Abstract
Background The long-term
impact of childhood cancer treatment on dietary intake is likely to be
complex and the length of time dietary behaviours are affected after
childhood cancer treatment is unknown. Aim The aim of this
study was to determine the diet quality in childhood cancer survivors
recently off treatment and identify possible contributing factors that
may affect diet quality in this population. MethodsParticipants were 65 parents and/or carers of childhood cancer survivors
(CCS) (aged 2-18 years), recently off treatment and 81 age-matched
controls. Methods Participants completed two self-administered
dietary intake and eating behaviour questionnaires. Study data was
explored to determine between group differences, bivariate analysis
using Spearman’s correlations was used to determine the relationship
between diet quality and identified variables, and hierarchical cluster
analysis was completed to characterise specific variables into clusters.Results CCS had a significantly poorer diet quality score than
the age-matched controls (t=-2.226, p=0.028). Childhood cancer survivors
had significantly higher parent-reported rates of ‘picky eating’
behaviour than the control group (t=0.106 p=0.044). Factors such as
picky eating, emotional overeating and Body Mass Index z-score appeared
to drive diet quality in survivors. Conclusions A CCS with
picky eating behaviours could avoid complete food groups, have strong
food preferences/aversions and over- consume high energy foods to
maintain their energy intake, possibly affecting diet quality.
The outcomes highlighted the need
for a tailored intervention aimed at improving healthy eating behaviours
in CCS after treatment for cancer.
Background
Many children with cancer are diagnosed in the first 10 years of life(1). This developmental period includes several key
phases of eating and cognitive development which contribute to food
preferences, diet intake, energy intake and eating patterns as children
grow older (2). The
development of food preferences occurs through the interaction of foods,
sensory cues (olfactory, tactile and visual sensory systems) and the
consequence of ingestion, which may elicit a positive or negative
response to the food(2).
Eating is an essential human activity, yet evidence from the general
paediatric population suggests that up to 40% of children aged 3-6
years old experience mealtime
difficulties(3) and 25%
have feeding disorders, which can affect a child’s diet
quality(4). Feeding difficulties in young children can
range from chronic feeding disorders to more common behaviours such as
food refusal, food aversion, excessive mealtime length, inappropriate
behaviours and picky
eating(4). A child with
picky eating behaviours can avoid complete food groups, have strong food
preferences/aversions, over-consume high energy foods to maintain energy
intake and demonstrate an unwillingness to try new foods(3).
As in the general paediatric population, children receiving cancer
treatment can also have feeding difficulties and poor diet quality
during treatment (5), with the consequences having the
potential to be magnified in this population. Weight loss during
treatment is associated with poorer clinical outcomes such as impaired
immune competence, increased susceptibility to infection, reduced
treatment tolerance leading to dose reductions and treatment delays,
increased side-effects, decreased wound healing and reduced quality of
life (6-9). Despite the impact of cancer treatment
toxicities, which can result in the child feeling nauseated and unwell,
parents often pressure their child to eat during this stressful time to
maintain weight during childhood cancer treatment(10). Parent pressure, coupled with food becoming
associated with treatment side effects of vomiting/nausea and
taste/smell changes can lead to learned food aversions during treatment,
restricting adequate intake and compromising diet
quality(10,
11). During cancer treatment, young
children are unable to differentiate between the impact of the disease,
treatment and side effects on their eating, placing patients at a high
risk of ongoing adverse eating
behaviours(12).
With significant therapeutic
success and a resulting increase in survival outcomes, the medical
challenge has become the minimisation of the secondary effects of cancer
treatments (13). One of the most significant findings
of childhood cancer survivors (CCS) is the increased risk of developing
metabolic syndrome (MetS) and cardiovascular disease (CVD)(1 4). Poor dietary intake is associated with the
development and progression of MetS in the general population as well as
adult survivors of childhood cancer (14). What is not
known are the long-term implications that interrupted feeding
development and changes in eating behaviour during cancer treatment has
on dietary intake in childhood cancer survivors and the longer-term
impact on health including MetS.
When looking specifically at macro- and micronutrient intake, Cohen et
al (2015) found that children who had recently completed cancer
treatment had an inadequate micro-nutrient intake and were consuming an
excessive energy
intake(15). An increase
in the intake of high fat, high sugar and refined convenience foods has
also been found for cancer survivors (15-17). The
impact of childhood cancer treatment on dietary intake in young
childhood cancer survivors of is likely to be complex. The combination
of treatment toxicities (nausea, food aversions and taste and smell
changes) with maladaptive parent eating behaviours all potentially
influence dietary intake during and after cancer treatment. While recent
research shows that adult survivors of childhood cancer are displaying
frequent cravings for junk food (18) little is known
about the eating behaviours of young survivors of childhood cancer. It
is also unknown how the diet quality of young childhood cancer survivors
compares with the diet of the general paediatric population.
The primary aim of this study was to compare diet quality of childhood
cancer survivors with age-matched children from the general community.
Secondly, the study aimed to identify possible contributing factors that
may affect diet quality in this population.
Methods
Participants
Participants were parents and/or carers of CCS aged between 2-18 years,
who had received anti-cancer treatment at Kids Cancer Centre (KCC),
Sydney Children’s Hospital (SCH), and John Hunter Children’s Hospital
(JHCH), Newcastle, Australia. Parents and/or carers were eligible if
they were the mother, father or primary caregiver of a child who: 1) had
undergone treatment for any type of childhood cancer; 2) had completed
their cancer treatment protocol; 3) were less than five years’
post-diagnosis; and 4) had no cognitive or other mental impairments.
