CHANGES IN FOOD, BEVERAGES, AND DIETARY SUPPLEMENTS MADE BY

BREAST CANCER SURVIVORS (BCS) AFTER DIAGNOSIS: A PILOT STUDY

S. Logosh , A. Maroncelli , K. Ruckstuhl, M. Sustin, C. Holmes, P. Silverman, M.B. Kavanagh
Department of Nutrition, Case Western Reserve University University Hospitals Case Medical Center, Cleveland OH
ABSTRACT
Cancer survivors adopt complementary treatments without notifying their cancer treatment team (CTT). The
purpose of this pilot study was to determine (1) what, if any, changes were made to foods, beverages, dietary
supplements (DS), and cooking methods by BCS after diagnosis (2) to determine the source of information
about making changes and (3) to determine if the change was discussed with their CTT. The study was
approved by IRB.
Fifty-three BCS patients completed 103 item questionnaire. Mean age: 52.7, 100% female, 93.9% stage I or II,
95.4% non-Hispanic or Latino, 80.8% Caucasian. For changes in foods eaten, 47.1% increased intake of fruits
and vegetables, 45.1% made no change, and 35.3% reduced intake of processed foods. For changes in
beverages consumed, 46.2% stopped drinking soda, 33.3% started drinking green tea, and 23.1% started
drinking medical food supplements. For changes in DS, 84.6% started vitamin D, 30.8% chose other, and
25.6% started fish oil. For changes in food preparation, 44.8% stopped deep frying foods, 24.1% steamed
vegetables, and 20.7% stopped using the microwave. Sources of information about these changes were:
doctor, nurse, or dietitian = 26.5%, family or friends = 19.9%, and internet = 10.6%. For discussing changes
with CTT, 41.8% reported yes and 44.3% reported no. BCS reported discussing DS changes with CTT the most
= 61.5%. Results suggest that BCS make various changes in food, beverages, DS, and cooking methods.
Further research is needed to address the gap in knowledge of dietary changes made after diagnosis by BCS.

BACKGROUND
Breast cancer is the most common cancer among American women with 1
in 8 women developing invasive breast cancer at some point in their life.
There have been many dietary intervention studies aimed at preventing
breast cancer and treating survivors, however, much less is known about
changes made by breast cancer survivors (BCS) after diagnosis. Wayne et
al., found that breast cancer patients made modest dietary changes in the
types of foods eaten and quantity of intake (3). BCS often try
complementary and integrative approaches to take control over their own
health and improve their quality of life (1,2). In a report by Brown et al.,
complementary and integrative health approaches adopted by patients
diagnosed with any type of cancer included fasting, juice therapies,
vegetarian diets, or macrobiotic diets (2). Brown et al. also noted changes in
dietary supplement use by cancer patients and survivors, pointing out that
despite the many gaps in scientific knowledge about supplements, many
cancer survivors take supplements and are eager to learn more about
them (2). Frenkel et al., generated a list of the leading supplements used by
cancer patients. These included: curcumin, glutamine, vitamin D, Maitake
mushrooms, fish oil, green tea extract, milk thistle, Astragalus, melatonin,
and probiotics (1). The present study focuses on these supplements and
others frequently used by cancer survivors such as lycopene, modified
citrus pectin, pomegranate, zyflamend, coenzyme Q-10, and high dose
vitamin C. Many times, survivors decisions to use complementary and
integrative approaches are guided by the influence of the media or advice
from friends and relativesall of which may be unreliable sources.
Unfortunately, direct communication between patient and cancer
treatment team (CTT) does not always take place to the degree that it
should (1,2,3).

RESEARCH OBJECTIVES
The objectives of this study were to identify (1) the most frequent changes
made to foods, beverages, dietary supplements, and cooking methods by
breast cancer survivors, (2) the sources of information for these changes,
and (3) which changes were discussed with the cancer treatment team.

METHODS
Inclusion criteria were as follows: Women aged 18-80 years with stage 0,
stage I, or stage II breast cancer who completed active treatment and
could read and write English. Exclusion criteria were ages outside of the
18-80 year rang, advanced breast cancer staging, and those who could not
read English.
Based on the literature review findings, a four-part questionnaire was
developed to identify changes made by breast cancer survivors after
diagnosis. Data collected in the questionnaire included: (1) Changes in
foods eaten, (2) changes in beverages consumed, (3) dietary supplement
changes, and (4) changes in food preparation methods. Survivors were
asked where they learned about the benefits of the changes made.

