgarh, India. Fourteen patients were suffering from cancer in theregion of reproductive organs, 11 in the blood, 9 in the head and neck, 6 in the lung,and the remaining 13 in other organs. Biographical measurements and clinicalcharacteristics including date of diagnosis of primary tumor (PT), site and stage ofPT, treatment (chemotherapy), medications (drugs and dose), and performancestatus (PS) were recorded for each patient. The PS was rated according to the criteriaof Eastern Cooperative Oncology Group (ECOG; Oken et al. 1982). Patients in poorgeneral condition, i.e. PS above two were not included in the study. All patientsreceived chemotherapy during the tenure of this study. Chemotherapy consistedof a combination of two or three of the following medications: paclitaxel (200–260 mg/m2), cisplatin (50–180 mg/m2), oxaliplatin (110 mg/m2), leucovorin (200 mg/m2), docetaxel (100–150 mg/m2), carboplatin (450–600 mg/m2), etoposide

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(100–200 mg/m2), 5-fluorouracil (500–900 mg/m2), daunorubicin (40–70 mg/m2),gemcitabine (1600 mg/m2), and doxorubicin (70–90 mg/m2). Twenty-four apparentlyhealthy human subjects (median age: 30 years; age range: 22–52 years) consisting of11 males and 13 females were also studied for comparison. The biographical andclinical characteristics of the cancer in-patients and apparently healthy subjects aresummarized in Table 1. The study obtained approval of the Institutional EthicsCommittee on Human Research of the Pt. J.N.M. Medical College, Raipur, India.Both patients and healthy subjects, who participated voluntarily in the study, gavetheir written informed consent.

2.2. Evaluation of the circadian rhythms in physical activity and energy expenditure

Circadian rhythms in PA and EE were monitored non-invasively using an electronicdevice – the Actical (Mini Mitter Co., Inc., USA). ‘‘Activity count, a device-specificarbitrary unit, represents the frequency and amplitude of acceleration eventsoccurring over a user-defined measurement epoch’’. Actical also converts movement(activity counts) into energy units (calories). This yields the total kilocalories thesubject expended during the time span as a result of their activity above the restingmetabolic rate. The EE values for a given time span are summed and multiplied bythe subject’s weight in kilograms.

Patients wore Actical on the wrist of their non-dominant hand, when they wereadmitted to receive the chemotherapy. Data were gathered at 1-min epoch for atleast three to four consecutive days, which is the recommended duration forevaluating circadian rhythm in rest–activity (Littner et al. 2003; Morgenthaler et al.2007). During the study period, either the patients themselves or their attendantsrecorded the sleep log, such as bed time, sleep start time, and awakening time ondaily basis. Apparently, healthy subjects also wore the Actical for at least four to

Table 1. Biographical and clinical characteristics of cancer inpatients and control subjects.

Attribute Description

Number of cancer inpatients (M/F) 53 (37/16)Age (years), median/range 33/18–65BSA (m2) 1.52+0.02*BMI (kg/m2) 20.73+0.50Primary tumor site Head and neck (n ¼ 9), reproductive organs (n ¼ 14),

blood (n ¼ 11), lung (n ¼ 6), and other organs(n ¼ 13)

ECOG performance status 1-PS (23), and 2-PS (30)Treatment ChemotherapyCycles of chemotherapy received

before Actigraphy1 (22), 2 (12), 3 (7), 4 (4), 5 (3), 6 (4), 46 (1)

Drugs used for chemotherapy Paclitaxel, cisplatin, oxaliplatin, leucovorin, docetaxel,carboplatin, etoposide, 5-fluorouracil, daunorubicin,gemcitabine, doxorubicin

Number of control subjects (M/F) 24 (11/13)Age (years), median/range 30/22–52BSA (m2) 1.61+0.03BMI (kg/m2) 21.43+0.60

Note: *M+SE.

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seven days. The data were transferred from the Actical to a personal computer usingthe Actical reader.

