Consumption Pattern Score in Cancer Survivor with Chemotherapy Induced Nausea and Vomiting and Non-Cancer at Shelter Houses

Background: One of the most common effects of chemotherapy in cancer survivors is nausea and vomiting. This can affect the diversity of food consumed. Family support and assistance need to be done to increase food intake with one food provision. Objectives: This study aimed to find out the difference in the consumption pattern score among cancer survivors and non-cancers in shelter houses. Materials and Methods : This study was a cross-sectional study with a retrospective approach. The criteria of the case subject were undergoing chemotherapy, while the control subject criteria were included in one food supply. The total subject was 66 cancer survivors, with 33 subjects each. This research was conducted from August 2021 until October 2021 at Shelter Houses. The data included the subjects characteristic data, vomit nausea degree data using the Rhodes Index nausea vomiting and retching (RINVR), family support data, food intake data using the food frequency questionnaire (FFQ), and individual dietary diversity score (IDDS) questionnaires. Data collection is done by interviews in person and online. The data collected was analyzed using Chi-Square and bivariate test using Mann Whitney test. Results: The majority of cancer subjects were aged 40-59 years whereas non-cancer subjects were 20-39 years old. The subjects have special characteristics which are in low financial ability. Consumption of starchy foods (p<0.001) and green vegetables (p<0.006) in these two group subjects had significant differences. In addition, the consumption pattern score between cancer and non-cancer subjects made significant differences (p<0.001). Conclusion : Average consumption pattern scores showed cancer subjects were lower compared to non-cancer subjects. Thus, consumption patterns in cancer subjects did not variaty compared to non-cancer subjects. It is necessary to conduct further research by analyzing the diversity of food of each subject using a 1x24 hour for 3 days, food access questionnaire and food security.

survivors who experience nausea and vomiting also find it difficult to eat adequately and eventually, only spend on small foods such as bread or biscuits. 7 In addition, the most widely consumed food groups in cancer survivors are cereals and nuts because they are easier to digest by cancer survivors compared to meat, milk, and eggs. Meat and eggs are consumed the least because of the high price that is difficult to access by lowincome cancer survivors. 8,9 Research on consumption patterns with weak economic levels showed that these patients had low diversity of food, especially in animal and vegetable sources. Consumption patterns based on individual dietary diversity scores (IDDS) also indicate a lack of food variety, low food access, and nutritional inadequacy. Several factors that affect consumption patterns include income, education, environment, employment, knowledge, and access to food. 10 Diversity of food is an important indicator because it can assess nutritional status, access to food availability, and socioeconomic level. Dietary diversity among cancer and non-cancer survivors can be measured using IDDS since it can see the food groups that both groups is eating. 8,11 In 2015 research was conducted in East Java showed that cancer survivors will be more motivated to consume meals if accompanied by a companion. It can affect cancer survivors to increase their appetite, particularly in terms of food diversity. Support provided by the family are given in the form of eating together and accompanying cancer survivors in treatment and medication. 12 Nevertheless, in this study not necessarily all cancer survivors accompanied by a companion have the urge to eat a variety of foods. This study aims to find out the difference in consumption patterns of cancer survivors and non-cancer survivors in low-economic cancer survivors and their relatives, considering both groups have similarities in accessing food, coming from one kitchen and being patients from shelter houses. Families and cancer survivors get help from non-profit organizations that assist in carrying out therapy or treatment. In addition, cancer survivors in shelter houses have special characteristics which are in low financial ability. Food at shelter houses can be served with ready meals and some fresh food. 13

