Research Article

Podcast available online

at www.jneb.org

Nutrition Education Intervention for Women With Breast

Cancer: Effect on Nutritional Factors and Oxidative Stress
Cecilia C. Schiavon, MsC1; Francilene G. K. Vieira, PhD1; Vanessa Ceccatto, MsC1;
Sheyla de Liz, MsC1; Alyne L. Cardoso, MsC1; Cristiane Sabel, BHSc2;
David A. Gonzalez-Chica, PhD1; Edson L. da Silva, PhD2; Daisy Galvan, MsC1;
Carlos G. Crippa, PhD3; Patricia F. Di Pietro, PhD1

ABSTRACT
Objectives: To assess the effect of a nutrition education intervention on nutritional factors and oxidative
stress during treatment of breast cancer.
Design: Nonrandomized clinical trial conducted in 2010–2011, including an evaluation at baseline and
after 12 months.
Participants: Women from Brazil who had breast cancer, divided into an intervention group (IG)
(n ¼ 18) and comparison group (n ¼ 75).
Intervention: To increase intake of fruits and vegetables and reduce red and processed meats, via tele-
phone and printed materials.
Main Outcome Measures: Food intake, anthropometry, and levels of lipid hydroperoxide, carbonyl
proteins, reduced glutathione, and ferric reducing antioxidant power.
Analyses: Chi-square, Mann–Whitney or t tests for baseline data; Wilcoxon or paired t tests for intra-
group outcomes, linear regression models, and Bonferroni multiplicity adjustment.
Results: The researchers observed an increase in fruit and vegetable intake, reduction in red and processed
meat intake, no change in body weight, and an increase in glutathione in the IG over the comparison
group. However, after Bonferroni adjustment, only the consumption of fruits and vegetables and fruit
was significantly higher in IG.
Conclusions and Implications: This study presents improved dietary changes after a theory-driven
nutrition education intervention. Although the sample size is small, it has proven to be clinically relevant.
Key Words: intervention studies, food habits, breast neoplasms, oxidative stress (J Nutr Educ Behav.
2015;47:2-9.)
Accepted September 19, 2014.

INTRODUCTION disease has been increasing. However, study,2 the pooled estimate of 5-year
survival rates in Brazil are still low; survival in Brazil was 58.4%.2
Breast cancer is the most frequent 5-year relative survival for breast can- Anti-cancer treatments (radiation
cause of cancer death in women cer is generally higher in North Amer- and chemotherapeutic agents) exert
worldwide, including Brazil.1 Because ica, Australia, Japan, and northern, their effects generating oxidative
of increased longevity and more western, and southern Europe, and stress (OS) and potentially damaging
effective anti-cancer treatments, the lower in Algeria, Brazil, and eastern not only cancer cells but healthy cells
number of people surviving this Europe.2 According to the CONCORD as well. Oxidative stress has been asso-
ciated with greater cancer recurrence.3
Furthermore, known nutritional risk
factors for cancer recurrence and for
1
Department of Nutrition, Federal University of Santa Catarina, Florian
opolis, Santa Cata- an increase in OS (such as weight
rina, Brazil gain and increased consumption of
2
Department of Clinical Analyses, Federal University of Santa Catarina, Florian
opolis, Santa meat and fatty foods) are observed.4,5
Catarina, Brazil Patients who are overweight or who
3
Department of Tocoginecology, Federal University of Santa Catarina, Florian
opolis, Santa gain weight after being diagnosed
Catarina, Brazil with cancer have a greater risk of
Address for correspondence: Patricia F. Di Pietro, PhD, Programa de P
os-Graduaç~ao em recurrence or death compared with
Nutriç~ao, Centro de Ci^encias da Sa

ude, Universidade Federal de Santa Catarina, Campus those who maintain stable body
Universit
ario, Trindade, Cep 88040-900, Florian
opolis/SC–Brazil; Phone: þ55 48 3721 weight.6
8014; Fax: þ55 48 3721 9542; E-mail: patricia.di.pietro@ufsc.br Diet can help to lower the risk of
Ó2015 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR cancer recurrence through the antiox-
http://dx.doi.org/10.1016/j.jneb.2014.09.005 idant effects of fruits and vegetables

