Keywords:
Food - Chemotherapy - Adjuvant - Breast neoplasms - Diet - Feeding behavior - Nutritionists
Descritores:
Alimentos - Quimioterapia adjuvante - Neoplasias mamárias - Dieta - Comportamento
alimentar - Nutricionistas
INTRODUCTION
Breast cancer is the second most frequent cancer worldwide and the most common in
women. Risk factors include hormonal status, race, genetics, as well as life style.
Thus a decrease in incidence of this disease should be possible by life style alterations
such as an increase in physical activity, maintaining body weight within the limits
specified by body mass index (BMI) calculations, a moderate consumption of alcohol,
and an adequate diet.[1]
[2] Overweight or obesity at diagnosis can be a factor indicating a worse prognosis,
with recurrence and comorbidities.[3]
Nutritional education can be an important factor in maintaining an adequate energy
balance. A restriction of 10-40% of the total caloric intake has been shown to decrease
cellular proliferation and increase apoptosis; however, this is not considered a preventative
strategy, on its own. A decrease in alcohol intake and smoking, a good diet, and regular
physical activity also seem to be important for the prevention of cancer, as these
factors help control hormonal levels, and reduce the production of free radicals.[4]
[5]
Nutritional requirements are different before, during and after cancer treatment.
Often, patient receives conflicting information, which linked with taboos, aversions,
preferences and beliefs, lead to an increase or decrease in food intake, and may result
in dietary disequilibrium.[3] Nutritional alterations such as a direct effect of medication on metabolism or side
effects involving the gastrointestinal tract take place during chemotherapy. Appetite
may also be affected by the stress induce by a cancer diagnosis and chemotherapy.[5] Dietetic supervision to avoid weight loss is recommended during chemotherapy, as
well as to avoid interruptions in food intake with radiotherapy.[6] It is also a useful method to prevent and control associated side effects.[7]
After treatment, disease free patients constitute a risk group to develop diseases
such as diabetes, osteoporosis, and cardiovascular problems, as well as second primary
tumors. As one of the measures to prevent these disorders, this group should be encouraged
to adopt a more healthful lifestyle.[8]
There are a number of studies, which investigated the relationship among nutrients,
nutrition, and prevention of breast cancer. However, very few studies have focused
on alteration or maintenance of dietary habits combined with sociodemographic variables,
BMI, gastrointestinal (GI) symptoms, and altered food groups before and after treatment.
The objective of this study was to analyze changes in food intake during chemotherapy
in patients with breast cancer. To do this, patients responded to a food frequency
questionnaire (FFQ) about their intake from the various food groups (Appendix).
MATERIAL AND METHODS
This was a prospective study with breast cancer patients, 18 years of age or older,
who were seen in the Clinical Oncology Ambulatory Care, from November 2009 until October
2010. Patients included in the study were those with non-metastatic disease, in adjuvant
or neoadjuvant treatments, with curative intent with the following chemotherapy regime:
anthracyclines (4-8 cycles of adriamycin and cyclophosphamide (AC) with a 21 day break
between cycles. Exclusion criteria were the following: patients on parental or nasogastric
tube nutrition; presence of ascites; mechanical obstruction of the GI tract; previous
surgery involving the esophagus, stomach or intestines, concomitant radiotherapy.
There was no nutritional advice given at this stage; the study was then undertaken
according to a protocol developed by nutrition department of the hospital.
Before their first chemotherapy session, patients answered the questions about personal
details and life style, as well as the FFQ designed specifically for the Brazilian
population.[9] The questions on this form took between 20 to 40 minutes to answer. Following this,
height and weight were measured for calculation of BMI.[10] A nutritionist documented the diagnostic information (tumor, stage, associated diseases,
and chemotherapy treatment protocol)
using details from the patient's chart.
Thirty days after the finish of the current chemotherapy, on the return appointment
to the clinical oncology department, or for some other procedure, the research nutritionist
documented details related to side effects of treatment and weighed the patients.
