Infographic Submission

Partner. Sora Johnson

Title. Despite Four New Dietary Guidelines in the Time Period from 1999-2016, Cancer Survivors in NHANES Still Got Over 50% of their Total Calories from Ultraprocessed Foods

Legend. In the above infographic, statistics and other key numbers are indicated in large black type, while general text and illustrative figures are in blue. Pink text reflects ultraprocessed foods, and a pink color is also used to highlight the silhouettes of survivors who will develop late effects from the toxicity of their treatment. Purple text indicates the key take-home messages summarizing this infographic, while green text highlights the benefits of a healthy diet.

Infographic Revision

Partner. Sora Johnson

Title. Despite Four New Dietary Guidelines in the Time Period from 1999-2016, Cancer Survivors in NHANES Still Got Over 50% of their Total Calories from Ultraprocessed Foods

Title: Messages About Diet Quality and Ultraprocessed Foods Aren’t Reaching Cancer Survivors, an Especially Vulnerable Population

In the below infographic, statistics and other key numbers are indicated in large black type, with data from NHANES 1999-2016 and other sources cited on the image. General text and illustrative figures are in blue. Pink text reflects ultraprocessed foods, and a pink color is also used to highlight the silhouettes of survivors who will develop late effects from the toxicity of their treatment. Purple text indicates the key take-home messages summarizing this infographic, while green text highlights the benefits of a healthy diet.

Abstract

Cancer survivors have an increased risk of developing chronic comorbidities due to the toxicity of their treatments [1]. A survivor’s diet is a modifiable life factor known to prevent many of these comorbidities [2-4]. The consumption of ultraprocessed foods is thus of concern, since they are high in unhealthy fats, refined starches, sugars, and salt, and low in dietary fibers and micronutrients [5]. We used dietary data from the National Health and Nutrition Examination Survey (1999-2016) to examine average ultraprocessed food consumption among cancer survivors. Despite the release of four dietary guidelines during this time addressing the detrimental properties of ultraprocessed foods, the consumption of these remained high, at 55%. Adherence to the dietary guidelines, as measured by the Healthy Eating Index Score, was only 55%. Our work highlights the limited impact of dietary guidelines among cancer survivors, emphasizing the need to develop targeted intervention programs in this vulnerable group.

Abstract

Cancer survivors have an increased risk of developing chronic comorbidities due to the toxicity of their treatments.¹ It is estimated that 3 out of 5 survivors will develop these late effects.² A survivor’s diet is a modifiable life factor known to prevent many of these comorbidities.^3-5 The consumption of ultraprocessed foods is thus of concern, since they are high in unhealthy fats, refined starches, sugars, and salt, and low in dietary fibers and micronutrients [5]. We used dietary data from the National Health and Nutrition Examination Survey (1999-2016) to examine average ultraprocessed food consumption among cancer survivors. Despite the release of four dietary guidelines during this time addressing the detrimental properties of ultraprocessed foods, the consumption of these remained high, at 55%. Our work highlights the limited impact of dietary guidelines among cancer survivors, emphasizing the need to develop targeted intervention programs in this vulnerable group.

Keywords

cancer survivors; dietary guidelines; NHANES; ultraprocessed foods; Healthy Eating Index

Keywords

cancer survivors; dietary guidelines; late effects, NHANES; ultraprocessed foods

Highlights

• Cancer survivors get 55% of their total calories from ultraprocessed foods, with only 55% adherence to the Dietary Guidelines for Americans
• Are Dietary Guidelines actually impacting those vulnerable to a poor diet? Our research on ultraprocessed food intake among cancer survivors suggests they are not. 

Highlights

• Despite the importance of a healthy diet in this population, cancer survivors get 55% of their total calories from ultraprocessed food
• Are Dietary Guidelines actually impacting those vulnerable to a poor diet? Our research on ultraprocessed food intake among cancer survivors suggests they are not.

Visual Brief

Why aren’t the Dietary Guidelines for Americans impacting the diets of cancer survivors? Diet is especially important in this population, given the toxicity of radiation and chemotherapy and the known protective effects of a healthy diet. [1-4] Ultraprocessed foods are high in unhealthy fats, refined starches, sugars, and salt, and low in dietary fibers and micronutrients: in other words, poor dietary choices for this group. [5] Despite the release of four dietary guidelines during this time addressing the detrimental properties of ultraprocessed foods, the consumption of these remained high, at 55%. 