Control group participants were parents and/or carers of a child aged
between 2-18 years with no co-morbidities that affected nutritional
intake. Participants were recruited between September 2012 and March
2014. The study protocol had full ethical approval from SCHN HREC
(12/SCHN/29) and UNSW HREC (HC12659).
Recruitment
Study information packages were posted to eligible participants. To
recruit parents of the control group, staff of participating childcare
centres, community groups and volunteer community members were contacted
to identify eligible participants and to ensure that: a) it was
appropriate to approach each family identified; and b) they met the
study eligibility criteria. Potential participants were then provided
with a study package. Parents returned their completed questionnaires
and a signed consent form in the supplied reply-paid envelope.
Data collection
Parents/carers were asked to complete a separate self-report
questionnaire for their child’s demographic, treatment (if applicable)
and eating behaviour information followed by a dietary intake
questionnaire. The first questionnaire included information about the
child’s geographic location (i.e. postcode of residence) and demographic
data (i.e. gender, date of birth, weight and height, and current
medications). Clinical information included cancer diagnosis, date of
diagnosis, date of completion of cancer treatment, cancer treatment
regimen (surgery, radiation, chemotherapy and hematopoietic stem cell
transplant) and nutrition interventions (education, oral nutrition
support (ONS), Enteral Nutrition (EN), Total Parenteral Nutrition (TPN)
received during cancer treatment. Parent demographic information
collected included: socioeconomic status, gender, date of birth,
employment status, education and perceived health status, weight and
height.
The child’s eating behaviour was measured using the validated parent
report Children’s Eating Behaviour Questionnaire (CEBQ), which assesses
variation in eating style between children. The measure assesses the
child’s eating style though 35 items, comprising eight
subscales(19) . An objective measure of the child’s
food pickiness was determined using the Child Feeding Questionnaire
(CFQ), ‘picky eating’ subscale. The CFQ is a validated seven factor
parent self-report measure designed to assess parent attitudes, beliefs
and practices regarding their child’s eating
behaviour(20).
The second questionnaire was the Australian Child and Adolescent Eating
Survey (ACAES) which assessed the child’s dietary intake. The ACAES is a
validated parent reported 120 question self-administered
semi-quantitative Food Frequency Questionnaire (FFQ) that requests
specific information about foods and beverages consumed by the child to
assess their dietary intake(21).
Analysis
Child and parent weight and height were used to calculate body mass
index (BMI), using the formula: weight in kilograms divided by height in
metres squared. For each child aged > 2 years, a BMI
z-score was calculated using Epi Info™ (Version 3.5.1, 2008; Centres for
Disease Control and Prevention, USA). This allowed for equal comparison
across all age groups (22). Weight and height were
also used to determine the weight range category of the child (thinness,
healthy, overweight and obese) to define the child’s nutritional status(37). The dietary intake, proportion of energy intake
and serve size data were calculated using the ACAES(21).
The Australian Child and Adolescent Recommended Food Score (ACARFS) was
generated from the ACAES to determine each child’s diet quality. This
score reflected the relationship between the child’s dietary diversity
and nutrient adequacy by measuring their adherence to the Australian
dietary guidelines (24).
Study data were explored using univariate data analysis from the
statistical software package SPSS (version 22, 2014; SPSS Inc, Chicago,
IL, USA) to assess whether there were significant differences between
the survivor and control groups. Chi-squared and t-tests (two-tailed, α
= 0.05) were used to compare parent/child demographics, BMI z-scores and
Socio-Economic Indexes for Areas (SEIFA) index. Age and sex adjusted
means of the ACARFS were compared using analysis of covariance to
determine the difference between age and gender for diet quality scores.
Differences between the parent/child eating behaviours sub-scales
determined in the CEBQ and CFQ were compared using t-tests.
Bivariate analysis using Spearman’s correlations was used to determine
the relative contribution of child treatment regimen side effects,
parent feeding behaviour and child eating behaviour on the child’s diet
quality. Differences and associations were considered significant at p
< .05 (2-tailed) for all tests.
For the quantitative data variables, hierarchical cluster analysis was
completed using the software ‘R’ (version 3.0.1; Packages: ’mclust’
version 4.3; ’FactoMineR’ version 1.27). This analysis grouped
participants characterised by specific variables into clusters based on
the distance between each observation or variable. In this study, four
composite scores derived from the questionnaires (BMI z score, child
picky eating behaviour, child emotional overeating behaviour and diet
quality) were used after scaling and a logit transformation.
Results
Demographics
A total of 146 parents of children aged 2-18 years completed the study:
65 participants were parents of CCS (response rate 26%) and the control
group of 81 participants were parents of children without a cancer
diagnosis (response rate 64%).
Significant differences between control and cancer groups were for
parent age, education level, and employment, with control parents
working more hours per week.
There was no significant difference in BMI z-scores for participating
children, although the CCS had a higher proportion of participants
classified as being overweight (21% vs 6%) and having grade 1 thinness
(12% vs 2%) (TABLE 1).
In the CCS group, mean age at diagnosis was 6.2 (±4.5) years, mean time
since diagnosis was 50.3 (±15.6) months and mean time since treatment
completion was 24.9 (±17.3) months. CCS had a heterogeneous
representation of cancer diagnoses, with the most common being Acute
Lymphoblastic Leukaemia (ALL) 29% (n=19) (TABLE 2).