Journal of Human Nutrition and Dietetics
PUBLIC HEALTH NUTRITION AND EPIDEMIOLOGY Diet quality of Australian breast cancer survivors: a crosssectional analysis from the Australian Longitudinal Study on Women’s Health J. L. Potter,1 C. E. Collins,1,2 L. J. Brown3 & A. J. Hure4 1
School of Health Sciences, Faculty of Health, The University of Newcastle, University Drive, Callaghan, NSW, Australia Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Callaghan, NSW, Australia 3 Department of Rural Health, The University of Newcastle, Tamworth, NSW, Australia 4 Research Centre for Gender, Health and Aging, School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia 2
Keywords Australian Recommended Food Score, breast cancer survivors, diet quality, epidemiology, nutrition. Correspondence C. E. Collins, School of Health Sciences, Faculty of Health, The University of Newcastle, Hunter Building HA12, University Drive, Callaghan, NSW 2308, Australia. Tel.: +61 2 4921 5646 Fax: +61 2 4021 7053 E-mail: [email protected] How to cite this article Potter J.L., Collins C.E., Brown L.J. & Hure A.J. (2014) Diet quality of Australian breast cancer survivors: a cross-sectional analysis from the Australian Longitudinal Study on Women’s Health. J Hum Nutr Diet. 27, 569–576 doi:10.1111/jhn.12198
Abstract Background: Evidence supports strong associations between healthful eating patterns and maintaining a healthy weight with favourable health outcomes for breast cancer survivors (BCS). The present study aimed to evaluate the diet quality of Australian BCS and to determine whether diet quality differed between BCS and age-matched healthy controls (HC) or by geographical location. Methods: This cross-sectional study included 281 BCS and 4069 HC from the Australian Longitudinal Study on Women’s Health mid-aged cohort completing Survey 3 in 2001. Data from the Dietary Questionnaire for Epidemiological Studies food frequency questionnaire were used to calculate the Australian Recommended Food Score (ARFS), a validated summary estimate of diet quality based on adherence to the Australian dietary guidelines. Results: The mean (SD) ARFS of the BCS group was 33.2 (9.4) out of a maximum of 74. Mean (SD) total ARFS and component scores of BCS did not differ from the HC group [32.9 (8.7)] and no differences were found in ARFS between urban and rural BCS. Conclusions: This is the first study dedicated exclusively to describing the diet quality of Australian BCS. Although no difference was found when comparisons were made with a HC group, there is considerable room for improvement in the diet quality of Australian BCS. Given research suggesting higher risk of chronic conditions such as obesity amongst BCS, and the recognition of optimising diet quality as a key factor in health promotion for all population groups, data from the present study suggest the need for research targeting the feasibility and impact of improving diet quality of Australian BCS.
Introduction An increasing number of Australian women are being diagnosed and surviving breast cancer (Chiu et al., 2006; Australian Institute of Health and Welfare & Australasian Association of Cancer Registries, 2010; National Breast & Ovarian Cancer Centre, 2010). The promotion of healthful lifestyle habits, including dietary patterns, is key to improving health, well-being and longevity amongst this ª 2014 The British Dietetic Association Ltd.
growing population of breast cancer survivors (BCS) (World Cancer Research Fund & American Institute for Cancer Research, 2007; Rock et al., 2012). Although BCS comprise one of the largest cancer survivor cohorts in Australia (Australian Institute of Health and Welfare & Australasian Association of Cancer Registries, 2010), little is known about the dietary patterns of Australian BCS. Furthermore, although more than 30% of these women live outside metropolitan centres (National Breast & 569