2 Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015

Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015 Schiavon et al 3

(FV).3,4 Therefore, education strategies

are being evaluated, because it has
been shown that long-term adherence
to a dietary pattern is a challenge in
studies that investigate the relationship
between diet and disease. Most nutri-
tion education intervention methods
for breast cancer are based on Social
Cognitive Theory (SCT),6-8 which
essentially adopts the perspective of
acting for self-development, adapta-
tion, and change.9 However, few
studies assess the effects of nutrition ed-
ucation interventions during breast
cancer treatment10 and of OS on breast
cancer patients.3
Therefore, the objective of this
study was to assess the effectiveness
of a nutrition education intervention
that promotes increased FV intake
and reduced consumption of red and
processed meats (RPM) in improving
nutritional factors and OS biomarkers.
Intake of FV is important in preve- Figure. Study design for a nutrition education intervention for women with breast can-
nting cancer and its recurrence,11 cer. FFQ indicates food frequency questionnaire; OS, oxidative stress; T0, time zero
whereas RPM are hypothesized to (baseline); T1, time one (end).
have a negative impact on breast can-
cer, possibly owing to the biochem- and included all patients admitted for tables (1 small plate), and 2 servings of
istry of meat compounds and their surgical treatment of suspected malig- cooked vegetables (2 spoonfuls) and to
oxidative processes, such as the muta- nant breast tumors. Criteria for exclu- limit the intake of RPM to twice a
genic and carcinogenic effect of the sion were history of cancer or any week, represented by 1 medium steak
heterocyclic amines.12 surgical procedure in the previous each time.
year; pregnancy or breastfeeding at the During the first meeting (which
time of diagnosis; human immunodefi- occurred in the hospital), a 12-month
METHODS ciency virus–positive test result; neoad- calendar was given to participants,
Population and Study Design juvant anti-cancer treatment; and who were instructed to mark how
neurological disease diagnosis. This often they consumed RPM and FV.
A non-randomized, controlled clinical study followed ethical principles and This practice enabled patients to track
trial was developed in Floriano
polis, was approved by the Human Ethical their own dietary habits, and conse-
a city located in southern Brazil, Committee of Maternidade Carmela quently their involvement with the
which included women with breast Dutra Hospital, as well as the Commit- research. In addition, models of home
cancer at the time of diagnosis. The tee of Federal University of Santa Cata- food measurement were presented
data were collected in the Hospital rina. Participants signed an informed using a photo album.16 After the first
Maternidade Carmela Dutra before consent form during all interviews. hospital contact, the researchers
surgery and at the beginning (T0) made biweekly phone calls to patients,
and end of treatment 12 months later using a standard protocol. First, pa-
(T1). The comparison group (CG) was Intervention. The intervention study tients were asked how they were
composed of all women with breast stages described in the Figure were feeling and if they were able to eat nor-
cancer who were investigated be- conducted over 12 months. The main mally. Main points of the intervention
tween 2006 and 2010.13-15 Members objective conveyed to participants also were reviewed.
of the intervention group (IG) were was to consume at least 400 g FV/ Bimonthly 24-hour dietary recalls
invited to participate in the nutrition d (excluding fruit juices and starchy were conducted during a weekday
education intervention from March vegetables) and to limit RPM intake phone call, with a second recall
to June, 2010. It is important to to a maximum of 500 g/wk. Red meat conducted on the following Monday.
highlight that for CG patients, basic refers to beef, pork, lamb, and goat After hearing reports of food intake,
guidelines were provided before the meat. Processed meat is characterized the researcher commented on the
2 interviews, whereas IG patients as meat preserved by smoking, curing, quantities of RPM and FV, recom-
were given continuous guidelines salting, or adding chemical preserva- mending an increase or reduction in
during the treatment (Figure). tives.11 To facilitate their understand- consumption if necessary. The recalls
Recruitment, the initial interview, ing, participants were encouraged to and calendar were used only as a
and blood collection occurred at consume at least 2 servings of fruit/ cognitive reinforcement, as suggested
Maternidade Carmela Dutra Hospital d (2 cups), a small serving of raw vege- by Higgs.17
4 Schiavon et al Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015

