Physical activity, stress reduction, and nutrition interventions in cancer survivorship contribute to positive physical and psychosocial outcomes (1–3). For men with a diagnosis of prostate cancer, the evidence shows improvements to overall fitness, body composition, mental health, quality of life (QOL), and fatigue (4–9). Moderate and vigorous physical activity has also been linked to decreased mortality rates relating to prostate cancer (10–13). On the basis of current evidence, cancer-specific exercise guidelines have been developed from national governing bodies (4,14–16). A growing body of evidence describes the numerous benefits of physical activity during and after prostate cancer treatment (17). Despite this, a significant gap remains in the translation of this evidence into practice. Within Canada, integration of formal cancer-specific wellness programs is limited, as are exercise specialists with cancer-specific training within standard cancer care. This gap is especially problematic for prostate cancer survivors living with comorbidities associated with the disease and/or treatment.
Translational work aimed at developing evidence-based programming is required to address limitations and accessibility barriers currently faced by prostate cancer survivors seeking integrated supportive care. As protocols using multidisciplinary wellness programming for this population continue to be developed, reviewed, and vetted nationally (5,13), a concerted effort is required to translate this body of knowledge into programs that can be accessed by survivors in the community, as well as systemically integrated on a national scale.
TrueNTH is a global initiative to improve the QOL of all men with prostate cancer through action-oriented initiatives (18). Funded by the Movember Foundation, and delivered in Canada by Prostate Cancer Canada, TrueNTH aims to develop and deliver evidence-based solutions for issues that challenge the health and well-being of men living with prostate cancer, such as sexual health, health-system navigation, managing symptoms of androgen deprivation therapy, and lifestyle management (LM). In Canada, there are nine teams composed of researchers, clinicians, and patient advocates tasked with developing solutions to meet the needs of prostate cancer survivors in the Canadian context (19).
The focus of the TrueNTH LM solution is on improving survivor access to evidence-based prostate cancer wellness (physical activity, stress reduction, and nutrition) programs, resources, and professional advice in both community and online environments. The purpose of this article is to describe the development and piloting of a community-based program model for prostate cancer–specific physical activity, nutrition, and stress reduction (i.e., yoga) programming that comprise the TrueNTH Lifestyle Management solution.
All program procedures were approved by the Health Research Ethics Board of Alberta—Cancer Committee (HREBA.CC-16-0226).
Theoretical approaches used in the protocol development of TrueNTH LM have four overarching aims: 1) to develop a patient-centered program delivery model; 2) to develop/guide a contextually appropriate process for translating research into practice; 3) to develop communication strategies that are responsive to patients, healthcare, and wellness professionals; and 4) to conduct effective program evaluation. The overarching application, dissemination, and promotion of LM initiatives are guided by the Social Ecological Model, which has been used in similar multilevel and multistakeholder health initiatives (20). Social cognitive theory was used for dissemination and communication strategies with patients, healthcare, and wellness professionals (21). Educational resources, tools, and the overall structure of the program design use the transtheoretical model of behavior change (22). This approach specifically focuses on the development of patient-centered programming and messaging that is flexible and progressive. The transtheoretical model of behavior change helps foster individual capacity at different stages of behavior change to encourage the development of participant self-efficacy through stage progression. The promotion of self-efficacy is necessary for individuals to sustain long-term behavior change (23), which is a key component of the TrueNTH LM solution.
Progress in both public health and community-based interventions can be hampered by a lack of framework to effectively evaluate such programs (24). As such, the RE-AIM framework, which was originally developed to examine the effect of behavioral interventions on public health (i.e., programs, policy, and practice) in real-world, standard practice settings (24), was across all developmental stages of the TrueNTH LM solution. The five areas of focus included in this framework are reach, effectiveness, adoption, implementation, and maintenance. Using RE-AIM helped to address key issues associated with strategic development of dissemination and implementation of program initiatives and provided a balanced approach to examine the internal and external validity of TrueNTH LM solution.
