Discussion
This study aimed to describe the dietary intake and dietary quality of children during their treatment for cancer. The dietary data collected in this study suggests that children receiving cancer treatment are consuming diets of reasonable quantity, but poor quality. There were some potential inadequacies of nutrients, and under-representation of core food groups were seen amongst most of this childhood cancer population. This study also found that many parents reported that their children were able to eat what they liked and did not experience issues with treatment related side effects such as nausea or vomiting.
Overweight and obesity and its consequent inflammation is linked with the sequelae of metabolic diseases 41 of particular concern in childhood cancer survivors as rates of these disease are higher in this group 15. Our study found half of the children being treated for cancer were consuming greater than 110% of their energy requirements. It appears that for some patients, the excessive energy intake seen at the end of treatment is manifesting during treatment 19. Excessive energy intakes resulting in weight gain places a childhood cancer survivor at an even higher risk of developing a chronic health condition post treatment completion 42. A recent study has shown that it is possible to prevent excessive weight gain with a targeted nutrition intervention during maintenance therapy 43 though it may be that targeted interventions need to occur during early cancer treatment 23.
Comparisons to normative data from the Australian Health Survey suggest that fruit and vegetable intake of childhood cancer patients was greater than that of Australian children in the general population, primarily related to intake of discretionary foods, with fruit juice contributing to more than half of total fruit intake. Vegetable based discretionary foods including takeaway fries and chips comprised the majority of discretionary vegetable intake suggesting that total vegetable intake was of a poor nutrient quality. Given the role that adequate food intake of core vegetables, fruit and whole grains play in prevention of chronic disease 44, assisting families to improve diet quality in these food groups is important. Additionally, consuming a nutrient rich diet comprised of fruits, vegetables and whole grains may contribute to long-term weight maintenance among survivors of childhood cancer 45.
The goal of both parents and clinicians working in paediatric oncology until now has been the prevention of weight loss through the use of a high energy diet 46. This may encourage an ‘anything goes’ approach to intake, particularly intake of high energy foods. (11) Many nutrition information resources encouraging consumption of discretionary foods, including those high in saturated fat such as ice-cream, hot chips and fortification with butter and cream. Given that these poor dietary habits established during cancer treatment may persist into adulthood (3), a shift in focus from merely weight and weight maintenance is required. Specifically, clinical teams need to assist in establishment of good dietary habits, while managing side effects and barriers to achieving adequate intake. It may also be that dietary advice during cancer treatment may need to be targeted depending on treatment intensity and the potential for nutrition-related side effects. Focussing on dietary quality 23 while still avoiding malnutrition, both under- and over-nutrition15,20, is required.
There will still be some patients who receive high intensity treatment and are therefore known to have a high nutrition risk disease. This increases their likelihood of requiring supplementary nutrition, and a continued focus on the prevention of weight loss is required. However, for other paediatric oncology patients the nutrition therapy may need to be altered. Specifically, this may require a shift away from monitoring weight only and instead reviewing the nutritional value of the whole diet, working with families to manage food related treatment symptoms, and establishing long-term healthy dietary patterns to avoid risks to long-term health 15,20. Barriers to intake such as fussy or picking eating, are often not unique to sick children (27). In fact, one study found very few differences in eating and mealtime behaviours between children receiving cancer treatment and healthy children (27). This suggests that nutrition information for parents of children with cancer should not necessarily be dissimilar to regular messages provided to parents including eating a healthy, balanced diet, establishing good eating habits, and consuming fruits, vegetables, and wholegrains.