Monthly bulletins were sent via 0.44 for energy and for protein to absolute and relative frequency while
mail. These evidence-based bulletins 0.41 for fat and 0.34 for carbohydrates. continuous variables are expressed as
consisted of illustrated materials in The ratio of energy intake to estimated means and SD or median and inter-
understandable language and were basal metabolism among women was quartile range, depending on variable
prepared using scientific evidence on 1.15 for the 24-hour recall and 1.24 symmetry. The researchers used chi-
different topics such as physical activ- for the FFQ. square test to compare categorical
ity, how to minimize the side effects All data from the FFQ were con- variables (clinical and socioeconomic
of treatment, and the importance of verted to daily frequency of consump- data) between the IG and CG at T0
nutrition for the immune system. tion (expressed in grams or milliliters). whereas they used the t test for inde-
This methodology was based on Seasonal foods such as the group of FV pendent data or the Mann–Whitney
SCT, specifying the determinants that had consumption estimates obtained test to compare continuous variables.
promote psychosocial changes and in proportion to the period of the Paired t test or Wilcoxon test was
the mechanisms through which they crop. Based on daily intake, nutrition used for intra-group outcome com-
produce the desired effects, which calculation was performed in the Excel parisons (comparison between T0
basically adopts the perspective of program for each food, in which en- and T1). Bonferroni multiplicity
acting toward self-regulation, adapta- ergy (in kilocalories) and protein, car- adjustment was conducted by AN-
tion, and change. To be an agent bohydrates, total fat, saturated fat, COVA for energy at T1, result at T0,
means to influence one's own func- monounsaturated fat, polyunsaturated and endpoint that was different at
tioning and life's circumstances in an fat, and fiber (all in grams) were esti- baseline period. This test was con-
intentional way. According to this the- mated. The calculation was based on ducted because the study has multi-
ory, people are viewed as self- nutritional composition from the Bra- ple comparisons of variables from 1
organizing, self-regulating, proactive, zilian Table of Food Composition and data set.
and self-reflective, contributing to US Department of Agriculture table. The authors subsequently used a
and shaping their own life's circum- The questionnaire from study by linear regression model to compare
stances instead of being mere products the Vieira et al13 was used to obtain so- outcome values, subjecting them to
of life's conditions. This component ciodemographic, clinical, and anthro- logarithmic transformation to norma-
provides the main knowledge princi- pometric data, and standard World lize the data. The first model was
ples that can lead to change.9 Health Organization procedures19 adjusted for energy consumption
The second intervention compo- were used to measure height and data obtained in the study's final stage
nent is a model of translation and im- weight. Further details about data (T1) and a complementary model was
plementation, in which theoretical collection were described previ- used, also adjusting for the outcome
and academic language were converted ously.13,14 value at the beginning of the study
into everyday language.9 This model (T0) and for those values that
specifies the content, strategies for were different at T0. This adjustment
Biochemical analyses. Fasting blood
change, and implementation. Both for the initial value was done to cor-
samples were collected at T0 and T1.
components are present in the mate- rect data estimating patients' true
Oxidative stress was assessed through
rials, the language of phone calls, and mean change between the 2 periods.
antioxidant biomarkers: reduced
the interviews. In addition, the inter- Because of the use of natural loga-
glutathione (GSH)20 and antioxidant
vention did not require in-person con- rithms, the regression coefficients
capacity21; and oxidant biomarkers:
tact after the initial interview because were presented in exponential form
plasma lipid peroxidation measured
patients report lack of physical motiva- and should be interpreted as a relative
with serum lipid hydroperoxides
tion during anti-cancer treatment. risk (multiplying effect) of the IG in
(LH)22 and oxidized protein content
relation to the values of the CG, in
through the carbonyl protein (CP)
Questionnaires. The questionnaires which values > 1.0 indicate a percent-
technique.23
were applied identically at T0 and T1 age increase whereas values < 1.0 indi-
by trained interviewers who followed cate a decrease in the IG compared
a data collection manual developed Data analysis. The data were with the CG.
specifically for this study and used a analyzed using Stata program, version Because the study included all
photo album.15 A validated and adapt- 11.0 (StataCorp, College Station, TX, eligible patients seen in the hospital,
ed food frequency questionnaire (FFQ) 2009). Initial data assessed included the sample size was not calculated
was used. This FFQ18 for the Brazilian age; education; income; physical activ- previous to the data collection. Never-
diet was developed and compared ity level; use of tobacco, dietary supple- theless, the power of the study was
with 4 24-hour recalls among faculty ments, and alcoholic beverages; state estimated a posteriori based on the
and support staff at the University of of disease and tumor classification; available sample size, in the mean/
Rio de Janeiro, Brazil; both methods and use of chemotherapy and radio- median and SD (or a correspondent
were validated against the estimated therapy. Outcomes investigated in- value of 25% of the median for asym-
daily energy requirement. Results of cluded fruit, vegetable, and RPM metric variables) of the outcomes in
the FFQ and the 24-hour recalls were intake; macronutrients and fatty acids the CG and in the ratio of CG/IG
correlated to a similar degree as in (in grams); and OS biomarkers (in mi- (4.2). Considering an alpha of 5%,
studies of other populations. The cor- cromoles per liter). the study showed 80% power to
relation coefficients concerning vari- Categorical variables in the detect an increase of at least 18.5%
ables that were analyzed varied from descriptive statistics are expressed as in the mean/median for fruit
Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015 Schiavon et al 5

Table 1. Daily Dietary Intake, Oxidative Stress Biomarkers, Body Weight, and Body Mass Index at Baseline Time for Comparison
Group (n ¼ 75) and Intervention Group (n ¼ 18)

