Pediatric Hematology Oncology Journal 2 (2017) 25e28

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Pediatric Hematology Oncology Journal

journal homepage: https://www.elsevier.com/journals/pediatric-
hematology-oncology-journal/

Dietary perceptions and beliefs among families with children

undergoing therapy for cancer
Sidharth Totadri, Venkatraman Radhakrishnan*, Harshvardhan Atreya,
Praveen Kumar Shenoy, Prasanth Ganesan, Trivadi S. Ganesan, Tenali Gnana Sagar
Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India

a r t i c l e i n f o a b s t r a c t

Article history: Background: Malnutrition is associated with inferior survival and increased chemotherapy toxicity. The
Received 3 May 2017 present study was conducted to evaluate the level of knowledge regarding nutrition and prevalent
Received in revised form misconceptions about diet in families with children undergoing therapy for cancer.
26 June 2017
Procedure: Mothers of children <18 years of age undergoing treatment for cancer were included in the
Accepted 30 June 2017
Available online 1 July 2017
study. A structured questionnaire on diet and hygiene was administered by a physician to the parents.
Results: The study enrolled mothers of 72 patients. The median age of patients was 8 years. Sixty-two per
cent of the patients were underweight and 6% were obese. Diet was perceived to be causally related to
Keywords:
Healthy diet
cancer by 20% of mothers. Restriction of specific foods in children with cancer was practiced by 57% of
Neutropenic diet mothers. Junk foods and chicken were the commonest foods avoided. Certain foods were believed to
Pediatric cancer have the potential to boost white blood cell counts among 36% of mothers. There was a disparity be-
Nutrition myths tween the nutritional status of the children as per anthropometry and maternal perception.
Maternal education Conclusions: Misconceptions regarding diet are prevalent among families with children undergoing
therapy for cancer. Formulation of guidelines for nutrition and a robust nutritional education program
are essential.
© 2017 Pediatric Hematology Oncology Chapter of Indian Academy of Pediatrics. Publishing Services by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction compared to life saving cancer therapy [3]. Prevalent socio-cultural

Optimal supportive care during therapy has played a vital role in
improving survival in childhood cancer [1]. Nutrition is a funda-
mental aspect of supportive care in pediatric oncology. However,
there is significant disparity among the practices related to nutri-
tional advice and rehabilitation among pediatric oncologists [2].
Indications for initiation and discontinuation of a restricted diet
during neutropenia differ from center to center [2]. Further, there is
significant variability in the specific foods and beverages which are
restricted during therapy [2].
In lower and middle income countries (LMIC), the problem is
compounded by factors such as endemicity of malnutrition and
lack of time or resources for addressing nutritional issues when
* Corresponding author. Medical Oncology (Division of Pediatric Oncology),
Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India.
E-mail address: venkymd@gmail.com (V. Radhakrishnan).
Peer review under responsibility of Pediatric Hematology Oncology Chapter of
Indian Academy of Pediatrics.
practices play a vital role in influencing dietary intake [3]. Knowl-
edge of perceptions and practices related to diet, that are prevalent
in families of children receiving therapy at a center is essential. This
enables formulation of nutritional guidelines that are adapted to
the local setting. The objective of the study was to appraise the
dietary beliefs and practices among families of children with cancer
who were undergoing therapy at a tertiary cancer referral center.
2. Methods
The study was a cross-sectional questionnaire based study
conducted in the 50 bedded children's ward at our center. Children
with cancer aged less than 18 years are admitted for chemotherapy
or complications related to therapy such as febrile neutropenia in
the ward. Short duration chemotherapy is administered in a 5-
bedded day-care facility located within the ward. The hospital
kitchen provides vegetarian meals with additional protein sup-
plements such as eggs (3 main meals with 2 snacks) free of cost to
all inpatients. Every Thursday, a weekly meeting is held to counsel