The FFQ was applied again, for later correlation of any changes in BMI with food intake.
Statistics
SPSS version 13 for Windows was used for statistical analysis. Descriptive statistics
used were: relative and absolute frequencies, measurements of central tendency (mean
and median) and dispersion (standard deviation, and minimum and maximum percentages).
Alterations in BMI were evaluated using the Student t-test for paired observations,
while alterations in food consumption were analyzed using the Wilcoxon test for paired
samples.
The Mann-Whitney test was used for socio demographic variables, and for correlation
of GI side effects with food intake. The median age of the patients was 53 years and
this was used to divide the patients into two groups, above and below this age. Educational
qualifications were divided into three categories: university or college training
complete, university or college courses incomplete, or other. Marital status was considered
to be either married or one of the following as the alternative group: single, widowed,
or separated. These groups were used to compare increases or decreases in food consumption.
Level of significance for all tests was set at 95%.
RESULTS
A total of 41 patients with nonmetastatic breast cancer answered to the first questionnaire;
however, 15 were excluded (4 did not respond to the second questionnaire, 9 responded
after the study had closed, and 2 did not finish treatment).
Table 1
Socio demographic Variables of the study patients
|
Variable
|
Category
|
Freq.
|
%
|
|
Sex
|
Female
|
26
|
100
|
|
Civil Status
|
Single
|
6
|
2.1
|
|
Married
|
15
|
57.7
|
|
Separated/Divorced
|
4
|
15.4
|
|
Widowed
|
1
|
3.8
|
|
Formal
Educational
Level
|
Primary School - incomplete or complete
|
3
|
11.4
|
|
High School
|
7
|
26.9
|
|
College or University -incomplete
|
3
|
11.5
|
|
College or University-complete
|
13
|
50.0
|
|
Category
|
Brazilian National Health Service (SUS)
|
1
|
3.8
|
|
Private Health Plan
|
25
|
96.2
|
The second questionnaire was given 28-38 days after the latest chemotherapy treatment
(one patient replied in 28 days, another in 35, and another in 38 days). The median
age of the patients was 53 years (29-69 years). A total of 57.7% of women were married
and 50% had completed university level training. Surgery was performed on 70%. Only
one patient was treated on the Brazilian National Health Service (Sistema Único de Saúde - SUS), while all the others (96.2%)
had private health insurance plans. Disease staging was as follows: 6 patients (23%)
were stage I, 12 patients (46%) were stage II and 8 (31%) were stage III. Hypertension
was found in 38.5% and cardiovascular disease in 15.4% ([Table 1]). Side effects occurred in 22 (85%)
patients, either singly or together, such as nausea (17 patients), alteration in taste
(11 patients) loss of appetite in 7, vomiting (6 patients) mucositis in 3 patients,
diarrhea in 2 patients and pain in one patient.
At the first interview before treatment, 69% of women (n=18) were overweight or obese.
At the end of the chemotherapy cycles, 73% had a BMI greater than 25 kg/m2. This represented a weight increase of 7%, although there was no statistically significant
difference in weight before and after treatment. [Figures 1] and [2] illustrate the BMI at the two evaluations. Only 13 patients (32%) of those interviewed
took regular physical exercise (average of 5 hours per week)
before their cancer diagnosis. The other 68% did not do any regular exercise. Of the
26 participants, 9 (35%) took physical exercise. Three patients (11%) were smokers
with an average consumption of 14 cigarettes per day. Four patients reported occasional
alcohol ingestion of 2.9 times per week.
At the end of treatment, 58% (15 patients) were given nutritional advice. Some of
these women received information on other services (21%), although most of them were
advised at this institution (78%).
The answers to the FFQ gave us information referring to food intake of the previous
30 days. Each patient chose one of nine categories of intake frequency (monthly to
daily) for each of the 98 food items on the list. These replies were converted into
daily intake amounts for each item, as seen in [Table 2]. [Table 3] highlights those foods, which had a significant difference in intake before and
after treatment.