J. L. Potter et al.
Diet quality of Australian breast cancer survivors
Ovarian Cancer Centre, 2010), no research has examined differences in dietary habits between rural and urban Australian BCS. As more women survive their breast cancer diagnosis, long-term health sequelae are a growing public health concern (Demark-Wahnefried et al., 2005). Compared to the general population, cancer survivors are at increased risk of second primary cancers, death from causes other than cancer and co-morbid chronic diseases such as type 2 diabetes, cardiovascular disease and osteoporosis (Demark-Wahnefried et al., 2005). Breast cancer survivors are also more likely to be overweight or obese compared to general population groups (Protani et al., 2010; Vance et al., 2011) and this is a known aetiological factor in breast cancer incidence (Renehan et al., 2008). These latent health consequences and co-morbidities signal a need and warrant the promotion and ongoing surveillance of preventive health behaviours within BCS populations (Eakin et al., 2007). Dietary patterns are gaining recognition as key modifiable risk factors for reducing co-morbidities and promoting long-term health of BCS (Pekmezi & Demark-Wahnefried, 2011). Consistent with the American Cancer Society’s guidelines for cancer survivors (Rock et al., 2012), Australian BCS are encouraged to follow current national guidelines for health promotion (Cancer Council Australia, 2009). The 2013 Australian Dietary Guidelines encourage a nutrient-dense varied diet, low in fat and high in wholegrain cereals, vegetables and fruits [National Health and Medical Research Council (NHMRC), 2013]. Despite public health efforts promoting healthy eating for this population, research has shown poor adherence of Australian cancer survivors to dietary recommendations (Eakin et al., 2007). Several studies combine multiple dietary factors, such as overall variety, fruit, vegetable and fat intakes, to derive a diet quality score summarising eating pattern alignment with specific criteria (Wirt & Collins, 2009). Where diet quality aligns with national guidelines, data show associations with decreased morbidity and mortality along with a reduced risk of overweight and obesity and an improved quality-of-life (Kant et al., 2000; Wirt & Collins, 2009; Wolongevicz et al., 2010). Higher diet quality amongst BCS has also been associated with reduced comorbidity (Kant et al., 2000), improved survival (George et al., 2011; Kim et al., 2011) and wellbeing (Tangney et al., 2002; Wayne et al., 2006). Using data from the Australian Longitudinal Study on Women’s Health (ALSWH) mid-aged cohort, the primary aim of the present study was to describe diet quality of Australian BCS. The second aim was to compare diet quality of BCS with healthy mid-aged women enrolled in the ALSWH. The third aim was to compare diet quality of rural versus urban BCS. Few studies have reported die570
tary data of Australian cancer survivors (Eakin et al., 2007) and this is the first study dedicated exclusively to describing the diet quality of Australian BCS. Materials and methods This cross-sectional study accessed self-reported data that were collected prospectively as part of the ALSWH. Comprising a nationally representative study of factors affecting the health of Australian women, the ALSWH has been described in detail elsewhere (Brown et al., 1998; Lee et al., 2005). Briefly, the ALSWH commenced with baseline surveys in 1996 and has been designed to follow women throughout the life stages divided into three cohorts: those born 1973– 1978 (younger), 1946–1951 (mid-aged) and 1921–1926 (older). Women were randomly selected from the Australian health insurance database (Medicare), which includes a listing of all permanent Australian residents. To date, six major mail-based surveys have been completed by each cohort and dietary data have been collected during Survey 3 in 2001 and Survey 6 in 2012. Ethics approval for the ALSWH was obtained from the University of Newcastle and the University of Queensland Human Research Ethics Committees. Study participants Dietary data collected at Survey 3 in 2001 from the midaged cohort, then aged 50–55 years, were the focus of the present study. This cohort, of age range 50–69 years, was of interest because breast cancer incidence is highest amongst this age group (Breast Cancer Australia, 2012). Of the total ALSWH cohort, 14 072 women aged 45–50 years participated in Survey 1 (baseline) of mid-aged women in 1996. This was estimated to represent a 53–56% response rate for this cohort. From baseline, 11 228 women in the mid-aged cohort completed Survey 3, resulting in a response rate of 83% of those who completed Survey 1. Self-report data were used to identify BCS, with an affirmative response required for the question ‘Have you ever been told by a doctor that you have breast cancer?’ at Survey 1 and/or Survey 2 and/or the question ‘In the past three years have you ever been diagnosed with breast cancer?’ at Survey 3. For women in the mid-aged cohort, of those who responded in the affirmative based on the above criteria, 295 had a history of breast cancer at Survey 3. Of these BCS, 281 returned a usable food frequency questionnaire (FFQ) (
PUBLIC HEALTH NUTRITION AND EPIDEMIOLOGY Diet quality of Australian breast cancer survivors: a crosssectional analysis from the Australian Longitudinal Study on Women’s Health J. L. Potter,1 C. E. Collins,1,2 L. J. Brown3 & A. J. Hure4 1
School of Health Sciences, Faculty of Health, The University of Newcastle, University Drive, Callaghan, NSW, Australia Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Callaghan, NSW, Australia 3 Department of Rural Health, The University of Newcastle, Tamworth, NSW, Australia 4 Research Centre for Gender, Health and Aging, School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia 2
Keywords Australian Recommended Food Score, breast cancer survivors, diet quality, epidemiology, nutrition. Correspondence C. E. Collins, School of Health Sciences, Faculty of Health, The University of Newcastle, Hunter Building HA12, University Drive, Callaghan, NSW 2308, Australia. Tel.: +61 2 4921 5646 Fax: +61 2 4021 7053 E-mail: [email protected] How to cite this article Potter J.L., Collins C.E., Brown L.J. & Hure A.J. (2014) Diet quality of Australian breast cancer survivors: a cross-sectional analysis from the Australian Longitudinal Study on Women’s Health. J Hum Nutr Diet. 27, 569–576 doi:10.1111/jhn.12198
Abstract Background: Evidence supports strong associations between healthful eating patterns and maintaining a healthy weight with favourable health outcomes for breast cancer survivors (BCS). The present study aimed to evaluate the diet quality of Australian BCS and to determine whether diet quality differed between BCS and age-matched healthy controls (HC) or by geographical location. Methods: This cross-sectional study included 281 BCS and 4069 HC from the Australian Longitudinal Study on Women’s Health mid-aged cohort completing Survey 3 in 2001. Data from the Dietary Questionnaire for Epidemiological Studies food frequency questionnaire were used to calculate the Australian Recommended Food Score (ARFS), a validated summary estimate of diet quality based on adherence to the Australian dietary guidelines. Results: The mean (SD) ARFS of the BCS group was 33.2 (9.4) out of a maximum of 74. Mean (SD) total ARFS and component scores of BCS did not differ from the HC group [32.9 (8.7)] and no differences were found in ARFS between urban and rural BCS. Conclusions: This is the first study dedicated exclusively to describing the diet quality of Australian BCS. Although no difference was found when comparisons were made with a HC group, there is considerable room for improvement in the diet quality of Australian BCS. Given research suggesting higher risk of chronic conditions such as obesity amongst BCS, and the recognition of optimising diet quality as a key factor in health promotion for all population groups, data from the present study suggest the need for research targeting the feasibility and impact of improving diet quality of Australian BCS.
Introduction An increasing number of Australian women are being diagnosed and surviving breast cancer (Chiu et al., 2006; Australian Institute of Health and Welfare & Australasian Association of Cancer Registries, 2010; National Breast & Ovarian Cancer Centre, 2010). The promotion of healthful lifestyle habits, including dietary patterns, is key to improving health, well-being and longevity amongst this ª 2014 The British Dietetic Association Ltd.
growing population of breast cancer survivors (BCS) (World Cancer Research Fund & American Institute for Cancer Research, 2007; Rock et al., 2012). Although BCS comprise one of the largest cancer survivor cohorts in Australia (Australian Institute of Health and Welfare & Australasian Association of Cancer Registries, 2010), little is known about the dietary patterns of Australian BCS. Furthermore, although more than 30% of these women live outside metropolitan centres (National Breast & 569