Review of Existing Programs, Resources, and Literature
An initial scoping review was conducted of existing programs, resources, and literature involving wellness programs and interventions for prostate cancer. Specifically, three independent searches were conducted pertaining to men with prostate cancer and 1) physical activity/exercise, 2) nutrition, and 3) stress reduction/mindfulness. Prostate cancer–specific programs and interventions using physical activity, nutrition, and/or stress reduction modalities alone or in combination were also included. Searches used NIH-NLM MEDLINE/PubMed, Elsevier-Embase, APA-PsychINFO, Allied and Complementary Medicine, Google Scholar, and Cochrane Database of Systematic Reviews. Methods were examined, and those using an intervention protocol delivered by trained professionals were further evaluated to determine effectiveness. All scientific reviews (4–9,13) and/or accredited organizations/colleges offering evidence-based guidelines and recommendations pertaining to prostate cancer were also examined (14–16).
In addition to this review, a series of environmental scans have been conducted to review open-access educational resources and associated gray literature. The utilization of evidence in the development of each identified resource was examined to determine their appropriateness for use within the scope of TrueNTH LM solution. Industry professionals and organizations offering wellness programs and resources for prostate cancer survivors were also identified and contacted for possible collaboration (n = 15, see Table 1). Outreach of this nature helped identify additional resources to supplement existing care for prostate cancer survivors.
A final environmental scan identified gaps in existing educational resources, programming, and referral processes that could be addressed within the LM solution. Evidence collected throughout the scoping review has since been synthesized and used to create a foundational framework to guide the development of LM resources and professional training curriculum (Table 2).
Lastly, two industry workshops have been held in Central (Toronto) and Western (Calgary) Canada to gain additional insight into the various logistics that would need to be addressed within community-based facilities (i.e., availability of equipment and staff certification levels) to support the development of a pragmatic and feasible program design (25). Both workshops involved multidisciplinary “Expert Champions” (i.e., physical activity, nutrition, and stress reduction researchers and practitioners specializing in prostate cancer care). Data collected from these workshops have been used to further inform LM processes for identifying suitable community-based partners and establishing formal agreements with each delivery sitec training and supporting health and fitness professionals to deliver the LM programming, engaging men with prostate cancer to participate in the program, screening participants to ensure their safety for exercising in community-based fitness facilities, and program evaluation.
Community-based Intervention Sites
Community-based LM intervention sites are identified, and eligible fitness professionals are invited to participate in a specialized training program at no personal cost. All delivery sites are required to have a qualified fitness professional—typically a certified exercise physiologist (CEP) accredited by the Canadian Society of Exercise Physiology (CSEP) or equivalent—involved in either direct facilitation of classes or via supervision of facilitators with other certifications (e.g., certification from a National Fitness Leadership Alliance organization, or a certified personal trainer [CPT] by CSEP). Fitness instructors involved with delivering the intervention are required to complete comprehensive training specific to prostate cancer and the TrueNTH LM solution, thereby ensuring programs were delivered safely and consistently by qualified personnel.
Facilitator Training Program
In collaboration with Thrive Health Services (www.thrivehealthservices.com), an evidence-based cancer and exercise training program has been implemented for credentialed health and fitness professionals. Program delivery is guided by a comprehensive cancer and exercise training curriculum (26) and includes online and in-person training components. Material completed online (approximately 12 h) includes a review of the cancer and exercise evidence and guidelines, screening and evaluation, exercise prescription, psychosocial considerations, health behavior change considerations, class management techniques, and training adaptations to accommodate side effects and comorbidities. Following successful completion of these modules, optional in-person training is also available to facilitators upon request. These 8-h sessions are delivered by members of the central TrueNTH LM team and focus on developing practical skills for class facilitation, as well as delivery logistics and strategies for promoting participant adherence to maximize survivor satisfaction and health outcomes (27). The scope of the material covered in the online and in-person training provides program facilitators with the skills and experience necessary to deliver the 12-wk intervention within the TrueNTH LM framework. A yoga-specific professional training program has also been developed (Yoga Thrive Teacher Training, University of Calgary and The Yoga Effect Calgary ) and is delivered in a similar format for the yoga instructors within TrueNTH LM.
Group Exercise Classes
The intervention is designed as a 12-wk physical activity program delivered to participants in 60-min supervised group-based classes twice a week. This format has been chosen to facilitate interaction among survivor peers for enhanced emotional support and other psychosocial benefits of participation (29). The classes consist of either (a) a combination of mild to moderate/somewhat hard-intensity aerobic and resistance training or (b) gentle yoga with cooldown and meditation (i.e., savasana). The number of participants per group is limited to a maximum ratio of 1 facilitator per 15 participants. Group sessions are either exclusive to prostate cancer survivors, or, at the discretion of community facilitators, open to support persons (i.e., spouses and adult family members) and survivors diagnosed with other forms of cancer. Prostate cancer survivors are offered the initial 12-wk program at no cost; however, maintenance programs transition to a fee-for-service model for all participants, with the fee being determined by the host site. Maintenance fees varied depending on length of maintenance program (10–12 wk), times per week (1,2), and access to additional resources at the facility (i.e., full membership to access the facility or only access to the maintenance class). If applicable, support persons and survivors from other tumor groups are also subject to program delivery fees. Eligibility criteria is broad, with the program open to all men previously diagnosed with prostate cancer and cleared for unrestricted or progressive physical activity.