We utilized data from the National Health and Nutrition Examination Survey (1999-2016) to show this, examining average ultraprocessed food consumption over time among cancer survivors (n=4527, self-reported 24-hour dietary recalls). We also looked at adherence to the Dietary Guidelines for Americans by calculating a Healthy Eating Index score for each participant, and found that, on average, diets in general were only 55% aligned with the guidelines. This was despite the release of four dietary guidelines addressing components of ultraprocessed foods like unhealthy fats, sugars, and salt. All data was weighted according to NHANES analytic guidelines so that infographic results were representative of the United States population at the time of each survey year.

Based on our findings that cancer survivors were consuming large amounts of ultraprocessed foods and had poor adherence to the Dietary Guidelines for Americans, we targeted our infographic towards providers and care teams who work with cancer survivors. Statistics and other key numbers are indicated in large black type to highlight our statistical findings and their importance, while general text and illustrative figures are in blue. We used pink text for the words “ultraprocessed foods,” to make this key word of our graphic stand out; the same color is also used to highlight the silhouettes of survivors who will develop late effects from the toxicity of their treatment. We chose to do this to emphasize the detrimental impacts of the components of ultraprocessed foods, arguably in line with the treatment late effects. Purple text indicates the key take-home messages summarizing this infographic, while green text was chosen to highlight the benefits of a healthy diet.

Limitations of this study include the self-reported nature of the data, as well as a lack of consideration of other confounders that might affect diet access and quality. In order to maintain the visual appeal of our infographic and stay focused in our message to providers, we chose to present only a small number of statistics and facts. However, our research still highlights the limited impact of the dietary guidelines the cancer survivor population, emphasizing the need to develop and evaluate more targeted intervention programs in this vulnerable group. 

1.American Cancer Society. Long-Term Side Effects of Cancer. Secondary Long-Term Side Effects of Cancer  2022. https://www.cancer.org/treatment/survivorship-during-and-after-treatment/long-term-health-concerns/long-term-side-effects-of-cancer.html.

2. Van Blarigan EL, Fuchs CS, Niedzwiecki D, et al. Association of Survival With Adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis: The CALGB 89803/Alliance Trial. JAMA Oncol 2018;4(6):783-90 doi: 10.1001/jamaoncol.2018.0126.

3. Hurtado-Barroso S, Trius-Soler M, Lamuela-Raventós RM, Zamora-Ros R. Vegetable and Fruit Consumption and Prognosis Among Cancer Survivors: A Systematic Review and Meta-Analysis of Cohort Studies. Adv Nutr 2020;11(6):1569-82 doi: 10.1093/advances/nmaa082.

4. Schwedhelm C, Boeing H, Hoffmann G, Aleksandrova K, Schwingshackl L. Effect of diet on mortality and cancer recurrence among cancer survivors: a systematic review and meta-analysis of cohort studies. Nutr Rev 2016;74(12):737-48 doi: 10.1093/nutrit/nuw045.

5. Monteiro CA, Cannon G, Moubarac J-C, Levy RB, Louzada MLC, Jaime PC. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutrition 2018;21(1):5-17 doi: 10.1017/s1368980017000234

Visual Brief

The Dietary Guidelines for Americans are meant to provide advice to promote health and prevent chronic disease. Since the public isn’t expected to interpret them, why aren’t their messages trickling down from healthcare professionals,
especially to vulnerable groups like cancer survivors? 

Diet is especially important for cancer survivors, given the toxicity of radiation and chemotherapy they receive. Three out of five survivors will experience late effects due to their treatment.² However, healthy diet rich in fruits, vegetables, and whole grains and low in excess sugars and salts has a known protective effect.^1,3-5Ultraprocessed foods are high in unhealthy fats, refined starches, sugars, and salt, and low in dietary fibers and micronutrients: in other words, poor diet choices in this population. Our research on data from the National Health and Nutrition Examination Survey (1999-2016) illustrates that delivery of information from the guidelines to cancer survivors isn’t occurring, despite the importance of such conversations.