Variable Comparison Group Intervention Group P

Fruits and vegetables, ga 421.4 (305.2–663.4) 338.3 (192.6–607.2) .13
Fruits, ga 285.2 (191.4–459.7) 232.0 (123.8–340.3) .15
a
Vegetables, g 112.4 (73.5–158.4) 112.3 (54.3–161.1) .45
Red or processed meats, g 59.0 (36.0–99.1) 81.8 (54.2–149.9) < .001*
Energy, kcal 2,145.3 (1,727.1–2,764.3) 2,556.7 (2,141.4–3,118.4) .07
Proteins, g 78.3 (59.9–94.1) 88.9 (75.3–132.0) .09
Lipids, g 78.1 (58.7–101.2) 105.1 (72.2–122.0) .06
Carbohydrates, g 285.6 (211.5–378.2) 303.4 (273.6–326.5) .33
Saturated fat, g 25.2 (16.8–32.0) 36.8 (23.3–44.5) .02*
Monounstaurated fat, g 22.3 (16.3–29.1) 32.6 (20.5–39.9) .05*
Polyunsaturated fat, g 22.0 (14.4–28.8) 25.7 (16.3–32.1) .41
Lipid hydroperoxide, mmol/L 3.9 (2.8–7.9) 3.9 (2.9–4.4) .41
Carbonyl protein, mmol/L 0.7 (0.5–1.1) 1.2 (0.8–1.2) .001*
Reduced glutathione, mmol/L 78.3 (20.4) 106.3 (33.5) < .001*
Antioxidant capacity, mmol/L 625.8 (155.9) 588.2 (156.1) .37
Weight, kg 68.5 (127) 72 (147) .32
2
BMI, kg/m 27.6 (4.5) 28.9 (4.6) .29
*P < .05 was considered significant; Did not include fruit juice or starchy vegetables.
a

Note: Statistical tests used were t test or Mann–Whitney. Data are presented as median (interquartile range) or mean (SD).

consumption, vegetables consump- pants (aged 49.6  10.7 years) who dence interval, 333.9–766.3) in the
tion, FV consumption, FRAP, and LH completed all of the study's stages. CG (data not shown). This result
levels; 19.2% for GSH levels; 12.3% occurred mainly because of increased
for body mass index (BMI), and fruit intake, although vegetable con-
13.9% for weight. For RPM, energy, Baseline Characteristics sumption also increased significantly
macronutrients, and all the other lab- The IG and CG were not significantly in the IG; there was no significant
oratory levels, the study was able to different in terms of age, education,
change for fruits or vegetables in the
detect a reduction of at least 15–16% income, physical activity level, use of
CG. A significant reduction in RPM
as statistically significant. tobacco, dietary supplements or alco-
consumption was observed only in
the IG. The same result was found in
holic beverages, disease stage, or tumor
relation to energy and intake of pro-
size. With respect to the study out-
RESULTS teins, total lipids, and saturated and
comes, significantly higher intakes
monounsaturated fats, which were
were observed at T0 in terms of RPM
The CG was composed of 75 women intake, saturated fatty acid intake, CP,
significantly reduced only in the IG.
(aged 51.8  11.0 years). Twenty- and GSH biomarkers for the IG
However, after Bonferroni correction
eight provisionally eligible patients the consumption of FV and fruit
(Table 1).
were invited at the hospital to partici- increased significantly for IG (Table 2).
pate in the intervention (Figure). The LH and CP biomarkers
However, 2 could not be contacted Differences After Treatment and increased in the CG. No change was
by phone a posteriori, 1 was under- Intervention/Treatment Periods observed in the IG. With respect to
going radiotherapy treatment at the the antioxidant biomarkers, antioxi-
end of the intervention's 12 months, Table 2 shows the changes in con- dant capacity was reduced only in the
3 were diagnosed with a benign dis- sumption of food and nutrient IG. A significant increase in body
ease after pathologic evaluation, and groups, OS biomarkers, body weight, weight was observed only in the CG;
1 was diagnosed with Alzheimer and BMI between T0 and T1. The IG this value was nearly 2 times greater
disease (Figure). Of the sample losses, significantly increased its intake of than in the IG. A similar situation
3 occurred during the intervention, 2 FV whereas the CG did not. The was observed for BMI but in this case,
subjects chose not to continue, and study's final assessment (T1) revealed the increase in the CG was 3 times
1 could not be contacted at the tele- that mean FV intake in the IG was greater than in the IG.
phone number provided. In the end, 748.2 g (confidence interval, 397– Table 3 lists the crude value differ-
the IG was composed of 18 partici- 941.1) whereas it was 494.6 g (confi- ence in which FV intake was 70% to
6 Schiavon et al Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015

Table 2. Differences Between Time 0 and Time 1 in Daily Dietary Intake, Oxidative Stress Biomarkers, Body Weight, and Body
Mass Index in Comparison Group (n ¼ 75) and Intervention Group (n ¼ 18) and Bonferroni Adjustment for Multiple
Intergroup Comparisons