Group exercise classes consist of resistance training exercises presented in small circuits (i.e., 3–4 exercises) with adapted plyometric aerobic activities to integrate high-intensity interval training (30). Facilitators are trained to follow the structured protocol, with specific exercise order, volumes, and work-to-rest ratios (see Table, Supplemental Data Content 1, FITT exercise recommendations for prostate cancer survivors used by TrueNTH LM, http://links.lww.com/TJACSM/A22). The class protocol uses exercises that can be completed with minimal equipment, specifically using modalities such as exercise bands and balls, body weight, and free weights (30). All exercises can be adapted to accommodate individual preferences and limitations and follow a progressive trajectory to achieve recommended targets for resistance training in men with prostate cancer (4,7).
Each exercise is performed together as a group so that the trained facilitators have the opportunity to monitor participant form, correct technique errors, and provide modifications as required. Participants are instructed to self-monitor the intensity of their session throughout the session using the 0–10 Borg rating of perceived exertion scale (30), with the aim to monitor intensity level from mild to moderate/somewhat hard-intensity levels through the duration of the class. Fatigue and energy “thermometers,” modeled after the 0–10 Borg rating of perceived exertion scale, are formally completed by participants at the beginning and end of each class as a way of monitoring and potentially modifying exercises and intensity levels for each participant.
Facilitators are taught exercise modification using a “traffic light” analogy (31). Each exercise is first presented at a moderate intensity (or “yellow light”) and can be modified to a lower difficulty level (“red light”) or a higher difficulty level (“green light”) as indicated by the participant. If individuals feel limited on any given day due to fatigue or other issues, they are encouraged to reduce intensity to light (“red light”) activity levels to avoid over exertion and the potential for increasing fatigue (30).
Stress reduction (Yoga)
The inclusion of group yoga classes into the program design is meant to encourage mindfulness and stress reduction. It is delivered in 1-h weekly group class session and is designed based on previous prostate cancer–specific protocols (32) and established yoga for cancer survivor programs (33). The yoga classes are intended to be completed at a light or “gentle” intensity with a brief mindfulness practice included during a final period of resting supine meditation (savasana), guided by the instructor with the use of meditation scripts. The selection and order of poses incorporate passive pelvic floor muscle training techniques. Classes are delivered in a progressive manner; therefore, the complexity of posture sequencing increases each week. Yoga instructors also use the “red, yellow, green light” cueing system to understand the individual capacity of participants and to modify their poses accordingly.
Nutrition Education Protocol
Nutrition recommendations for men living with prostate cancer follow the same plant-based, heart healthy diet recommendations for the prevention and treatment of cardiovascular disease (34). This prioritizes the consumption of fruits and vegetables, whole grains, legumes, lentils, nuts, and seeds over foods derived from dairy and meat sources (34). On the basis of resources previously created by Canadian organizations such as Prostate Cancer Canada (34), the nutrition education has been developed by two Registered Dietitians with prostate cancer and nutrition experience (CB and CVP). These are delivered to participants via 12 handouts presented on a weekly basis with content designed to serve as a complement to the existing resources. In addition, community partners are encouraged to establish a relationship with local registered dietitians to facilitate individual consultations and/or group seminars.
All TrueNTH LM educational resources are designed to facilitate healthy behavior change and maximize survivor motivation to engage in physical activity and promote adherence to wellness programming (21–23). Infographics and other resources are tailored for biweekly delivery over the 12-wk program. Facilitators are provided with materials to distribute to participants along with instructions on how to integrate the educational topics into their class plans. A full summary of the physical activity, yoga, nutrition, and educational programming can be seen in Table 2.