J. L. Potter et al.
Diet quality of Australian breast cancer survivors
Ovarian Cancer Centre, 2010), no research has examined differences in dietary habits between rural and urban Australian BCS. As more women survive their breast cancer diagnosis, long-term health sequelae are a growing public health concern (Demark-Wahnefried et al., 2005). Compared to the general population, cancer survivors are at increased risk of second primary cancers, death from causes other than cancer and co-morbid chronic diseases such as type 2 diabetes, cardiovascular disease and osteoporosis (Demark-Wahnefried et al., 2005). Breast cancer survivors are also more likely to be overweight or obese compared to general population groups (Protani et al., 2010; Vance et al., 2011) and this is a known aetiological factor in breast cancer incidence (Renehan et al., 2008). These latent health consequences and co-morbidities signal a need and warrant the promotion and ongoing surveillance of preventive health behaviours within BCS populations (Eakin et al., 2007). Dietary patterns are gaining recognition as key modifiable risk factors for reducing co-morbidities and promoting long-term health of BCS (Pekmezi & Demark-Wahnefried, 2011). Consistent with the American Cancer Society’s guidelines for cancer survivors (Rock et al., 2012), Australian BCS are encouraged to follow current national guidelines for health promotion (Cancer Council Australia, 2009). The 2013 Australian Dietary Guidelines encourage a nutrient-dense varied diet, low in fat and high in wholegrain cereals, vegetables and fruits [National Health and Medical Research Council (NHMRC), 2013]. Despite public health efforts promoting healthy eating for this population, research has shown poor adherence of Australian cancer survivors to dietary recommendations (Eakin et al., 2007). Several studies combine multiple dietary factors, such as overall variety, fruit, vegetable and fat intakes, to derive a diet quality score summarising eating pattern alignment with specific criteria (Wirt & Collins, 2009). Where diet quality aligns with national guidelines, data show associations with decreased morbidity and mortality along with a reduced risk of overweight and obesity and an improved quality-of-life (Kant et al., 2000; Wirt & Collins, 2009; Wolongevicz et al., 2010). Higher diet quality amongst BCS has also been associated with reduced comorbidity (Kant et al., 2000), improved survival (George et al., 2011; Kim et al., 2011) and wellbeing (Tangney et al., 2002; Wayne et al., 2006). Using data from the Australian Longitudinal Study on Women’s Health (ALSWH) mid-aged cohort, the primary aim of the present study was to describe diet quality of Australian BCS. The second aim was to compare diet quality of BCS with healthy mid-aged women enrolled in the ALSWH. The third aim was to compare diet quality of rural versus urban BCS. Few studies have reported die570
tary data of Australian cancer survivors (Eakin et al., 2007) and this is the first study dedicated exclusively to describing the diet quality of Australian BCS. Materials and methods This cross-sectional study accessed self-reported data that were collected prospectively as part of the ALSWH. Comprising a nationally representative study of factors affecting the health of Australian women, the ALSWH has been described in detail elsewhere (Brown et al., 1998; Lee et al., 2005). Briefly, the ALSWH commenced with baseline surveys in 1996 and has been designed to follow women throughout the life stages divided into three cohorts: those born 1973– 1978 (younger), 1946–1951 (mid-aged) and 1921–1926 (older). Women were randomly selected from the Australian health insurance database (Medicare), which includes a listing of all permanent Australian residents. To date, six major mail-based surveys have been completed by each cohort and dietary data have been collected during Survey 3 in 2001 and Survey 6 in 2012. Ethics approval for the ALSWH was obtained from the University of Newcastle and the University of Queensland Human Research Ethics Committees. Study participants Dietary data collected at Survey 3 in 2001 from the midaged cohort, then aged 50–55 years, were the focus of the present study. This cohort, of age range 50–69 years, was of interest because breast cancer incidence is highest amongst this age group (Breast Cancer Australia, 2012). Of the total ALSWH cohort, 14 072 women aged 45–50 years participated in Survey 1 (baseline) of mid-aged women in 1996. This was estimated to represent a 53–56% response rate for this cohort. From baseline, 11 228 women in the mid-aged cohort completed Survey 3, resulting in a response rate of 83% of those who completed Survey 1. Self-report data were used to identify BCS, with an affirmative response required for the question ‘Have you ever been told by a doctor that you have breast cancer?’ at Survey 1 and/or Survey 2 and/or the question ‘In the past three years have you ever been diagnosed with breast cancer?’ at Survey 3. For women in the mid-aged cohort, of those who responded in the affirmative based on the above criteria, 295 had a history of breast cancer at Survey 3. Of these BCS, 281 returned a usable food frequency questionnaire (FFQ) (