2.3. Statistical analyses

Data on PA and EE were analyzed using specific Actical software (Version 2.12). PAand EE are expressed in activity count per minute (AC min71), and kilocalories perhour per kilogram of subject’s body weight (Kcal kg71 h71), respectively. The dataconsisting of PA and EE were log-transformed to minimize variance and weresubjected to further statistical analyses. Rhythm detection in PA and EE wereanalyzed with the help of Cosinor rhythmometry (Nelson et al. 1979; Gupta and Pati1992) at two fixed windows (t ¼ 24 h and t ¼ 12 h). Rhythm parameters, such as24-h average/Mesor (M, rhythm-adjusted mean), amplitude (A, half of the differencebetween the highest and the lowest value of the best fitting cosine function), andacrophase/peak (Ø, the timings of the highest value with reference to midnight) werecomputed. Harmonic means were computed for M, A, and Ø obtained at bothwindows. Rhythm detection ratio was also calculated for both the variables. Thet-test was employed to compare the averages of M, A, and Ø of EE and PA betweencancer in-patients and healthy subjects. A two-way ANOVA followed by theDuncan’s multiple-range test was employed to estimate the effects of gender (maleversus female) and disease (cancer versus control) on total activity count (TAC) andtotal energy expenditure (TEE). Data on TAC and TEE of each subject were takenon daily basis for the analysis. Further, PA was categorized into four differentintensities, such as sedentary (e.g. sleep and rest), light (e.g. shorting cards andwriting letter), moderate (e.g. vacuuming and dusting), and vigorous (e.g. treadmillwalking and treadmill jogging) based on existing accelerometer thresholds. Thedefault threshold for light–moderate (0.031) and moderate–vigorous (0.083) PA wasused for the comparison between cancer in-patients and healthy subjects. Thestatistical software, SPSS (version 10.0) was used for analysis of the data.

3. Results

3.1. Actogram

Figure 1 shows illustrative examples of actograms that depict patterns of PA and EEin cancer in-patients (Figure 1(a, c)) and control subjects (Figure 1(b, d)). Themagnification of the ordinate was kept similar for plotting actograms for both cancerin-patients and control subjects. The apparently healthy subjects, irrespective ofgender, exhibited higher level of activity during the daytime (Figure 1(b, d)). Inaddition, both female and male controls showed day-to-day consistency andregularity in their day–night pattern of PA and EE (Figure 1(b, d)). However, thecancer in-patients, irrespective of gender, displayed greatly reduced activity. Inaddition, the consistency and regularity in day–night patterns of EE and PA werediminished (Figure 1(a, c)).

3.2. Rhythm detection ratio in physical activity and energy expenditure

Statistically significant circadian rhythms in PA and EE were validated in all controlsubjects and most of the cancer in-patients. However, the rhythm detection ratio was oflow magnitude in cancer in-patients, especially with reference to EE (Table 2). In control

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Figure 1. Illustrative examples of PA and EE profiles (actogram) in cancer in-patients (a andc) and apparently healthy subjects (b and d). Abscissa depicts clock hour. Each row represents24 h span, i.e., for a given day. The height of the black marks in each row indicates the level ofactivity (counts per minute) and the green bar shows EE (Kcal/per hour) for the correspondingtime in the abscissa.

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subjects, the rhythm detection ratio in PA was one, irrespective of computation window,i.e. t ¼ 24 h or t ¼ 12 h.

3.3. Twenty-four-hour average/Mesor

Twenty-four-hour averages of PA and EE, of each subject, obtained at the fixedwindows of 24 h or 12 h were averaged separately and presented in Tables 3 and 4,respectively. Harmonic means of PA and EE were also presented in Tables 3 and 4.Twenty-four-hour average of PA was significantly lower in cancer in-patients ascompared to the control subjects, irrespective of the computation window (Table 3).Comparable difference was also observed for the harmonic mean of PA. Twenty-four-hour average of EE exhibited the similar trend as that of PA (Table 4). Figure2(a) depicts differences in harmonic mean of PA with reference to gender. Harmonicmean of PA was statistically significantly declined in both male and female cancerin-patients than those of their respective controls. Results obtained for EE supportthe findings of PA and depicted lower harmonic mean of EE in cancer in-patients,irrespective of gender (Figure 3(a)).

Table 2. Rhythm detection ratio in physical activity (PA) and energy expenditure (EE) atfixed windows with t ¼ 24 h or t ¼ 12 h in cancer inpatients and control subjects.

Cancer in-patients Control subjects

PA EE PA EE

t ¼ 24 h t ¼ 12 h t ¼ 24 h t ¼ 12 h t ¼ 24 h t ¼ 12 h t ¼ 24 h t ¼ 12 h

Male 0.97 0.97 0.76 0.59 1 1 1 0.73Female 1 1 0.81 0.56 1 1 1 0.85All 0.98 0.98 0.77 0.58 1 1 1 0.79

Table 3. Summary of the characteristics of circadian rhythm in physical activity (PA) ofcancer inpatients and control subjects.