Figure 1 BMI (Body mass índex) before and after treatment with chemotherapy.
Table 2
Transformation into daily consumption (portions/day) of the nine categories of the
FFQ used in the study
|
Frequency/ Category-FFQ
|
Daily Consumption (portions/day)
|
|
Never to less than once a month
|
0.0
|
|
|
1 -3 times a month
|
2,5 portions/month ÷ 30 days = 0.08
|
|
|
1x per week
|
4 portions/month ÷ 30 days = 0.13
|
|
|
2 to 4x/week
|
12 portions/month ÷ 30 days = 0.4
|
|
|
5 to 6x/week
|
22 portions/month ÷ 30 days = 0.7
|
|
|
1x/day
|
1.0
|
|
|
2 to 3x/day
|
2.5
|
|
|
4 to 5x/day
|
4.5
|
|
|
6x or more /day
|
6.0
|
|
Figure 2 Average of weight before and after chemotherapy.
In terms of food items consumed more than once per month, there was a numeric change
in all items. [Table 3] presents a summary of the foods with altered intake, and [Table 4] compared the results in terms of food groups for the questionnaires done before
and after treatment. There was no influence of socio demographic variables on food
consumption from any food group (Mann-Whitney test, details not shown).
Table 3
Food consumption with statistically important difference during treatment
|
Frequency Never to less than once per month
|
2 to 3x/ month
|
1x/week
|
2 to 4x/ week
|
5 to 7x/ week
|
1x/day
|
2 to 3x/ day
|
|
Food Item
|
B
|
A
|
B
|
A
|
B
|
A
|
B
|
A
|
B
|
A
|
B
|
A
|
B
|
A
|
p =
|
|
Milk
|
73.1
|
57.7
|
0
|
7.7
|
3.8
|
7.7
|
0
|
3.8
|
3.8
|
0
|
11.5
|
15.4
|
7.7
|
7.7
|
0.042
|
|
Stroganoff
|
76.9
|
50
|
15.4
|
23.1
|
77
|
23.1
|
0
|
3.8
|
0
|
0
|
0
|
0
|
0
|
0
|
0.015
|
|
Liver
|
88.5
|
50
|
7.7
|
30.8
|
3.8
|
3.8
|
0
|
11.5
|
0
|
0
|
0
|
3.8
|
0
|
0
|
0.003
|
|
Tuna/Sardines
|
76.9
|
57.7
|
19.2
|
15.4
|
0
|
11.5
|
0
|
11.5
|
0
|
0
|
3.8
|
3.8
|
0
|
0
|
0,018
|
|
Shrimp
|
92.3
|
69.2
|
3.8
|
19.2
|
0
|
3.8
|
3.8
|
7.7
|
0
|
0
|
0
|
0
|
0
|
0
|
0.024
|
|
Lettuce/Escarole
|
7.7
|
11.5
|
0
|
3.8
|
7.7
|
11.5
|
30.8
|
34.6
|
11.5
|
15.4
|
19.2
|
19.2
|
23.1
|
3.8
|
0.011
|
|
Papaya/Papaya Juice
|
19.2
|
11.5
|
15.4
|
7.7
|
11.5
|
19.2
|
34.6
|
23.1
|
7.7
|
23.1
|
11.5
|
14.4
|
0
|
0
|
0.032
|
|
Cashew Juice
|
69.2
|
53.8
|
15.4
|
19.2
|
7.7
|
11.5
|
7.7
|
7.7
|
0
|
3.8
|
0
|
3.8
|
0
|
0
|
0.041
|
|
Barbados Cherry
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Juice (Acerola)
|
69.2
|
50
|
11.5
|
15.4
|
7.7
|
7.7
|
11.5
|
23.1
|
0
|
0
|
0
|
3,8
|
0
|
0
|
0.027
|
|
Peanuts/Chestnuts
|
57.7
|
42.3
|
23.1
|
19.2
|
0
|
11.5
|
7.7
|
11.5
|
3.8
|
3.8
|
7.7
|
11.5
|
0
|
0
|
0.026
|
|
Macaroni/Pastas
|
15.4
|
7.7
|
11.5
|
3.8
|
61.5
|
65.4
|
7.7
|
15.4
|
0
|
3.8
|
3.8
|
3.8
|
0
|
0
|
0011
|
B: Before treatment A: After treatment
Table 4
Comparison of food groups on questionnaires before (FFQ 1) and after (FFQ 2) chemotherapy
treatment
|
Food Groups
|
FFQ
|