Intergroups
Variable Comparison Group P Intervention Group P (Adjusted P)
Fruits and vegetables, ga 14.9 (198.5 to 239.7) .48 225.3 (132.6 to 555.4) .001* .001
Fruits, ga 43.3 (109.5 to 211.7) .09 220.6 (305.3) .007* < .001
Vegetables, ga 6.23 (59.6 to 51.3) .57 35.9 (18.28 to 134.4) .04* .062
Red or processed meats, g 4.96 (55.96) .45 31.4 (111.2 to 11.0) .001* .065
Energy, kcal 50.1 (844.8) .61 720.7 (1,104.8) .01* .264
Proteins, g 0.3 (20.1 to 20.1) .96 26.8 (36.0) .07 .312
Lipids, g 0.9 (38.4) .84 39.3 (47.3) .003* .084
Carbohydrates, g 16.7 (132.2) .28 47.6 (160.1) .22 .159
Saturated fat, g 0.3 (9.1 to 8.0) .78 14.3 (14.3) < .001* .614
Monounsaturated fat, g 0.2 (11.3) .86 12.7 (13.6) .001* .296
Polyunsaturated fat, g 1.3 (11.8) .33 8.8 (13.0 to 3.1) .26 .076
Lipid hydroperoxide, mmol/L 1.5 (5.6) .02* 0.8 (2.3) .19 .941
Carbonyl protein, mmol/L 0.2 (0.1 to 0.4) .01* 0.1 (0.2 to 0.1) .16 .548
Reduced glutathione, mmol/L 0.0 (35.2) .99 7.7 (32.2) .34 .465
Antioxidant capacity, mmol/L 50.2 (224.0) .06 93.2 (137.9) .01* .109
Weight, kg 2.0 (1.0 to 4.8) < .001* 1.2 (3.3) .14 .453
Body mass index, kg/m2 1.0 (1.9) < .001* 0.3 (1.3) .28 .580
*P < .05 was considered significant; Did not include fruit juice or starchy vegetables.
a

Note: Statistical tests used were t test or Mann–Whitney. Data are presented as median (interquartile range) or mean (SD).
Adjustment for multiple comparisons: Bonferroni by ANCOVA for energy at Time 1, result at Time 0, and end point that was
different at baseline period.

80% higher in the IG than in the CG. counseling in a nutritional care changes in behavior regarding health,
The RPM consumption was 50% context and defined it as a process car- as was done in this study. This can
lower in the IG than in the CG and ried out through a dialog between the contribute to patients' treatment and
similar associations were observed client with a life history and the nutri- consequently to their long-term
with total energy and intake of pro- tionist, who must be prepared to survival.28
teins, lipids, saturated and monounsat- analyze the dietary problem through In this study, subjects had a lower
urated fats, and CP biomarkers (values the person's biological, psychological, educational level than those in
were 20% to 40% lower). When food social, and cultural context. Thus, other studies using similar method-
intake values were adjusted for con- study effectiveness can be attribu- ologies. In the Women's Healthy
sumption of energy (Model 1), the ted to the proposed methodology be- Eating and Living study,8,29 > 50%
magnitudes of effect and statistically ing implemented in a noninvasive of individuals had attended college,
significant values remained stable. manner, respecting the patient's time whereas most participants in this
Model 2 allows comparison between and occurring mainly via telephone study had # 8 years of school. Patients
the IG and CG through an additional and mail. with higher educational levels tend
adjustment for the baseline values of Although similar results were found to benefit more from the cognitive-
each outcome and for values that were in others studies,25,26 there is a lack behavioral approach for self-manage-
different at T0. This model confirms of intervention studies conducted ment. However, chronically ill patients
the result of adjustment between the immediately after disease diagnosis, as with lower educational levels can
2 groups: IG improved the consump- was done in this study. According obtain greater benefits if their level of
tion of fruit and FV. to Kushi et al,27 studies of patients cognition is taken into account
who completed chemotherapy or radio- in designing the interventions (as
therapy demonstrate changes in diet was done in this study), using under-
DISCUSSION influenced by the treatment that do standable language in the education
not represent long-term dietary patterns and materials.30 In addition, telephone
The study intervention provided die- or potential effects of the intervention. counseling has proven to be a good
tary counseling using an educational Thus, the post-diagnostic stage seems strategy, as shown in a systematic
approach. Rodrigues et al24 discussed to be an appropriate time to suggest review of nutrition interventions,31
Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015 Schiavon et al 7