Options included: (1) doctor/nurse/dietitian, (2) chiropractor, (3)

naturopathic doctor, (4) the internet, (5) television, (6) books, (7)
magazines, (8) radio, (9) friends/family, or (10) other with space
available to identify the source. The survey also assessed whether or not
these changes were discussed with the patients healthcare providers.
Date of initial diagnosis and stage, as well as demographic data were
collected.
Surveys were distributed by staff at University Hospitals Case Medical
Center Seidman Cancer Center and satellite locations around the greater
Cleveland area. The questionnaire was handed to the survivors by either
their physician or nurse at their follow-up appointment. Completed
surveys were then collected and coded. Data was entered into Excel
documents and a univariate analysis was performed to highlight the
trends in the data along with descriptive statistics. This study was
approved by University Hospitals Case Medical Center Institutional Review
Board.

RESULTS
Fifty-eight surveys were available for analysis with at least one question
answered and completed demographic data. The age range of the
respondents was 35 to 78 years. The average age of the respondents was
52.7 years old. 96% of respondents were non-Hispanic or Latino and 76%
were White. The majority (52%) of respondents were married. Other
demographic data include: 38% reported drinking less than two alcoholic
beverage per week, 22.4% had four years of college with a degree, 22.4%
of respondents completed graduate school, and 26% reported an annual
household income over $100,000. Almost half (49.1%) reported current
full-time employment.
Table 1 shows the three most frequently reported changes in the types of
foods consumed by the survivors. Fifty-seven BCS responded to this
portion of the survey. Of these, 47.4% (n=24) reported increased intake of
fruits and vegetables, 48.6% (n=17) learned of this change from their
doctor, nurse, or dietitian, and 53.5% (n=23) indicated that they did not
discuss changes in types of food consumed with their healthcare provider.
Changes in types of food consumed

N = 57

Increased intake of fruits and

vegetables
No changes
Reduced intake of processed foods

27

% of total
responses
47.4

24
22

42.1
38.6

Source of information
Doctor, nurse, dietitian
Friends or family
Internet

N = 35
17
16
12

%
48.6
45.7
34.3

Discussion with healthcare provider

Yes

N = 43
23

%
53.5

Table 1: The most frequent responses to Question 1, Have you made any of the following
changes (for at least 1 month) to the foods that you eat? Where did you learn about the
benefits of the changes you made?; Did you discuss these changes with any of your healthcare
providers?

Table 2 shows the three most frequently reported changes in the types of
beverages consumed by the survivors. Thirty-nine survivors responded to
this portion of the survey. Of these, 46.2% (n=18) reported that they
stopped drinking soda pop, 44.4% (n=16) learned of this change from their
doctor, nurse, or dietitian while 44.4% (n=16) learned of this change from
their friends or family, and 60% (n=21) reported that they did not discuss
changes in types of beverages consumed with their healthcare
provider.

Changes in types of beverages consumed

N = 39

Stopped drinking soda pop

Started drinking green tea
Reduced alcohol consumption
Switched to fruit and vegetable juicing

18
16
9
9

% of total
responses
46.2
41.0
23.1
23.1

Source
Doctor, nurse, dietitian
Friends or family
Book
Magazine
Internet
Television

N = 36
16
16
9
9
8
8

%
44.4
44.4
25.0
25.0
22.2
22.2

Discussion with healthcare provider

No

N = 35
21

%
60.0

Table 2: The most frequent responses to Question 2, Have you made any of the following
changes to the beverages that you drink? Where did you learn about the benefits of the
changes you made?; Did you discuss these changes with any of your healthcare providers?

Table 3 shows the three most frequently identified changes in dietary

supplements used by the survivors. Forty-four BCS responded to this
portion of the survey. Of these, 88.6% (n=39) indicated that they began a
vitamin D supplement regimen, 82.1% (n=32) learned of this change from
their doctor, nurse, or dietitian, and 65.9% (n=29) indicated that they
discussed changes in dietary supplements used with their healthcare
provider.

Changes in dietary supplements

Started taking Vitamin D
Started taking Fish Oil
Other

N = 44
39
13
13

% of total responses
88.6
29.5
29.5

Source
Doctor, nurse, dietitian
Friends or family
Television

N = 39
32
10
5

%
82.1
25.6
12.8

Discussion with healthcare provider

Yes

N = 44
29

%
65.9

Table 3: The most frequent responses to Question 3, Have you started taking any of the
following dietary supplements since you were first diagnosed?; Where did you learn about
the benefits of the changes you made?; Did you discuss these changes with any of your
healthcare providers?