MATERIALS AND METHODS
This research was conducted on cancer survivors and non-cancer at Rumah Singgah Sedekah Rombongan (RSSR Semarang, Yogyakarta, Malang), Rumah Singgah Sahabat Lestari, Rumah Singgah Peduli, Rumah Singgah Hanum, Yayasan Kanker Indonesia (YKI Semarang dan Yogyakarta), Rumah Sehat Mandiri Yogyakarta, Rumah Imajinasinya Indonesia Yogyakarta, dan IZI Jawa Tengah. This research was held from August 2021 until October 2021 and included in the field of community nutrition with a crosssectional study under a retrospective approach. All research protocols were approved by the Health Research Ethics Committee (KEPK) Faculty of Medicine, University of Sultan Agung Semarang Number.203/VII/2021/Commission on Bioethics. The minimum sample using unpaired comparative analytics for each subject was 30 people and the total sampling obtained was 33 people who filled out the informed consent. 14 The inclusion criteria of cancer and non-cancer groups were women aged 20-59 years, including in a low-income family according to the Central Bureau of Statistics in Indonesia year 2016, who can communicate clearly and cooperatively, and were willing to become research respondents. 15 In addition, subjects from noncancer group were as the same food supply/kitchen as cancer survivors. Whereas the cancer survivor group had undergone chemotherapy and being a patient assisted by shelter houses. Exclusion criteria in this study were the subject moved away from the shelter houses, passed away prior to the data being completed and withdrew their informed consent to participate in the study.
The independent variable in this study was consumption patterns, that is eating habits which include diversity, types or kinds of food. Determination of consumption patterns can show the nutritional value of food, nutritional adequacy, food availability, variety and the combination of food types. Firstly, the type of food and the frequency of consumption in the past month was obtained using the Food Frequency Questionnaire form. The next step was this data then converted into Individual Dietary Diversity Score (IDDS) questionnaire. IDDS consists of nine food groups, which are foods made from flour, cereals and legumes, nuts/seeds, all dairy products, animal (meat, fish), eggs, green vegetables, vegetables and fruit sources of vitamin A, vegetables and other fruit. If the subjects consumed each nine food groups, then it scored 1 in each group, and if not consumed then it scored 0. IDDS was categorized as a variety if the total score was five or above, and was not variety if the score was under five. 11,[16][17][18] The dependent variable in this study was cancer and non-cancer survivors. The data collected including the subject's characteristics, nausea and vomiting information, family support, and food intake for each subject. Data collection through in-person interviews and using online. Interviews via online were conducted by contacting the subject remotely using telephone or WhatsApp. Data collection were carried out by researchers and enumerators, with a nutritional background knowing how to FFQ intake and interviews regarding the degree of nausea and vomiting. Due to time constraints, communication tools such as handphone, and the facilities needed for data collection were carried out directly to the shelter houses. In order to Covid-19 restriction, health protocols were carried out during direct interviews such as using complete personal protective equipment, administering vaccines and antigen swabs, and before contacting the subject, cleaning/washing hands. Time allocated for researchers and enumerators needed to interview was approximately 45 minutes for each respondent.
Characteristics data on both cancer and non-cancer group consisted of name, address, education level, income, occupation, and access to food availability. Access to food availability aims to find out in terms of the distance from the house to the place of buying and selling and the ease of getting food availability. The category for easy access to groceries was the distance from home to the market that is close and affordable. In addition, data on the cancer group included the type of therapy, medical diagnosis, year of diagnosis, and feelings when interviewed.

Characteristic Cancer Survivors and Non-Cancer
Characteristics of cancer survivors and non-cancer include age, education level, gender, access to food availability, and income. Table 1 presented the distribution of characteristics of cancer and non-cancer survivors.  easily accessible (64%). In terms of the degree of nausea and vomiting experienced by subjects, more than half of the subjects were severe (51.5%) because of the effects of chemotherapy.