Table 3. Linear Regression Models for Nutritional Variables and Oxidative Stress Biomarkers Comparing Intervention Group
(n ¼ 18) and Comparison Group (n ¼ 75) Values

b Coefficient in Linear Regression Models

Variable Gross Model 1 Model 2

Fruits and vegetables, ga 1.8 (1.3–2.5)* 2.1 (1.4–3.2)* 2.3 (1.4–3.8)*
Fruits, ga 12.6 (3.9–39.6)* 11.0 (3.5–35.5)* 11.0 (3.3–38.5)*
a
Vegetables, g 1.8 (1.1–2.9)* 1.6 (1.1–2.3)* 1.7 (1.0–2.5)
Red or processed meats, g 0.5 (0.3–0.8)* 0.6 (0.4–1.0)* 0.6 (0.2–1.8)
Energy, kcal 0.8 (0.6–0.9)* 0.9 (0.6–1.0) 1.1 (0.9–1.3)
Proteins, g 0.8 (0.6–0.9)* 1.0 (0.9–1.2) 0.9 (0.7–1.1)
Lipids, g 0.7 (0.5–0.9)* 0.9 (0.8–1.1) 1.1 (0.9–1.3)
Carbohydrates, g 0.8 (0.7–1.0) 1.0 (0.9–1.1) 0.9 (0.7–1.0)
Saturated fats, g 0.6 (0.5–0.8)* 0.9 (0.7–1.0) 0.9 (0.7–1.1)
Monounsaturated fats, g 0.7 (0.5–0.9)* 0.9 (0.7–1.0) 1.0 (0.8–1.2)
Polyunsaturated fats, g 0.8 (0.6–1.0) 1.0 (0.8–1.2) 1.3 (1.0–1.7)
Lipid hydroperoxide, mmol/L 1.2 (0.6–2.3) 1.1 (0.6–2.0) 1.4 (0.7–3.1)
Carbonyl protein, mmol/L 0.8 (0.6–1.0)* 1.0 (0.9–1.1) 1.1 (0.9–1.2)
Reduced glutathione, mmol/L 1.0 (0.8–1.3) 1.3 (1.1–1.6)* 1.1 (0.9–1.4)
Antioxidant capacity, mmol/L 1.0 (0.8–1.1) 0.9 (0.8–1.0) 0.9 (0.7–1.1)
Weight, kg 1.1 (0.0–3.4) 0.1 (0.0–3.8) 1.0 (0.9–1.0)
2
Body mass index, kg/m 1.0 (0.9–1.0) 1.0 (0.9–1.0) 1.0 (0.9–1.0)
*P < .05 was considered significant; Did not include fruit juice or starchy vegetables.
a

Note: Statistical test used was Wald test. Data are presented as median (range). Owing to the use of natural logarithms, regres-
sion coefficients are presented in exponential form and should be interpreted as a relative risk (multiplier effect) of intervention
group in relation to comparison group values. Model 1: values adjusted for energy intake at Time 1 (excluding biochemical
markers) and outcome value at Time 0. Model 2: values adjusted for energy intake at Time 1 (excluding biochemical markers),
outcome value at Time 0, red and processed meat consumption at Time 0, saturated and monounsaturated fat at Time 0, and
carbonyl protein and reduced glutathione at Time 0.

particularly considering that the breast cancer diagnosis regardless of studies showed reduced GSH during
women were undergoing anti-cancer age, energy intake, clinical status, or the initial stages of breast cancer and
treatment. BMI at the time of the diagnosis.35 in patients undergoing the 5-
In the multicenter Women's Inter- An insignificant gain was observed in fluorouracil, doxorubicin, and cyclo-
vention Nutrition Study, which had the current study among IG partici- phosphamide anthracycline protocol
a larger sample size, a nutrition inter- pants whereas there was a significant commonly administered to breast can-
vention based on dietary fat intake weight gain in the CG, although there cer patients, including those in this
for women with breast cancer who was no statistical difference between study.36,37 Demark-Wahnefried et al38
had already undergone anti-cancer groups (Table 2). reported even greater difficulties in an
treatment concluded that there was With respect to OS, there was a sig- intervention with breast cancer pa-
a reduction in dietary fat intake and nificant increase in oxidation bio- tients who received adjuvant chemo-
a moderate influence on body weight. markers in the CG whereas no such therapy, in which only 9 of 22
This was reflected in improved sur- change occurred in the IG, and the anti- patients recruited completed the inter-
vival rates and reduced recurrence oxidant capacity was larger at IG vention.
among participants who followed (Table 2). Despite this, after Bonferroni Beyond the final sample size,
this diet.32 One side effect that can correction the researchers detected no which arguably was not enough to
be caused by breast cancer treatment significant differences between groups. detect statistical differences from
is weight gain.33 The reasons for Each patient showed a different OS, changes that were detected, the study
weight gain during and after adjuvant which makes it difficult to interpret had other limitations. This study was
chemotherapy have not been well es- the scope of the biomarker in this study not randomized and data were
tablished,34 even though chemo- owing to variation in the results. A collected in the IG and IC at different
therapy treatment is described as a similar difficulty was cited by times, potentially influencing base-
strong clinical predictor of weight Kasapovi
c et al.36 Nevertheless, these line characteristics. Nevertheless, re-
gain in women in the initial stage of results remain relevant because prior sults provide some evidence that
8 Schiavon et al Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015

