Table 2 List of adaptations

Behavioral and environmental fit

Shifting the focus from weight loss to healthy eating and physical activity

Emphasize the importance of healthy lifestyle on overall HRQoL

Acknowledge the difficulty of behavior change given the symptoms and side effects burden

Keep their health care team updated of any weight changes > 5%

Diet quality: Stronger focus on a plant-based diet (based on vegetables, fruits, whole grains, beans,nuts and limiting the amount of red and processed meat, other processed foods, salt, added sugars, refined grains, and saturated fats)

Diet quantity: Portion recommendation based on a 2.000 kcal diet. “Cut down on quantity” section rephrased to “Keep an eye on portion sizes” with respective changes in food portion recommendations

Physical activity: Emphasize the link between physical activity and cancer and its benefits particularly for cancer survivors

Addition of muscle strengthening exercises

Addition of section on sleep hygiene

Update of the suggested cookbooks

Reference to potentially useful mobile applications

Determinants and change methods fit

Addition of practical applications:

• Understanding the risk benefits of supplements

• Approval of the booklet content from cancer nurses

• Recognize ways of maintaining a balanced diet in the presence of bowel symptoms

• Recognize ways of avoiding risk for food born-illnesses

• Be prompted to carry wallet-size cards with healthy and unhealthy options in various types of restaurants

• Be prompted to identify the triggers for unhealthy eating and generate a strategy to overcome them (e.g. do not skip meals before going to a party to avoid overeating)

• Know about the link between physical activity and sleep

• Provide pictures of cancer survivors demonstrating sample strength, balance, and flexibility exercises and instructions of how to perform those

• Practice some of the resistance exercises during the session following the booklet’s instructions

• Be prompted to identify the triggers for sedentary behaviors and generate a strategy to overcome them (e.g. have an alternative PA plan in case of foul weather)

• Understand what fatigue is

• Select strategies from a list of suggestions to help them overcome fatigue and facilitate physical activity

Removal of practical applications:

 • Recognition of the various factors that influence weight and the health consequences of obesity

 • Differentiate refined and unrefined carbohydrates and low/high GI

 • Calculate % calories from fat in food and compare it with guidelines

 • Recognize the value of healthy range of weight rather than an ideal weight and the benefits of gradual weight loss

 • Set a realistic weight goal (either loss or maintenance) as an outcome of changed eating and physical activity patterns

 • Receive advice to weight themselves on a regular basis that they will decide upon

 • Record weight in the diaries

 • Demonstrate BMI calculation

 • Apply the BMI to their own weight and height and] compare it with standard cut-offs

 • Recognize the connection between weight control and PA

 • Recognize approximate energy expenditure (kcal) for various lifestyle activities

Design, delivery, and cultural fit

Addition of motivational quotes from other cancer survivors

Addition of cancer-specific resources (e.g. Macmillan Cancer Support)

Addition of recommendations for managing fatigue and bowel issues

Addition of a section on healthy lifestyle specifically for endometrial cancer survivors

Implementation fit

Addition of short briefing about the adapted program in the facilitators’ training