Variable Cancer in-patients Control subjects t value; df; p value

Rhythm parameter at t ¼ 24 h24-h average (M) 00.79+ 0.04* 01.45+ 0.06 08.30; 75; 5 0.001Amplitude (A) 00.30+ 0.02 00.78+ 0.05 10.22; 75; 5 0.001Acrophase (Ø in h) 13.34+ 0.46 14.72+ 0.59 01.73; 75; 0.09

Rhythm parameter at t ¼ 12 h24-h average (M) 00.80+ 0.04 01.45+ 0.07 08.29; 75; 5 0.001Amplitude (A) 00.20+ 0.02 00.45+ 0.04 06.78; 75; 5 0.001Acrophase (Ø in h) 08.01+ 0.32 08.97+ 0.25 01.89; 75; 0.06

Rhythm parameter (Harmonic mean)24-h average (M) 00.79+ 0.04 01.45+ 0.06 08.31; 75; 5 0.001Amplitude (A) 00.24+ 0.02 00.52+ 0.04 08.10; 75; 5 0.001Acrophase (Ø in h) 09.63+ 0.37 10.96+ 0.41 02.17; 75; 0.03

Note: *Values are mean+ 1 SEM. Rhythm parameters were computed at fixed windows with t ¼ 24 h ort ¼ 12 h. The harmonic means of each parameter obtained at t ¼ 24 h and t ¼ 12 h were also calculated.

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3.4. Amplitude

Likewise, decrement in circadian amplitudes of PA and EE was observed in cancerin-patients than control subjects (Tables 3 and 4). The harmonic means computedfor amplitudes of PA and EE rhythms were significantly lower in patients than thoseobtained for the control subjects, irrespective of the gender (Figures 2(b) and 3(b)).

3.5. Acrophase/peak

A significant advancement of acrophase of PA occurred for harmonic mean only incancer in-patients than controls (Table 3). However, the acrophase of EE occurredsignificantly earlier in patients than that of controls, irrespective of computationwindow (Table 4). Further, harmonic mean of the circadian acrophase of PAoccurred significantly earlier in male patients only as compared with their healthycounterparts (Figure 2(c)). On the other hand, harmonic mean of acrophase of EEoccurred significantly earlier in both male and female cancer in-patients than theirrespective group of controls (Figure 3(c)).

3.6. Role of factors – disease and gender on physical activity and energyexpenditure

The results of two-way ANOVA revealed a statistically significant effect of the factordisease on TAC (p 5 0.001) and TEE (p 5 0.001). However, factor gender did notproduce any significant effect on these variables. Further, interaction of both thefactors disease and gender also produced significant effect on TAC (p 5 0.001) andTEE (p 5 0.001) (Table 5).

The results of Duncan’s multiple-range test depict that cancer in-patients hadsignificantly lower TAC and TEE as compared to control subjects (Figures 4 and 5).Interestingly, TAC and TEE were always significantly higher in males than theirrespective group of females (Figures 4 and 5).

Table 4. Summary of the characteristics of circadian rhythm in energy expenditure (EE) ofcancer inpatients and control subjects.

Variable Cancer in-patients Control subjects t value; df; p value

Rhythm parameter at t ¼ 24 h24-h average (M) 00.92+0.04* 01.33+0.04 5.92; 75; 5 0.001Amplitude (A) 00.19+0.01 00.39+0.02 8.63; 75; 5 0.001Acrophase (Ø in h) 12.88+0.43 14.66+0.24 2.69; 75; 0.01

Rhythm parameter at t ¼ 12 h24-h average (M) 00.92+0.04 01.34+0.04 6.03; 75; 5 0.001Amplitude (A) 00.15+0.01 00.24+0.02 4.98; 75; 5 0.001Acrophase (Ø in h) 07.67+0.22 08.54+0.26 2.38; 75; 0.02

Rhythm parameter (Harmonic mean)24-h average (M) 00.92+0.04 01.33+0.04 5.98; 75; 5 0.001Amplitude (A) 00.15+0.01 00.29+0.02 7.59; 75; 5 0.001Acrophase (Ø in h) 09.27+0.23 10.77+0.27 3.85; 75; 5 0.001

Note: *Values are mean+1 SEM. Rhythm parameters were computed at fixed windows with t ¼ 24 h ort ¼ 12 h. The harmonic means of each parameter obtained at t ¼ 24 h and t ¼ 12 h were also calculated.

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3.7. Intensity of physical activity

Figure 6 (a, b, c, d) shows illustrative examples of different PA intensity levels on thebasis of accelerometer thresholds in cancer in-patients (Figure 6(a, c)) and controlsubjects (Figure 6(b, d)). In cancer in-patients, the intensity of PA was below the

Figure 2. Twenty-four-hour average based on harmonic means (a), amplitude based onharmonic means (b), and acrophse based on harmonic means (c) of the circadian PA rhythmof control subjects and cancer in-patients. Statistically significant (*p 5 0.05, ***p 5 0.001)differences were discerned between cancer in-patients and control subjects for all threecircadian rhythm characteristics.