women undergoing breast cancer 7. Newman VA, Thomson CA, Rock CL, 21. Benzie IFF, Strain JJ. The ferric reducing
treatment might benefit from imme- et al. Achieving substantial changes in ability of plasma (FRAP) as a measure of
diate, individualized, and detailed eating behavior among women previ- antioxidant power: the FRAP assay.
nutrition monitoring. ously treated for breast cancer—An Anal Biochem. 1996;239:70-76.
overview of the intervention. J Am 22. Nourooz-Zadeh J, Tajaddini-
Diet Assoc. 2005;105:382-391. Sarmadi J, Wolff SP. Measurement of
IMPLICATIONS FOR 8. Pierce JP, Newman VA, Natarajan L, plasma hydroperoxide concentrations
RESEARCH AND PRACTICE et al. Telephone counseling helps main- by the ferrous oxidation-xylenol or-
tain long-term adherence to a high- ange assay in conjunction with triphe-
Because of the small sample size of the vegetable dietary pattern. J Nutr. 2007; nylphosphine. Anal Biochem. 1994;220:
IG and the difficulty in detecting 137:2291-2296. 403-409.
changes in OS status, more studies 9. Bandura A. The evolution of social cogni- 23. Levine RL, Garland D, Oliver CN,
should be conducted to clarify the tive theory. In: Smith KG, Hitt MA, eds. et al. Determination of carbonyl con-
importance of nutrition education Great Minds in Management. Oxford, tent in oxidatively modified proteins.
during breast cancer treatment. United Kingdom: Oxford University Methods Enzymol. 1990;186:464-478.
Press; 2005:9-35. 24. Rodrigues EM, Soares FPTP,
10. Kutynec CL, McCargar L, Barr SI, et al. Boog MCF. Resgate do conceito de
Energy balance in women with breast aconselhamento no contexto do atendi-
ACKNOWLEDGMENTS cancer during adjuvant treatment. J mento nuticional. Rev Nutr. 2005;18:
Am Diet Assoc. 1999;99:1222-1227. 119-128.
The authors express sincere gratitude 11. World Cancer Research Fund. Food, Nutri- 25. Velentzis SV, Keshtgar MK,
for the resources provided by the tion, and the Prevention of Cancer: a Global Woodside JW, et al. Significant changes
Fundaç~ao de Amparo a Pesquisa e Perspective. Washington, DC: American in dietary intake and supplement use after
Inovaç~ao do Estado de Santa Catarina– Institute for Cancer Research; 2007. breast cancer diagnosis in a UK multi-
FAPESC (15.952/2009), the scholarship 12. Nowell SA, Ahn J, Ambrosone CB. centre study. Breast Cancer Res Treat.
from the Coordenaç~ao de Aperfeiçoa- Gene-nutrient interactions in cancer eti- 2011;128:473-482.
mento Pessoal de Nível Superior– ology. Nutr Rev. 2004;62:427-438. 26. Pierce JP, Faerber S, Wright FA, et al.
CAPES, and the support from Pro- 13. Vieira FGK, Di Pietro PF, Boaventura BCB, A randomized trial of the effect of a
grama de Po
s-Graduaç~ao em Nutriç~ao et al. Factors associated with oxida- plant-based dietary pattern on addi-
(PPGN-UFSC). tive stress in women with breast can- tional breast cancer events and survival:
cer. Nutr Hosp. 2011;26:528-536. the Women’s Healthy Eating and
REFERENCES 14. Ambrosi C, Di Pietro PF, Living (WHEL) Study. Control Clin
Rockenbach G, et al. Fatores que influen- Trials. 2002;23:728-756.
1. Minist
erio da Sa
ude. Instituto Nacional de ciam o consumo energ
etico de mulheres 27. Kushi LH, Kwan ML, Lee MM, et al.
C^ancer. Estimativa 2012: Incid^encia de no tratamento do c^ancer de mama. Rev Lifestyle factors and survival in women
C^ancer no Brasil/Instituto Nacional de C^ancer. Bras Ginecol Obstet. 2011;33:207-213. with breast cancer. J Nutr. 2007;137:
Rio de Janeiro, Brasil: INCA; 2011. 15. Galvan D, Di Pietro PF, Vieira FGK, 236S-242S.
2. Coleman MP, Quaresma M, Berrino F, et al. Increased body weight and blood 28. Kwan ML, Ergas IJ, Somkin CP, et al.
et al. Cancer survival in five continents: oxidative stress in breast cancer patients Quality of life among women recently
a worldwide population-based study after adjuvant chemotherapy. Breast J. diagnosed with invasive breast cancer:
(CONCORD). Lancet Oncol. 2008;9: 2013;19:555-557. the Pathways study. Breast Cancer Res
730-756. 16. Zabotto CB, Vianna RTP, Gil MF. Treat. 2010;123:507-524.
3. Thomson CA, Stendell-Hollis NR, Registro Fotogr
afico para Inqu
eritos Die- 29. Thomson CA, Flatt SW, Rock CL,
Rock CL, et al. Plasma and dietary ca- t
eticos: Utens
ılios e Porç~oes. Campinas, et al. Increase fruit, vegetable and fiber
rotenoids are associated with reduced SP: UNICAMP, Goi^ania; 1996. intake and lower fat intake report
oxidative stress in women previously 17. Higgs S. Memory and its role in appe- among women previously treated for
treated for breast cancer. Cancer Epide- tite regulation. Physiol Behav. 2005;85: invasive breast cancer. J Am Diet Assoc.
miol Biomarkers Prev. 2007;16:200-215. 67-72. 2002;102:801-808.
4. Thomson CA, Giuliano AR, Shaw JW, 18. Sichieri R, Everhart MD. Validity of a 30. Bosma H, Lamers F, Jonkers CC, et al.
et al. Diet and biomarkers of oxidative Brazilian frequency questionnaire Disparities by education level in outcomes
damage in women previously treated against dietary recalls and estimated en- of a self-management intervention: the
for breast cancer. Nutr Cancer. 2005;51: ergy intake. Nutr Res. 1998;19: DELTA trial in The Netherlands. Psy-
146-154. 1649-1659. chiatr Serv. 2011;62:793-795.
5. Rockenbach G, Di Pietro PF, 19. World Health Organization (WHO). 31. Pomerleau J, Lock K, Knai C, Mckee M.
Ambrosi C, et al. Dietary intake and Physical status: the use and interpretation Interventions designed to increase adult
oxidative stress in breast cancer: before of anthropometry. Geneva, Switzerland: fruit and vegetable intake can be effec-
and after treatments. Nutr Hosp. 2011; WHO; 1995. WHO Technical Report tive: a systematic review of the litera-
26:737-744. Series 854. ture. J Nutr. 2005;135:2486-2495.
6. Chlebowski RT, Aiello E, 20. Beutler E, Duron O, Kelly BM. 32. Chlebowski RT, Blackburn GL,
McTiernan A. Weight loss in breast Improved method for the determina- Thomson CA, et al. Dietary fat reduc-
cancer patient management. J Clin On- tion of blood glutathione. J Lab Clin tion and breast cancer outcome: interim
col. 2002;20:1128-1143. Med. 1963;61:882-890. efficacy results from the Women’s
Journal of Nutrition Education and Behavior  Volume 47, Number 1, 2015 Schiavon et al 9