The RE-AIM framework is a widely used program evaluation method for health promotion initiatives and is consistently used for reporting results within the field of implementation and dissemination research (24). RE-AIM assists in knowledge translation when research is applied into real world/practical settings, providing a framework to examine the strengths and weaknesses in both the application and dissemination of evidence-based programming (24). A pilot study to demonstrate the feasibility of the program design in different community settings was undertaken in advance of national dissemination efforts, with the RE-AIM elements of reach and effectiveness specifically addressed within the pilot evaluation.
To ensure proper evaluation of the pilot’s “reach,” the 12-wk protocols were implemented over a 1-yr period at locations representative of the types of facilities that would be targeted in the national dissemination phase. This consisted of a clinical and postsecondary setting (Calgary, AB), civic recreation and wellness centers (CRWC; Calgary, AB), and a private fitness center (PFC; Halifax, NS). Recruitment at each location began once facilitators completed training and the program could be scheduled into the site’s existing calendar. The clinical and postsecondary location (C/PS) recruited participants on an ongoing basis over a 3-month period, with programming running for a total of 6 months (using a multipurpose room with exercise equipment). The CRWC programs recruited participants for a 3-month period, with programming occurring at three different locations with similar start dates. The PFC program was recruited for a 6-month period with two programs taking place over a 6-month period.
Recruitment methods occurred primarily through presentations given to local support groups and cancer care centers, as well as via self-referral from posters, brochures, and community center program guides. All materials in Calgary referred individuals to contact the Health and Wellness Lab at the University of Calgary, Faculty of Kinesiology, whereas Halifax materials referred individuals to the Kinesic Sport Lab.
To assess the “effectiveness” component of RE-AIM, standardized testing protocols were implemented. Specifically, all participants underwent physical assessments at baseline and 12 wk, using a protocol combining tests from the CSEP-Physical Activity Training for Health (35) and Senior Fitness tests (36) that were deemed most appropriate for the characteristics of the prostate cancer population. Physiological measures of resting heart rate and blood pressure were gathered immediately before any tests to ensure participant readiness for testing that day. Body composition and anthropometric measures included weight, height, BMI, waist circumference, and hip circumference. Musculoskeletal fitness tests included those for strength (i.e., grip strength), endurance (i.e., 30-s sit to stand, push-ups), balance (i.e., unipedal stance, 8-foot timed up-and-go), and flexibility (i.e., sit and reach). Functional aerobic capacity was gathered through the 6-min walk test. All testing was performed by a CSEP-CEP in a one-on-one (C/PS site) or small group (CRWC and PFC sites) setting. In addition, psychosocial outcomes were measured through the completion of a questionnaire package at each time point. This included measures of perceived QOL (FACT-P and EQ-5D) and weekly reported physical activity (Godin Leisure Time Exercise Questionnaire) (37–39). All participants underwent initial screening, were cleared for unrestricted or progressive physical activity, and provided informed consent. Participants were not required to attend any minimum number of classes during the 12-wk period. Upon completion of the intervention, participants had an option to continue attending group exercise classes for an additional 12 wk (i.e., maintenance program). Printed packages of education handouts were distributed to each participant following the baseline assessment.
Evaluating the effectiveness of the pilot allowed for the investigation into whether the proposed community-based programming structure demonstrated levels of effectiveness similar to that seen in previous literature. Therefore, no a priori power calculations were used to inform sample sizes, and registration numbers were not capped for inclusion into the program. All statistical analyses were conducted in SPSS Version 24.0 (Chicago, IL). Changes in each of the physical and psychosocial outcome measures from baseline to 12 wk were analyzed using two-sided paired t-tests with a significance factor of P < 0.05. Participant success in reaching the American College of Sports Medicine (ACSM) weekly activity guidelines was analyzed using the Wilcoxon signed-rank test.
A summary of participant clinical descriptive information can be found in Table 3, and participant demographics are summarized in Table 4. The most common sources of participant referral were from community presentations given by program delegates to survivor groups (i.e., within clinics or at support groups) or from survivors being given information on the programs from cancer care staff (Table 3). The age of the cohort was (65.6 yr), and the majority were Caucasian, with a higher education and socioeconomic level (Tables 3 and 4). The number of eligible individuals and the treatment rates in each community were not available but a varied sample of participants joined the programs. In fact, 21% of the participants were still on active treatment when they signed up, whereas 28% had gone more than a year since their last treatment (Table 3).