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moderate level, irrespective of gender and time of the day (Figure 6(a, c)). However,in apparently healthy male and female subjects the activity levels were above themoderate intensity during the day time (Figure 6(b, d)). This visual observation was

Figure 3. Twenty-four-hour average based on harmonic means (a), amplitude based onharmonic means (b), and acrophse based on harmonic means (c) of the circadian EE rhythmof control subjects and cancer in-patients. Statistically significant (**p 5 0.01, ***p 5 0.001)differences were discerned between cancer in-patients and control subjects for all threecircadian rhythm characteristics.

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digitized and compared between patients and controls using the Student t-test.Statistically significant differences in all the PA intensity levels were witnessedbetween both the groups (Figure 7(a, b, c, d)). Intensity of activity under sedentarycondition was significantly higher in patients (p 5 0.05), whereas other intensities,such as light (p 5 0.001), moderate (p 5 0.001), and vigorous (p 5 0.001) werelower in patients as compared to their control counterparts (Figure 7(a, b, c, d)).

4. Discussion

This study was designed to investigate the temporal profiles of PA and EE in cancerin-patients. In this study, a marked difference in 24-h PA and EE rhythms has beendocumented between cancer in-patients and control subjects. The normal day–nightpattern and day-to-day consistency in PA and EE were absent in cancer in-patients.On the other hand, control subjects exhibited more activity during day time and veryless or no activity during night time. In addition, they exhibited day-to-dayconsistency in their PA and EE rhythms. These results could be favorably compared

Table 5. Effects of factors, disease (cancer versus control) and gender (male versus female)on total activity count and energy expenditure (TAC d71 and TEE kcal d71).

ANOVA summary

Factor F-value Degree of freedom p value

TACDisease 579.43 1325 50.001Gender 2.75 1325 0.098Disease6gender 49.50 1325 50.001

TEEDisease 399.37 1325 50.001Gender 0.32 1325 0.57Disease6gender 71.03 1325 50.001

Figure 4. Effects of disease (cancer versus control) and gender (male versus female) on totalactivity count (TAC). TAC of each subject obtained on daily basis was pooled separately.Means bearing the same letter are not significantly different from each other at p 5 0.05(based on Duncan’s multiple-range test).

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with the findings of earlier studies in that the researchers documented lessdemarcation between day-time and night-time activity in cancer patients sufferingfrom breast cancer (Roscoe et al. 2002), metastatic colorectal cancer (Mormont et al.2000; Mormont and Waterhouse 2002; Chevalier et al. 2003), lung cancer (Levinet al. 2005), and head and neck cancer (Pati et al. 2006). It has been reported thatrest–activity rhythm altered in early stage, which get disturbed later in moreadvanced stages in patients suffering from prostate cancer (Bartsch et al. 1994).

We observed a statistically significant circadian rhythm in PA and EE in cancerin-patients and control subjects, although rhythm detection ratio was declined inpatients. The findings are in agreement with the earlier reports in which a significantcircadian rhythm in rest activity, melatonin, and cortisol has been demonstrated incancer patients and control subjects (Mormont et al. 2000, 2002; Pati et al. 2006).Raida et al. (2002) also reported maintenance of the serum cortisol rhythm inpatients with advanced gastrointestinal carcinomas. Granda and Levi (2002)explained that circadian rhythm in rest–activity is usually maintained in slowgrowing and early stage tumor. It seems that a statistically significant circadianrhythm may persist even with disturbed sleep-activity pattern.

At the same time, in this study, alterations in the rhythm characteristics of EEand PA have been reported in patients. Lower level of activity, decreased amplitude,and shifting of the acrophase for both the studied variables has been documented incancer in-patients as compared to apparently healthy subjects, irrespective of gender.Pati et al. (2006, 2007) also reported a drastic alteration in the circadian rest–activityrhythm parameters in cancer patients. They emphasized that ‘‘these alterations couldbe attributed to disease, irrespective of variability due to gender and site of primarytumor’’.

The findings of this study also showed significant decline in TAC and TEE incancer in-patients than those of their control counterparts. Likewise, reduction hasbeen observed in cachectic patients with advanced pancreatic cancer (Moses et al.2004) and small-cell lung cancer (Gibney et al. 1997). Moses et al. (2004) explainedthe reduction in PA in terms of adaptive response that may keep a balance betweentotal energy intake and EE. However, an increase in the resting energy expenditure

Figure 5. Effects of disease (cancer versus control) and gender (male versus female) on totalenergy expenditure (TEE). TEE of each subject obtained on daily basis was pooled separately.Means bearing the same letter are not significantly different from each other at p 5 0.05(based on Duncan’s multiple-range test).