We utilized data from the National Health and Nutrition Examination Survey to examine average ultraprocessed food consumption among cancer survivors from 1999-2016; our analysis was conducted using appropriate survey weighting so that results are nationally representative. There were four dietary guidelines during this time addressing components of ultraprocessed foods including unhealthy fats, sugars, and salt. We identified 4527 participants in this time period who indicated at least one prior cancer diagnosis. Using dietary information from these participants’ self-reported 24-hour dietary recalls, we categorized foods using the NOVA classification system as 1) unprocessed or minimally processed foods, 2) processed culinary ingredients, 3) processed foods, and 4) ultraprocessed foods.⁶

Since ultraprocessed foods are of concern in this population, we focused our analysis on this last group. We found that, from 1999-2016, 55% of total calories in a cancer survivors’ diet came from ultraprocessed foods, despite the four dietary guideline releases over these 17 years addressing the components of ultraprocessed foods.

In our visual display of these results, we chose to emphasize several key statistics with large black text. We also used color to connect certain parts of the visual and emphasize particular messages. We used pink text to reflect the negative effects of ultraprocessed foods, and a pink color is also used to highlight the silhouettes of survivors who will develop late effects from the toxicity of their treatment. Purple text indicates the key take-home messages summarizing this infographic, while green text highlights the benefits of a healthy diet. Blue was used for illustrative figures and general text messaging. To emphasize the important action step healthcare professionals should take, we chose to place this message at the top of our visual.

This visual representation of our work highlights the limited impact of dietary guideline recommendations among cancer survivors, questioning not only their overall utility in this population but also how such information is shared. Healthcare professionals should strive to focus guideline recommendation delivery to patients in ways that can most effectively reach this vulnerable population.

1.         American Cancer Society. Long-Term Side Effects of Cancer. Accessed 10-14-2022, https://www.cancer.org/treatment/survivorship-during-and-after-treatment/long-term-health-concerns/long-term-side-effects-of-cancer.html

2.         Klonoff-Cohen H, Polavarapu M. Existence of late-effects instruments for cancer survivors: A systematic review. PLOS ONE. 2020;15(2):e0229222. doi:10.1371/journal.pone.0229222

3.         Van Blarigan EL, Fuchs CS, Niedzwiecki D, et al. Association of Survival With Adherence to the American Cancer Society Nutrition and Physical Activity Guidelines for Cancer Survivors After Colon Cancer Diagnosis: The CALGB 89803/Alliance Trial. JAMA Oncol. Jun 1 2018;4(6):783-790. doi:10.1001/jamaoncol.2018.0126

4.         Schwedhelm C, Boeing H, Hoffmann G, Aleksandrova K, Schwingshackl L. Effect of diet on mortality and cancer recurrence among cancer survivors: a systematic review and meta-analysis of cohort studies. Nutr Rev. Dec 2016;74(12):737-748. doi:10.1093/nutrit/nuw045

5.         Hurtado-Barroso S, Trius-Soler M, Lamuela-Raventós RM, Zamora-Ros R. Vegetable and Fruit Consumption and Prognosis Among Cancer Survivors: A Systematic Review and Meta-Analysis of Cohort Studies. Adv Nutr. Nov 16 2020;11(6):1569-1582. doi:10.1093/advances/nmaa082

6.         Monteiro CA, Cannon G, Moubarac J-C, Levy RB, Louzada MLC, Jaime PC. The UN Decade of Nutrition, the NOVA food classification and the trouble with ultra-processing. Public Health Nutrition. 2018;21(1):5-17. doi:10.1017/s1368980017000234

Peer Feedback Review

When providing feedback on your partner’s initial submission, please comment on ways the visual can be improved with respect to the 4 E’s. Keep your responses to 1-2 sentences per principle. Use the template shown here to structure your feedback, which should be posted as a comment below.

Feedback Giver Name: Please enter your name here.
• Evidence: Please enter your comment here.
• Efficiency: Please enter your comment here.
• Emphasis: Please enter your comment here.
• Ethics Please enter your comment here.

Self Reflection

Please reflect on what revisions you have made to your visual and abstract. Respond to the following questions regarding questions you have made in 1-2 sentences each. Use the template shown here to structure your feedback, which should be posted as a comment below.

• What changes did you make when revising your visual?
I worked to strengthen the connection between UPF and poor health outcomes by reorganizing parts of my visual and adding more images/text elements to highlight this connection. I also flipped my visual so that the action step was on top.

• What changes did you make when revising your general and scientific description? Why?
I made the same changes to both the general and scientific description, so I am combining those responses. I removed the reference to to the Healthy Eating Index, since this index refers to the 2015 guidelines only and my graphic and research was focused on multiple years (and four different dietary guidelines), so I realized that including this statistic was not “ethical.” I also chose, for these particular descriptions of my infographic, to also spend some time describing the visual elements that I chose to emphasize my points and methods.