Of the 58 survivors who enrolled, 32 participants (55%) completed baseline and 12-wk questionnaires and 39 participants (62%) completed pre- and postintervention fitness testing. The average class attendance for the C/PS site was 26% (6.3 ± 7.8) for fitness classes and 27% (1.6 ± 2.2) for yoga classes, 53% (9 ± 3.2) fitness attendance and 36% (1.8 ± 1.4) yoga attendance at the PFC site, and finally 50% (6 ± 4.4 fitness; 6 ± 3.7 yoga) attendance for both class types at the CRWC sites.
A summary of psychosocial and physical results for pooled data with participants from all sites can be found in Table 5. A trend toward improvements in QOL was seen over the 12-wk period (FACT-P Trial Outcome Index P = 0.07), whereas significant improvements were seen in multiple physical outcomes. This included body composition (waist-to-hip ratio: P = 0.02), functional aerobic capacity (6-min walk test: P = 0.02), flexibility (Sit and reach test: P = 0.00), dynamic balance (8-foot timed up-and-go: P = 0.00), and lower body muscular endurance (30-s sit-to-stand: P = 0.03). A trend toward improvement was also seen in the key physiological outcome of grip strength (P = 0.08). In addition, health behavior improvement was seen through an increase in reported weekly physical activity minutes (Godin Leisure-Time Exercise Questionnaire: P = 0.00). In addition, individuals who were on average not meeting the ACSM physical activity guidelines of 150 min of weekly moderate/vigorous activity (15) at baseline reached this level postintervention (Godin Leisure-Time Exercise Questionnaire: P = 0.00). However, there was large variability around this mean change (baseline: 56.1 ± 51.8 min; postintervention: 168.4 ± 128.9 min). No adverse events were reported throughout the duration of the pilot at any site. A total of 38 men (65%) reported that they continued with maintenance programming, either within the provided group setting of the TrueNTH LM or by enrolling in a new activity option following the intervention.
Finally, although not formally examined, the RE-AIM components of “adoption” and “implementation” were also addressed in the pilot through the unique delivery and logistical characteristics observed for each site. Although all of the 12-wk exercise programs offered a minimum of two group physical activity classes on a weekly basis, the exact frequency and modalities differed at each location. The C/PS site recommended attending two classes a week but offered three different time options, with a yoga class being offered every 2 wk. The CRWC site offered one fitness class and one yoga class each on a weekly basis. The PFC site offered two fitness classes each week as well as an additional yoga class every 2 wk. Beyond the class delivery characteristics, the background credentials for each facilitator also varied between locations. Although all fitness or yoga instructors received the cancer and exercise training, the fitness classes at the C/PS and PFC sites used CSEP-CPTs with extensive experience working with the population, whereas the CRWC classes were run by National Fitness Leadership Alliance certified instructors with previous experience in older adult group class facilitation.
Previous literature and guidelines for wellness activities specific to older adults and cancer survivors (1–4,14–16) have described the effectiveness of interventions. Recent findings also demonstrate the positive effect that an active lifestyle can have on health outcomes for men diagnosed with prostate cancer (11). However, a gap exists in translating the evidence into real-world programming opportunities (17). TrueNTH LM provides a framework to guide feasible and sustainable community program implementation to enhance wellness for prostate cancer survivors. This work also represents the initial steps (pilot work) to prepare for the delivery of evidence-based wellness programming to an oncology population on a national scale. Lessons learned through the development of community-based protocols and professional trainings can be applied to future wellness programming, including the determinants of appropriate scalability at the national level.
The physical and psychosocial results from the pilot phase of the project were comparable with the expected outcomes synthesized previously in a systematic review and meta-analysis from Bourke et al. (4). In addition, results were similar to those seen in general cancer programs hosted in community-based settings (40). Given potential differences between the various pilot sites due to the pragmatic design of the program and the differences in protocol execution by each host facility, seeing overall results consistent with previous literature that has primarily implemented and tested single community-based sites is encouraging. Findings such as these not only demonstrate the feasibility of community programming specific for prostate cancer but also show that programming applied within practical, real-world constraints can be effective. Future work on the TrueNTH LM program will provide continued examination of larger data sets to examine such issues as the relationship between adherence and outcomes, as well as potential site differences.
Multiple aspects of this initiative improved accessibility to prostate cancer–specific wellness resources. The physical activity, nutrition, and yoga program designs translate the most current evidence into programming designed to be implemented in varied community settings. The educational resources available to both survivors and professionals promote behavior change strategies both within and outside group classes. Finally, the professional trainings increase the number of fitness and yoga professionals providing evidence-based class facilitation to cancer survivors, thus improving overall access for survivors.