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Figure 6. Illustrative examples of actograms representing different PA intensity levels, whichare categorized on the basis of accelerometer thresholds, in cancer in-patients (a and c), andcontrol subjects (b and d). Abscissa depicts clock hour. Each row represents 24 h span, i.e. fora given day. The upper line shows the cutpoint for the moderate to vigorous activity (0.083)and the lower line shows cutpoint for light to moderate activity (0.031). Actograms of cancerin-patients reveal lower activity level than the controls.

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(REE) has been documented in patients with pancreatic cancer (Falconer et al. 1994;Moses et al. 2004) and gastrointestinal tumors (Bosaeus et al. 2002). These authorsemphasized that increased REE is on account of hypermetabolic rates because oftumor burden and host tumor competition. Increased metabolic rate is a significantcomponent behind weight loss in cancer disease. Thus, the decreased level of EEinfluences nutritional status and day-to-day functional abilities of cancer patients.

Figure 7. Comparison of different PA intensity levels (total activity count), namelySedentary (a), Light (b), Moderate (c), and Vigorous (d) between cancer in-patients andcontrol subjects.

Figure 6. (Continued).

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Energy balance represents the difference between energy intake by eating and EEthrough PA. However, in this study, we did not determine the REE, though it is animportant parameter that may be helpful in preventing weight loss of cancer patients.Further, in this study, gender as an independent factor did not produce any significanteffect on TAC and TEE. However, the Duncan’s multiple range tests showed that TACand TEE were significantly higher in males than their female counterparts in bothcontrols and patients. Ferraro et al. (1992) also reported higher 24-h EE in healthymales as compared to healthy females. Results of ANOVA, in this study, can beexplained in terms of masking effect of the factor disease on gender.

A noticeable low level of PA has been witnessed in cancer in-patients. Thepatients were admitted to receive chemotherapy, therefore, they spent more time insedentary condition, although they were ambulatory within and outside the ward inthe premises of the hospital. Under such circumstances a decreased level of activitymay be apparent. A previous study also demonstrated a similar pattern of decreasedactivity in small-cell lung cancer patients (Gibney et al. 1997). Courneya andFriedenreich (1999) and Irwin and Ainsworth (2004) reported that PA has positiveeffect on biological and physiological processes. Nowadays greater attention is beingpaid to the research by considering PA for treatment of cancer. It has beendocumented that PA plays an important role to reduce fatigue, improve physicalfunctioning, and improve QoL in cancer patients during and after cancer treatment(Luctkar-Flude et al. 2007). Slattery (2004) and Meyerhardt et al. (2009) showed thatgreater PA was associated with lower risk of colorectal cancer and overall mortality.About 30–60 min of moderate to vigorous PA per day is needed to protect againstcolon cancer. Physical activity was also found to be associated with better QoL andprolonged survival in female patients with breast cancer (Ogunleye and Holmes2009). On the basis of above findings we should also integrate the PA as a part of thetreatment along with the drug therapy given to cancer patients of this region.

Furthermore, it has been reported that overall level of PA and EE decreasedsignificantly when patients received chemotherapy (Demark-Wahnefried et al. 1997).They suggested that chemotherapy may aggravate the changes in the metabolism ofbody, which eventually affect the energy balance. This could be another possibleexplanation for lowering of the activity level in patients in this study.

With reference to PA intensity levels a gradual reduction from sedentary tovigorous has been witnessed in cancer in-patients. Activity count under sedentarycondition was significantly higher in patients as compared to controls. It seems thatpatients had more restlessness during their sleep period. Similarly, Irwin et al. (2003)found a significant decrease in total, moderate-intensity and vigorous-intensity PAafter the diagnosis of breast cancer. However, there is a paucity of peer studies insupport of the present findings.

To conclude, the findings of this study indicate disruption of the CTS of PA andEE characterized by the lower mean value, lower amplitude, and advancement ofpeak timings. However, further intensive studies involving more patients arerequired to strengthen the above conclusion.

Acknowledgements

Financial assistance from University Grants Commission (UGC), New Delhi, India isgratefully acknowledged. We are very much thankful to Dr. A.K. Pati, Professor and Head,School of Life Sciences, Pt. Ravishankar Shukla University, Raipur, who read the draftversion of this article and offered valuable suggestions, and for providing us with the adequate

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research facilities. We are grateful to the cancer in-patients and control subjects for theirvoluntary participation in this study.

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