http://dx.doi.org/10.1016/j.phoj.2017.06.004
2468-1245/© 2017 Pediatric Hematology Oncology Chapter of Indian Academy of Pediatrics. Publishing Services by Elsevier B.V. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
26 S. Totadri et al. / Pediatric Hematology Oncology Journal 2 (2017) 25e28
families of children regarding diet and hygiene. The pediatric
oncologist, dietitian, psycho-oncologist and nursing staff partici-
pate in the meeting and advise healthy practices related to diet and
hygiene in addition to addressing queries. Mothers of children
consecutively admitted in the ward/receiving chemotherapy in the
day care during a one week period in January 2016 were included in
the study. Mothers of patients admitted in the intensive care unit
were excluded. A structured objective questionnaire (Supplemental
Table 1) was administered by a physician to the parents, in the
native language spoken by them. Educational status of the mother
was recorded and classified as illiterate, passed primary school,
passed high school and college graduate. Age of the child, diagnosis
and phase of therapy were noted. Recent weight and height of the
child were noted from the case record. Weight and height are
routinely recorded in the case record during each admission and
outpatient visit to the clinic at our center. An electronic weighing
machine is utilized for measuring weight and stadiometer is used
for vertical height. Crown heel length is measured in infants. Body
mass index (BMI) was calculated using the formula BMI ¼ Weight
(Kg)/Squared height (m2). Z scores for weight for age and BMI for
age were assigned based on the World Health Organization growth
charts for the age groups 0e5 years and 5e19 years [4,5]. Under-
weight was defined as weight for age z core < 2 in children up to 5
years of age and BMI z score < - 2 in children aged > 5 years. Obesity
was defined as a BMI z score of >3.
3. Statistical analysis
Statistical analysis was performed using SPSS software version
17 (SPSS Inc, IBM, Chicago). Answers to the questionnaire were
analyzed by descriptive statistics. Frequency and percentages were
used to represent the responses to the structured questionnaire.
4. Results
The questionnaire was administered to the mothers of 72 pa-
tients. The median age of the patients was 8 years (range: 0.4e18),
and male: female ratio was 2.4:1. The diagnoses of the patients
encompassed acute lymphoblastic leukemia (55), bone sarcoma
(5), acute myeloid leukemia (3), Hodgkin lymphoma (3), non-
Hodgkin lymphoma (2), rhabdomyosarcoma (2), Wilms tumor (1)
and neuroblastoma (1). Based on educational status, 13 (18%)
mothers were illiterate, 23 (32%) had passed primary school, 26
(36%) had passed high school, and 10 (14%) were graduates. The
majority of children were underweight (45, 62%),4 (6%) were obese,
and 23 (32%) had normal weight/BMI. Sixty-four (89%) mothers
acknowledged that they had received education regarding diet/
hygiene during therapy of their children.
Diet was believed to have contributed to development of cancer
in children in 14 (20%) mothers. Excessive consumption of milk
products and junk food, and inadequate feeding were attributed to
be possible triggers for cancer in children. Twenty-seven (37%)
mothers professed that they had made significant changes in their
child's diet after starting therapy for cancer. Forty-one (57%)
believed that certain foods had to be avoided during therapy. Junk
food (n ¼ 16) and chicken (n ¼ 10) topped the list of foods which
had to be avoided. Other avoided foods included mutton, oily foods,
fish, raw foods and nuts. Twenty-two (31%) mothers considered
that meat in any form should be avoided. Three (4%) thought that
milk must be removed from the diet. Twenty-seven (37%) mothers
supposed that certain “special” foods needed to be added/increased
in the diet during therapy. These foods included vegetables, eggs,
fish, meat, juice, “ragi” (finger millet), commercially available pro-
tein supplement powders, pulses, nuts, milk and mushroom.
Twenty-six (36%) mothers perceived that certain foods could aid
in increasing the white blood cell (WBC) count during periods of
neutropenia. Meat, milk, eggs and pulses were the commonest
foods which were thought to be “boosters” of WBC count, followed
by fish, vegetables, pomegranate and nuts. The traditional south
Indian preparation made from legumes known as “sundal,”
drumstick, spinach and dates were specific foods which were
thought by some to exert a favorable effect on WBC count. Sixty-
eight (94%) concurred that it is unsafe to consume street food,
while the remaining 4 (6%) deferred. Sixty-three (88%) mothers did
not consider commercially available tetra-pack products of fruit
juices to be safe. Safe potable water was interpreted as being
mineral water, boiled water, canned water, boiled as well as filtered
water, filtered water, water from the tap by 20 (28%), 20 (28%), 13
(18%), 7 (9%), 5 (7%), 5 (7%) mothers, respectively (2 were unsure).
There was disparity between the maternal perception of the
child's nutritional status when compared to status as per weight/
BMI based z score (Table 1).
5. Discussion
Childhood cancer and nutrition are intimately related. Malnu-
trition can contribute to reduced tolerance of chemotherapy,
altered drug metabolism and additional immunosuppression
leading to infections [6]. Sub-optimal nutritional status has been
associated with treatment abandonment and inferior event-free-
survival in children with cancer [7]. The third National Family
Health Survey (NFHS-3) conducted in India in the year 2005e06
revealed that almost 50% of under-5 children were stunted and 20%
were wasted [8]. Therefore, cancer and its incumbent therapy
related adversities pose additional nutritional challenges on a
subset of a population that is already largely malnourished. In our
study, most children were malnourished. Nutritional education of
families with children undergoing therapy for cancer is the first
step towards addressing this issue. A survey was conducted by the
nutrition working group of the International Society of Pediatric
Oncology committee for Developing Countries (SIOP-PODC) in 96
centers across the world [9]. Merely 35% of the institutions, re-
ported provision of nutrition education to families of children with
cancer [9]. In a survey of Indian centers, approximately two thirds
of the respondents reported having a clinical dietitian and routine
education of families regarding nutrition [10]. Lack of time and
educational material were cited as barriers [10]. Additionally, the
success of such programs also depends on the knowledge, attitude