Family Support Data on Cancer Survivors
Family support data for non-cancer subjects consisted of emotional support, instrumental support, information/knowledge support, and appreciation/assessment support. Table 2 presents the distribution of data on family support provided to cancer subjects.  Table 2. showed the majority of family support given to cancer survivors was in a good category (75.8%). The majority of cancer survivors' companions always provide support during care and treatment, such as reminds to meal, giving time, providing information, and giving appreciation. Table 3. showed that non-cancer subjects (69.7%) significantly consumed more starchy food than cancer subjects (15.2%). Both groups consumed cereals and nuts/seeds. The majority who consumed all dairy products (6.1%) and animal groups (57.6%) were non-cancer subjects. In food ingredients, eggs are consumed the most were cancer subjects (90.9%). In the consumption of green vegetables, there was a significant difference between cancer subjects (57.6%) and non-cancer subjects (87.9%). The most cancer subjects are not comsumption green vegetables and choose other vegetables such as carrot, eggplant, broccoli, cauliflower, mushrooms, and tomatoes. Vegetables and fruit containing sources of vitamin A were mostly consumed by non-cancer subjects (54.5%) while cancer subjects consumed a lot of other vegetables and fruits (52.5%).  Table 4. showed the average consumption pattern in cancer and non-cancer subjects was significantly different with the average in cancer subjects was lower (4.27±1.13 ) compared to non-cancer subjects (5.64±1.58). In thus, that cancer survivors have a low diversity of food compared to non-cancer. feeling of nauseous and experience vomiting. Snacks for example bread, biscuits, and traditional snacks were only consumed when cancer survivors are waiting in line for therapy. This condition were pictured by minimal consumption for the past month based on FFQ analysis. 27 Meanwhile, the majority of non-cancer subjects (69.7%) chose to eat starchy foods. Most of them were deeply fried, such as fermented soy tempura, vegetables tempura, and fried bananas. When compares to starchy food, cereals were the most favourable carbohydrates-based food in both groups. Basically, this group of food, particularly rice is a staple food for families in developing countries, including in Indonesia. Carbohydrates are useful for preventing excessive body protein breakdown, mineral loss, and helping fat and protein metabolism. In addition, cancer survivors need a high energy intake to carry out chemotherapy so that the body is well-prepared and does not become susceptible to infection. 28,29 In this study, the majority of the both groups consumed legumes because it contained high protein, for example green beans and soybeans. High protein consumption for cancer survivors can reduce nausea and vomiting experienced by cancer survivors. [30][31][32][33] Based on food intake data for both cancer and non-cancer subjects, tofu and tempeh were the most commonly consumed food ingredients in a daily basis. Not only it is accessible in terms of its affordable price and is the most popular plant-based food in Indonesia. 34 In the animal protein group, there was not a significant difference (p = 0.069) between cancer subjects (36.4%) and non-cancer subjects (57.6%). The majority of these both subjects only consumed animal protein such as chicken and fish and rarely consumed red meat since the price was not affordable. Previous research studied the relationship between food and digestive tract effects showed cancer survivors rarely eat red meat because it is rich in fat, which tends to increase nausea and vomiting. Other research on cancer subjects in India stated that excessive fat consumption can increase the risk of cancer, because fat has cancer promoting properties. Food rich in fat leads the body to produce more estrogen and abnormal cell division. Thus cancer survivors need to limit red meat and preserved products. 26,[35][36][37] Furthermore, the majority of both subjects often consumed eggs (p = 0.500) because it is more affordable and accessible than red meat. In addition, cancer survivors also prefer to eggs that do not trigger nausea and vomiting and are more well received. The egg was packed with high nutritional content since its protein can induce apoptosis in cancer cells, protect against DNA damage, reduce the invasiveness of cancer cells, and exhibit cytotoxic and antimutagenic activity in various cancer cell lines. Eggs are a highly nutritious food source and essential amino acids. This compotition needed by the body for the healing process replace damaged tissue, and form body defense system. The protein contained in egg white and egg yolk are considered as functional food substances because it has biological activities such as antimicrobial, antioxidant, anticancer, and immunomodulatory activities. 38 A significant difference was shown in terms of green leafy vegetable consumption between groups (p<0.006). Most non-cancer subjects consumed more green leafy vegetables, vegetables and fruits containing vitamin A compared to cancer subjects. Based on FFQ analysis, green leafy vegetables that were consumed quite often in these subjects such as spinach, kale, cassava leaves, and papaya leaves. While for vegetables and fruits that contain vitamin A such as carrots, pumpkin, sweet potatoes, mango, and papaya. Other vegetables and fruits that was often consumed such as mushrooms, bean sprouts, beans, long beans, and broccoli. Previous research on cancer chemotherapy subjects, explained that vegetables and fruits can provide protection for breast cancer prognosis since it contained high fiber, vitamins A, C, E, folate, and carotenoids. Vitamin C contains antioxidants that are useful for neutralizing free radicals in the development of cancer. In addition, it also play a role in stimulating the immune system (immunity) and preventing platelet clumping. Consumption of fruits and vegetables can be a good diet and lifestyle. Therefore, vegetables and fruits can be reached from low and high economies. 39 In this study, cancer subjects were still minimal in consuming vegetables and fruits containing vitamin A because the majority chose to consume as desired.

Differences in IDDS Scores for Cancer and Non-Cancer Subjects
The results of this study showed that the mean score of the consumption pattern of cancer subjects was lower (4.27±1.13) than non-cancer subjects (5.64±1.58). Food groups that were not consumed by cancer survivors according to FFQ analysis were milk, red meat, vegetables and fruits. Not only because of nausea and vomiting experienced by these subjects, but also the ability to access these kind of food. In contrast, noncancer subjects did not consumed milk and fruits. Therefore, it is necessary to educate both subjects to increase the variety of food and convey the benefits of each food ingredient.. Knowledge of dietary patterns is important since it can provide an understanding of how to fulfill nutrients optimally for each individual.

CONCLUSION
There was a significant difference in consumption pattern scores on cancer and non-cancer survivors who have the same socio-economic background and access to food availability. The average score of the consumption pattern of cancer subjects was lower than that of non-cancer subjects. The food diversity of cancer subjects was lower than non-cancer subjects. In terms of IDDS food group, starchy foods and green vegetables were two food groups that had a significant difference among cancer subjects and non-cancer.

SUGGESTION
It is necessary to conduct further research by analyzing the diversity of food of each subject using a 3x24 hour recall, food access questionnaire and food security in cancer subjects who experienced CINV compared to non-cancer subjects due to the lack of research in this study field.