Average 2.07 2.02
|
Median 1.91 1.90
|
SD 1.22 1.05
|
Mín
|
Max
|
p
|
|
I. Milk and milk products
|
FFQ 1 FfQ 2
|
0.13 0.26
|
4.90 4.90
|
0.542
|
|
II. Meat, fish and eggs
|
FFQ 1 FFQ 2
|
1.83 2.17
|
1.36 1.70
|
1.41 1.53
|
0.66 0.60
|
7.38 8.04
|
0.020
|
|
III. Vegetables and legumes
|
FFQ 1 FFQ 2
|
5.32 4.72
|
3.94 4.29
|
4.10 3.56
|
0.29 0.50
|
21.23 16.73
|
0.576
|
|
IV. Fruits and Natural Fruit Juice
|
FFQ 1 FFQ 2
|
4.40 4.68
|
3.69 4.26
|
2.88 2.67
|
1.08 1.30
|
12.63 12.79
|
0.294
|
|
V. Bread, cereals, root vegetables and legumes (beans)
|
FFQ 1 FFQ 2
|
5.13 5.27
|
4.72 5.39
|
2.31 2.23
|
1.29 1.00
|
10.70 9.51
|
0.376
|
|
VI. Oils and fats
|
FFQ 1 FFQ 2
|
2.38 2.22
|
2.04 2.00
|
1.72 1.59
|
0.00 0.08
|
7.50 6.00
|
0.623
|
|
VII. Desserts, Savory snacks and iced baked sweets
|
FFQ 1 FFQ 2
|
1.56 1.92
|
1.52 1.62
|
0.99 1.04
|
0.00 0.37
|
3.61 4.23
|
0.019
|
|
VIII. Drinks
|
FFQ 1 FFQ 2
|
1.82 1.96
|
1.37 1.29
|
1.27 1.50
|
0.00 0.08
|
5.58 5.71
|
0.444
|
|
IX. Preparations and Miscellaneous
|
FFQ 1 FFQ 2
|
1.46 1.66
|
1.10 1.30
|
1.19 1.19
|
0.13 0.21
|
5.08 5.08
|
0.108
|
Table 5
Comparison of the significance value (p<0.05) among food groups x side effects during
treatment for the patients who completed both FFQs
|
Food Groups
|
Nausea
|
Vomiting
|
Loss of appetite
|
Alterations in taste
|
|
I. Milk and milk products
|
0.243
|
0.656
|
0.497
|
0.878
|
|
II. Meat, fish and eggs
|
0.535
|
0.457
|
0.022
|
0.443
|
|
III. Vegetables and legumes
|
0.269
|
0.072
|
1.000
|
0.683
|
|
IV. Fruits and Natural Fruit Juice
|
0.978
|
0.929
|
0.778
|
0.281
|
|
V Bread, cereals, root vegetables and legumes (beans)
|
0.027
|
0.533
|
0.651
|
0.413
|
|
VI. Oils and fats
|
0.617
|
0.324
|
0.821
|
0.217
|
|
VII. Desserts, Savory snacks and iced baked sweets
|
0.373
|
0.882
|
0.735
|
0.878
|
|
VIII. Drinks
|
0,192
|
0.457
|
1.000
|
0.540
|
|
IX. Preparations and Miscellaneous
|
0.745
|
0.656
|
0572
|
0.330
|
Table 6
Comparison of the percentage consumption of an item eaten more than once a month from
the FFQ done before and after chemotherapy treatment
|
Item
|
FFQ1
|
FFQ2
|
p
|
|
1. Whole Milk 1 full cup
|
26.9
|
42.3
|
0.042
|
|
10. Stroganoff 1/2 soup ladle
|
2.1
|
50.0
|
0.015
|
|
14. Liver 1 large slice
|
11.5
|
50.0
|
0.003
|
|
20. Tuna /sardines Tinned 4 soup spoons
|
23.1
|
42.3
|
0.018
|
|
21. Shrimp 3 soup spoons
|
7.7
|
30.8
|
0.024
|
|
22. Lettuce/ escarole 4 medium leaves
|
92.3
|
88.5
|
0.011
|
|
40. Papaya/ Juice 1/2 fruit/ 1 cup 250 ml
|
80.8
|
88.5
|
0.032
|
|
45. Cashew Juice 1 cup 250 ml
|
30.8
|
46.2
|
0.041
|
|
46. Barbados Cherry Juice 1 cup250 ml
|
30.8
|
50.0
|
0.027
|
|
50. Nuts (peanuts chestnuts) 2 small handfuls
|
42.3
|
57.7
|
0.026
|
|
86. Beer -1 can
|
15.4
|
15.4
|
0.705
|
|
87. Wine -1 small glass
|
7.7
|
19.2
|
0.083