The main limitation in the program design originates through the purposeful introduction of pragmatic program delivery and the inherent inconsistencies associated with this philosophy. Although this flexible structure is a strength in terms of future adoption and sustainability, it must be acknowledged that this pragmatic approach also results in slight deviations from the previous literature. For example, adherence to group classes varied considerably between the three sites within the pilot. The underlying reasons may include facility characteristics (i.e., parking or location accessibility), instructor background and interpersonal skills, scheduling (i.e., season of delivery and time of day), and survivor demographics (i.e., time since treatment). However, as long as the main tenants of the program structure are followed, such as screening, program design principles, and the presence of trained facilitators, it is not unreasonable to expect that programs can be consistently effective and safe across diverse settings and populations.
Another potential limitation to further dissemination of community-based programming seen through the pilot phase is the reach of the initiative. This structure is not immune to the unavoidable selective sampling inherent with most interventions, such as a bias toward participants being from urban settings and predominantly Caucasian and of a higher socioeconomic status. However, potential new sources of bias were also observed, with employment status, marital status, and treatment profiles as examples. For instance, pilot offerings were nearly all offered during business hours, likely precluding more full- or part-time employed survivors from taking part. Trends of survivors from specific treatment backgrounds were also seen, likely based on the referral sources promoting the program and treatment trends in each community. At the C/PS pilot site, for example, the vast majority of participants had completed treatment, potentially due to referrals originating from community presentations given to support groups for men. Also, in Halifax, the rates of participants who had received radiation were greater than those in either Calgary site. Such limitations need to be accepted as inherent with clinic-to-community models; however, systematic referral across sites, ensuring all men have the opportunity to engage in wellness, may reduce differences across locations.
Programming in the pilot phase was covered by the grant. Although this characteristic can be perceived as a strength in establishing the program, it may affect the motivation of participants to attend class. In addition, free programming is not a sustainable model for community partners. Thus, as part of the “maintenance” component of RE-AIM, the TrueNTH LM team worked with each of the pilot sites to implement a user-pay model for maintenance activity options based on cost-recovery.
TrueNTH LM presents an unprecedented level of comprehensive infrastructure for community-based programming specific to the needs of men with prostate cancer. Future participant and program sustainability outcomes will be evaluated within the RE-AIM framework. Table 6 presents a summary of the outcomes, measures, and data sources that will be used, with data collection occurring at baseline, 12 wk, 24 wk, and 1 yr. The effectiveness of several traditional data administration and collection strategies will also be examined within the community setting. For example, depending on program logistics (i.e., personnel, time constraints, and participant preferences), sites can collect questionnaire data locally via article and pen, online through a secure website or link, or online or through mail channels through fillable and printable pdf files. In addition, screening data can be administered either in person, over the phone, or online.
Practical wellness programming using several evidence-based modalities presented in community-based settings by trained instructors has the potential to result in sustainable and feasible clinic-to-community care models. The national scale of the TrueNTH LM initiative provides an opportunity to undertake unprecedented RE-AIM evaluation of community program implementation and dissemination.
Dr. Culos-Reed is the cofounder of Thrive Health Services. The remaining authors declare they have no other competing interests to disclose.
TrueNTH Lifestyle Management is a program developed by the Faculty of Kinesiology, University of Calgary, in partnership with core investigators at the Faculty of Kinesiology and Physical Education, University of Toronto, and Kinesic Sport Lab in Halifax. Additional community partners include professionals in British Columbia, Alberta, Manitoba, Ontario, Quebec, Nova Scotia, and Newfoundland. Funding was provided by the Movember Foundation as a part of the Global TrueNTH initiative (previously “A Survivorship Action Partnership”), awarded in Canada by Prostate Cancer Canada. The results of the present study do not constitute endorsement by the ACSM.
The authors thank all of the expert and regional champions, staff and students, and healthcare advocates who have contributed to the development and dissemination of TrueNTH LM. SNCR, AZ, and DSM were involved in the initial grant application and conception of TrueNTH. SNCR, with assistance from MD, established the methods, data collection procedures, and dissemination procedures. SNCR, AZ, and DSM were involved in the development of the physical activity content; CB and CV were involved in the development of the nutrition content; and TA and MM were involved in the development of the stress reduction content. KW provided project team management and manuscript development.
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