Intervention Nutrition Study. J Natl 35. Goodwin PJ, Ennis M, Pritchard KI, 37. Panis C, Victorino JV, Herrera ACSA,
Cancer Inst. 2006;98:1767-1776. et al. Adjuvant treatment and onset of et al. Differential oxidative status and
33. Kroenke CH, Chen WY, Rosner B, menopause predict weight gain after immune characterization of the early
et al. Weight, weight gain, and survival breast cancer diagnosis. J Clin Oncol. and advanced stages of human breast
after breast cancer diagnosis. J Clin On- 1999;17:120-129. cancer. Breast Cancer Res Treat. 2012;
col. 2005;23:1370-1378. 36. Kasapovi
c J, Peji
c S, Stojiljkovi
c V, 133:881-888.
34. Demark-Wahnefried W, Case LD, et al. Antioxidant status and lipid per- 38. Demark-Wahnefried W, Kenyon AJ,
Blackwell K, et al. Results of a diet/ex- oxidation in the blood of breast cancer Eberle P, et al. Preventing sarcopenic
ercise feasibility trial to prevent adverse patients of different ages after chemo- obesity among breast cancer patients
body composition change in breast can- therapy with 5-fluorouracil, doxoru- who receive adjuvant chemotherapy:
cer patients on adjuvant chemotherapy. bicin and cyclophosphamide. Clin results of a feasibility study. Clin Exerc
Clin Breast Cancer. 2008;8:70-79. Biochem. 2010;43:1287-1293. Physiol. 2002;4:44-49.