|
|
88.Other alcoholic drinks:” Pinga”/ Whiskey etc -
1shot
|
3.8
|
19.2
|
0.059
|
[Table 5] and [Table 6] show a significant relationship between the increase of bread and cereals with nausea,
and also an increase in consumption of meat, fish and eggs with a loss of appetite
(Mann-Whitney test). There was no significant association found for the other food
groups. The number of patients was too small to evaluate pain (n=1), diarrhea (n=2
or 8%), and mucositis (n=3 or 11 % of patients).
DISCUSSION
The FFQ has been used worldwide for epidemiologic studies and should be adapted for
specific populations.[11] The FFQ chosen for this study had been based on food information sheets filled in
over 24 hours by 200 adults older than 25 years, living in the Metropolitan region
of São Paulo, during the first six months of 2002.[12]
Our study sample was homogenous: women with an average age of 53, who were or are
married (76.9%) with 11 to 15 years of formal education (88.4%), and private health
care coverage (96.2%). There was no association between any sociodemographic variable
and a change in the food group consumption. Differently of us, Patterson et al. (2003)[13] found that patients between the ages of 35 to 59 years modified their diets more
than those people over 60 years of age. Salminen et al. (2004)[14] showed that the probability of a positive modification in dietary habits was greater
in the group with a higher level of education, younger age and with a longer time
from diagnosis.
A significant statistical difference was found in the increased ingestion of whole
milk. On the second questionnaire, 15.4% of patients who previously never consumed
this product began to use this item 2-3 times per month. Patients (3.8%) who consumed
items in this group once per week, increased their consumption to 2-4 times per week
and those which consumed these 5-7 times per week began to consume these once per
day ([Table 3]).
Stroganoff (red meat) also was consumed more frequently. During chemotherapy, women
are encouraged by their health professionals and care givers to diversify their intake
of food to avoid a monotonous diet. This could have been a creative and nutritious
option to vary the menu. [Table 3] also shows an increase in consumption of beef liver: 38.5% of women began to eat
this meat. 30.8% of those who initially ate this 2-3 times per month began to eat
it from once a week up to once a day.
Tuna and shrimp also were consumed more frequently. Fish (fresh or tinned) are rich
in omega 6 and omega 3 fatty acids to heart. In the first questionnaire, 92.3% of
women said they did not eat shrimp, and in the second questionnaire, this number had
decreased by 23.1%, with the consumption frequency being reported as 2-3 times per
month (19.2%).