and practices pertaining to diet in the local community. This was
the driving force behind our study. The educational profile of the
mothers included in our study revealed that half of them were
illiterate or not educated beyond primary school. This reiterates the
need of regular and interactive sessions in which families can
engage in discussions held in their native language and clear mis-
conceptions related to diet.
The diet is invariably restricted in patients undergoing chemo-
therapy and bone marrow transplant [11]. The concept of a “neu-
tropenic diet” was to prevent intake of food harboring pathogens
that could lead to increased infectious complications in this
immunosuppressed cohort [11]. There are wide inconsistencies in
the dietary advice provided by different physicians and dietitians to
patients [2,12]. Information from unregulated sources such as the
internet, unsolicited advice from relatives/friends and locally
prevalent socio-cultural beliefs add to the confusion. Our study
exemplifies the vast discrepancy in the dietary perceptions among
families of children with cancer. A common misconception in pa-
tients with cancer is that if they had eaten differently, the cancer
would not have developed [13]. Twenty per cent of the mothers
shared this misconception. Health professionals must allay such
beliefs by explaining the multifactorial etiology of cancer and
 S. Totadri et al. / Pediatric Hematology Oncology Journal 2 (2017) 25e28
Table 1
Comparison of nutritional status as perceived by the mothers and status based on z scores.
Nutritional status as perceived by mother Underweight by z score
N (%) N (% of status as perceived by mother)
Underweight 5 (22)
23 (32%)
Normal 13 (29)
45 (62.5%)
Obese 0 4 (100)
4 (5.5%)
underscore the importance of focusing on a healthy diet now rather
than worrying about the past [13].
There is lack of empirical evidence for following a special diet
during therapy for cancer [14]. The Berlin-Frankfurt-Münster group
trial for Acute Myeloid Leukemia [AML-BFM 2004] conducted in
patients with acute myeloid leukemia concluded that there was no
significant benefit of dietary restrictions [11]. More than one-third
of patients in our study had changed their diet significantly after
start of therapy. A significant proportion were avoiding chicken/
meat, although the population to which our institute caters to is
predominantly meat eating. In a large survey of practices related to
dietary regulation in patients with neutropenia, 78% of a total of
156 institutions reported restriction of diets [15]. In most centers,
dietary advice is sought from physicians or in-house dietitians.
Among physicians from 175 centers who were members of the
Children's Oncology group (COG), there was significant inconsis-
tency in the indications, recommendations and duration of dietary
restriction for neutropenia [2]. In a study from the United Kingdom,
more than 50% dietitians acknowledged that there was no institu-
tional policy for dietary recommendations in neutropenia/they
were unaware of the same [12]. It is erroneous to consider that
children with cancer must not consume a diet similar to normal
children of their age [13]. On the contrary, efforts should be made to
ensure that they continue to have access to a healthy diet which
would be appropriate for their age [13]. Undercooked or deli meats
and unpasteurized milk products are commonly restricted by
physicians as well as dietitians [2,12]. This might be misinterpreted
by patients to imply complete avoidance of meat and milk, which
are important sources of nutrition.
Nutritional interventions thought to prevent cancers are also
perceived as having the ability to treat cancers [13]. This may be a
possible reason for addition of “special” foods to the diet. In LMIC, it
is not uncommon to observe families from lower socioeconomic
strata utilizing their scarce resources to purchase exotic fruits,
commercial nutritional products and dry fruits; which they believe
to be beneficial during therapy. Health professionals involved in the
care of children with cancer must emphasize intake of commonly
available, indigenous foods which constitute the everyday diet at
home. Dietary restrictions are largely due to the concern of intro-
ducing harmful pathogens through the diet, to neutropenic pa-
tients. Interestingly, families seem to assume the corollary to this
concept, that neutropenia itself may be “reversed” by certain foods.
Fellow patients often prescribe “WBC boosting foods,” which they
falsely associated with rapid improvement in the blood counts.
Such myths must be busted and fellow patients must provide
encouragement and emotional support rather than unsolicited
medical/nutritional advice [13].
It is noteworthy that a proportion of mothers had a false
perception of the nutritional status of their children in our study.
Subjective perception of underweight children as “normal” by
mothers, could lead to false complacence and inadequate dietary
intake. On the contrary, excess weight is often perceived as a sign of
being “healthy” by mothers.
27
Normal by z score Obese by z score
N (% of status as perceived by mother) N (% of status as perceived by mother)
18 (78) 0
28 (62) 4 (9)
0
The study highlights the need of formulating guidelines for
nutritional advice in children undergoing therapy for cancer. The
study is limited by its cross-sectional design. The patients were at
different phases of therapy. Families of patients who had been
receiving treatment for a longer duration of time, may have had
better knowledge and experience than those of recently diagnosed
patients. However, it represents a pertinent requirement in LMIC, to
address dietary beliefs and practices in the families of children
undergoing therapy for cancer. Knowledge of the same would be
essential for adapting nutritional interventions according to local
needs.
Nutritional advice must reiterate utilizing home based,
commonly available sources of nutrition. Unnecessary dietary re-
strictions must be avoided. Regular interactions of health pro-
fessionals and families of children can dispel misconceptions and
support a healthy diet in children. This would go a long way in
improving nutritional status and outcomes in children with cancer.
Conflict of interest statement
The authors have no conflict of interest to disclose.
Acknowledgements
We gratefully acknowledge the contribution of our dietitian,
Srividya Arunachalam who was actively involved in the nutritional
assessment, counselling and support of the children treated at our
center.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.phoj.2017.06.004.
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