Table 4 shows the three most frequently reported changes in type of

cooking method used by the survivors. 34 survivors responded to this
portion of the survey. 50.0% (n=17) indicated that they stopped deep
frying foods. 46.4% (n=13) learned of this change from their doctor,
nurse, or dietitian. 57.6% (n=19) indicated that they did not discuss
changes in types of food consumed with their healthcare provider.

REFERENCES
1. Frenkel M, Abrams DI, Ladas EJ, Deng G, Hardy M, Capodice JL, Winegardner MF, Gubili JK, Yeung S, Kussmann H, Block KI. Integrating Dietary Supplements into
Cancer Care. Integrative Cancer Therapies. 2013; 12(5): 369-394.
2. Brown J, Byers T, Thompson K, Eldridge B, Doyle C, Williams AM. Nutrition During and After Cancer Treatment: A Guide for Informed Choices by Cancer
Survivors. CA: a Cancer Journal for Clinicians. 2001; 51: 153-187.
3. Wayne SJ, Lopez ST, Butler LM, Baumgarner KB, Baumgartner RN, Balland-Barbash R. Changes in Dietary Intake after Diagnosis of Breast Cancer. Journal of the
American Dietetic Association. 2004; 104: 1561-1568.
4. McBride CM, Clipp E, Peterson BL, Lipkus IM, Demark-Wahnefried W. Psychological Impact of Diagnosis and Risk Reduction among Cancer Survivors. PsychoOncology. 2000; 9: 418-427.
5. American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention: food additives, safety, and organic foods. CA: A Cancer Journal for
Clinicians. 2012. Retrieved from: http://www.cancer.org/healthy/eathealthygetactive/acsguidelinesonnutritionphysicalactivityforcancerprevention/acsguidelines-on-nutrition-and-physical-activity-for-cancer-prevention-food-additives. Accessed on November 15, 2014.

Changes in type of cooking method

N = 34

Stopped deep frying foods

Started steaming vegetables
Stopped using the microwave

17
9
6

% of total
responses
50.0
26.5
17.6

Source
Doctor, nurse, dietitian
Friends or family
Television

N = 28
13
11
6

%
46.4
39.3
21.4

Discussion with healthcare provider

No

N = 33
19

%
57.6

Table 4: The most frequent responses to Question 4, Where did you learn about the
benefits of the changes that you made? ?; Where did you learn about the benefits of the
changes you made?; Did you discuss these changes with any of your healthcare providers?

DISCUSSION
The most frequently reported change in food consumption was an
increased intake of fruits and vegetables. Most BCS learned of this change
from friends and family. Wayne et al., states that a diet high in fruit and
vegetables is hypothesized to improve breast cancer prognosis and
decrease risk of recurrence (3). Additional studies support this hypothesis,
suggesting an inverse relationship with survival (2,3,4,5). A diet high in fruits
and vegetables is a common recommendation, so BCS may not feel the
need to discuss this dietary change with their healthcare provider. Also,
many BCS stopped drinking soda pop. The American Cancer Society (ACS)
states that reducing the amount of soda pop can indirectly lower the risk
of cancer recurrence and prevent excess weight gain in women in
remission of breast cancer (5) . Reduction in soda, like increased intake of
fruits and vegetables, is generally recognized as a positive and encouraged
change. BCS may not feel the need to discuss this change with their CTT.
The most striking dietary change among BCS was the adoption of a
vitamin D supplement. Thirty-nine survey respondents started vitamin D
supplementation; of those who answered the dietary supplement
question, this is 90% of the total reported supplement changes. According
to a review on integrative cancer therapies, numerous studies have
supported the finding that lower serum 25-hydroxyvitamin D levels are
associated with increased risks of breast cancer (1). Current research
suggests that vitamin D analogues may produce anti-proliferative effects,
activate apoptotic pathways, and inhibit angiogenesis (1). Addition of a
vitamin D supplement after breast cancer diagnosis was both learned
from and discussed with health care providers. Because dietary
supplements may lead to negative interactions with other medications
and could lead to excessive dosing, it is important that survivors discuss
this change with their CTT (1). Response rates were highest for stopping
the use of deep frying for the last area the survey assessed, changes in
cooking preparation or method. Deep fried foods have high levels of fat. A
study suggests that low levels of fat in the diet might be associated with
lower recurrence rates of cancer and better survival (2). Respondents
learned of this change from family and/or friends and did not discuss the
change with their healthcare provider.
Limitations: Major limitations are the small sample size and the high risk
of reporting bias by the patients. Nine questionnaires were not used for
analysis because respondents did not fit inclusion criteria. An additional
demographic question that may be useful to include is rating of health as
determined by the patient. Self-rating of health may influence a patients
motivation to initiate lifestyle changes after cancer diagnosis (4).