The significant increase in these foods and in the all the protein groups could be
attributed to the awareness of the importance of adequate quantities of protein an
iron in the diet. Meat foods are avoided due to beliefs that certain food groups should
be eliminated during treatment, even though these food groups are not associated with
mortality.[5] Hanf and Gonder (2005) [15] quoted a possible increase in risk of breast cancer in women with a high consumption
of well grilled or baked red meat. However, they emphasize that even in a meta-analysis,
which included over 25,000 cases of breast cancer, there was no significant correlation
between breast cancer and red meat consumption, or with milk or milk products.
With respect to meat, fish and egg intake, we found a significant relation between
the increase in consumption of these items and loss of appetite ([Table 5]).
Consumption of lettuce and escarole was decreased significantly. In the first questionnaire,
23.1% of women ate these greens 2-3 times per day and during treatment this declined
to 2-4 times per week (34.6%). This could be explained by the fact that some patients
were advised to eat raw foods during chemotherapy.
Consumption of papaya increased by 7.7% (p=0.032). On the first questionnaire the most frequent consumption was reported to
be 2-4 times per week (34.¨), and on the second, this had increased to 5-7 times per
week as is shown in
[Table 3].
There was a significant increase in the consumption of cashew and acerola (Barbados
cherry), fruit juices ([Table 3]). Before treatment, 69.2% did not drink cashew fruit juice and its consumption was
2-3 times per month up to 2-4 times per week. After treatment, frequency was increased
from 2-3 times per month to up to once per day. 15.4% of patients did not modify their
consumption at all or less than once per month for other frequencies. Acerola fruit
juice also underwent change; 19.2% of women who never drank this juice began to drink
it 2-4 times per week. Both these fruits are high in vitamin C (acerola 1,500mg and
cashew 200mg). The significant increase in these fruit juices could be due to the
presence of vitamin C during treatment.
In the first questionnaire, 57.7% of patients did not eat nuts such as peanuts and
cashews, or ate them less than once per month. After the second questionnaire, the
group which never ate nuts had decreased by 42.3%, and 11.5% had begun to eat nuts
once per week.
The specific dietary changes found in this study agree with the results of Salminen
et al. (2004),[14] who studied dietary modifications in 345 women with breast cancer. One third of
their group (p=0.033) modified their diets. Higher educational levels, younger age and a longer
time with the diagnosis were all significantly associated with a probability of change.
The main alterations were a reduction in consumption of animal fat, sugar and red
meat, and an increase in intake of fruits and vegetables.
In our study, more women were also found to be eating macaroni and pasta, which are
sources of carbohydrate. The biggest change was found in the groups that never consumed
these items, in which frequency increased to as much as 5-7 times per week.
[Table 4] shows a significant increase in amount of meat, fish and eggs consumed (p=0.020) and in the group for sweets savories and cakes with icing (p=0.019), which suggests an increase in total caloric intake. This is likely due to
the fact that the last group contain simple carbohydrates and, principally, saturated
fats, which could explain the weight gain observed overall.
The increase in the group consisting of sweets, savories and iced baked goods represents
an increase in simple and complex carbohydrate consumption. The increase in consumption
of this group could be associated with an increase in weight during treatment.[16]
Group V, composed of bread, cereals, root vegetables and beans, was associated positively
with the occurrence of nausea. Almost all items in this group were eaten more frequently.
We think that the presence of nausea contributed to the increase in consumption in
this group.
In group II (meat, fish and eggs) 73% of patients increased the frequency of consumption
of these items on the second evaluation: in group IV (fruits and natural juices) and
V (bread, cereals, root vegetables, and beans), VII (sweets, savories, and iced baked
delicacies), 65% of patients increased their consumption frequency. For group VII,
15% of patients maintained their previous levels, while in groups IV and V this percentage
was 4% and 8%, respectively. Our sample was small, but in spite of this, these were
still significant differences in the two groups already discussed.
[Table 6] shows the maintenance of consumption of beer and an increase in the consumption
of wine and other alcoholic drinks. 54%
of those interviewed increased their alcoholic beverage intake during treatment. An
association between alcohol ingestion and the risk of breast cancer was confirmed
by Gonzalez and Riboli (2010).[17] In that study, in European women, they found an increase in risk of 3% for a recent
increase of 10g per day of alcohol.
Our study group of 26 cases was very homogeneous in terms of treatment and pathological
details, even with the limitations of the small sample size, diversity of tumor type
and age; the results presented here demonstrate that there was a change in the eating
habits of patients undergoing chemotherapy for breast cancer, as evidenced by the
FFQ. We show that more attention should be paid to overweight and obesity during treatment,
and patients, in fact, need to be guided about the initiation and/or maintenance of
healthy lifestyle habits. This could help stave off a second primary tumor and other
chronic diseases, as well as contribute to a better quality of life.
APPENDIX - Food Frequency Questionnaire (FFA)
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I. Milk and Milk products
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once a day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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1.Whole Milk 1 full cup
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2.Skimmed or semiskimmed milk (1 full cup)
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3. Cream 2 tablespoons
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4.Natural yoghurt/ pulp (1 pot ) whole or skimmed
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5.White cheese (fresh/cream spread/ricotta) 2 slices
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6. Yellow cheese (brick, gouda, mozzarella) 2 slices
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II. Meat, fish and eggs
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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7. Egg (fried, omelet, poached) 1 egg
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8.Chicken (cooked, baked, fried) 1 medium piece
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9. Beef 1 large slice or 1 steak, pressured cooked
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10.Stroganoff 150 g serving
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11. Crepe of ground beef 2 crepes
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12. Hamburger or cheeseburger 1 item
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13.Pork ( loin or steak ) 1 medium piece
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14. Liver 1 large slice
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15. Offal Chicken 1 portion (heart, liver etc)
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16. Mordatella, ham,, sliced 3 slices
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17. Sausage or Frankfurter (hot dog) 1 piece
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18. Bacon ( thick ) 1 medium piece
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19. Fish (poached / baked/ fried) 1 medium filet
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20.Tinned tuna or sardines 4 tablespoons
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21. Shrimp 3 tablespoons
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III. Vegetables and legumes
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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1Onc e per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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22. Lettuce / escarole 4 medium leaves
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23. Swiss Chard 3/4 small flat plate
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24. Savoy Cabbage 1 large spoonful
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25. Water cress / Chicory1/2 small flat plate full
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26. Brocolli cauliflower cabbage 2 stalks
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27. Tomato 3 medium slices
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28. Carrot 3 tablespoons
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29. Squash 2 tablespoons
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30. Garlic / onion 3 tablespoons / 3 slices
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31. Legumes: eggplant / cucumber 2 tablespoons
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32. Legumes: zucchini / beets 2 tablespoons
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IV. Fruits and natural fruit juices
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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1Onc e per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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33. Oranges/ tangerines 1 medium
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34. Orange Juice 1 cup 250ml
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35. Lemon juice 1 cup 250ml
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36. Bananas 1 medium
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37.Passion fruit juice 1 cup 250ml
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38. Pineapple juice 1 medium slice / 1 cup
250ml
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39. Apple/Pear 1 medium
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40. Papaya fruit or juice 1/2 small/1 cup
250 ml
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41. Strawberries 7 medium
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42. Persimmon 1 medium
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43. Avocado 1/2 medium
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44. Melon/Watermelon 1 medium slice / 1 cup 250ml
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45. Cashew Juice 1 cup 250ml
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46. Barbados cherry Juice 1 cup 250 ml
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47. Grapes 10 individual
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48. Mango/ mango /juice 1 unidade média/ 1 cup 250ml
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49.Other fruits : peaches/figs/plums 1 medium
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50. Nuts (peanuts chestnuts) 2 small handfuls
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51. Olives 6 individual
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V. Bread, Cereals, Root Vegetables legumes (beans)
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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52. French Bread 1 roll
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53. Bread / soft roll 1 slice or roll
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54. Diet whole wheat bread 2 slices
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55. Breakfast cereals 1 small cup-full
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56. Corn kernels 2 dessert spoonfuls
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57. Potato boiled / mashed / baked 1 small
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58. French fries (potatoes) 1 heaping tablespoonful
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59. Cooked Rice 1 small rice ladle full
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60. Polenta 2 heaping tablespoons
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61.Cassava cooked 1 large spoonful
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62.“Farofa” manioc flour toasted with onions and seasonings 2 soup spoons
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63. Macarroni / pasta / instant 2 small ladles
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64. Beans Cooked ( broad, black, red, brown) 1 medium soup ladle
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65. White beans / dried peas /
lentils 1 medium ladle
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VI. Oils and Fats
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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67. Óleo de Soy/Corn/Canola/Sunflower
1 soup spoon
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68. Margarine 1 teaspoon
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69. Butter 1 teaspoon
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VII. Desserts, Savory snacks decorated iced Danish, cupcakes, doughnuts
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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70. Assorted chocolates 1 small bar / 1 candy
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71. Chocolate sauce 1 soup spoon
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72.Creamy desserts- creme caramel, gelatin based with cream 1 small slice
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73.Crystalized fruit in sugar syrup 1 large spoon full/ 2 pieces
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74. Ice Cream or sherbets 1 large scoop
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75. Candied fruit or nut bars 1 ½ small bars
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76. Savory snacks -cocktail or bar food type - or tapas 1 piece
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77. Water biscuits or cream crackers --5 crackers
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78. Sugar biscuits or cookies commercial, no filling --5 pieces
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79.Sweet biscuits with cream filling commercial type 4 pieces
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80. Sponge cake --1 medium slice
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81. Sponge cake with cream filling and fruit topping or fruit pie- 1 large piece
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82.Meat pie 1 large slice
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83. Pizza-- 2 pieces
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84. Bread bun with cheese filling 2 small
buns
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VIII. Drinks
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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85. Soft Drinks with sugar (cola/
lime/ orange / guarana/ ginger ale) 1 cup 250 ml
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86. Beer --1 can
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87. Wine -- 1 small glass
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88. Other alcoholic drinks : “pinga”/
whiskey, rum, vodka etc --1 shot
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89.” Chá mate/ preto” ( type of Brazilian tea non alcoholic) -1 cup 250 ml
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90 Strong . Coffee with or without sugar -2 small cups
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91.Artificial sugar sweeetener 1 cup 250 ml
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IX. Preparations and Miscellaneous
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Never or less than once a month
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2-3 times per month
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Once a week
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2-4 times per week
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5-7 times per week
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Once per day
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2-3 times per day
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4-6 times per day
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More than 6 times per day
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92. Sugar ( to sweeten tea or coffee) 2 teaspoons
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93.Vegetable soup with beans and seasonings - 2 medium ladles
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94.Potato salad with lots of mayonnaise
1 tablespoon
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95. Vegetable salad with mayonnaise -1 small ladle
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96.Industrial saucesKetchup, mustard, chili sauce, BBQ sauce etc) 1 soup spoon
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97. Tomato paste 1 ½ soup spoon
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98. Soya extract 1/2 tea cup
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Bibliographical Record
Katia Cristina Camondá Braz, Celso Abdon Lopes Mello, Marcello Ferretti Fanelli, Ludmilla
Thomé Domingos Chinen. Evaluation of the impact of chemotherapy on eating habits of
women with non-metastatic breast cancer. Brazilian Journal of Oncology 2022; 18: e-20220331.
DOI: 10.5935/2526-8732.20220331
