Clinical Nutrition ESPEN 56 (2023) 135e141

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Clinical Nutrition ESPEN

journal homepage: http://www.clinicalnutritionespen.com

Original article

Adherence to safe food-handling practices and dietary patterns in

cancer survivors
n-Pincheira a, Samuel Duran-Aguero a, *
Paula Huanca a, b, Carla Guzma
a n y Diet
Escuela de Nutricio etica. Facultad de Ciencias para el Cuidado de la Salud. Universidad San Sebastian, Chile
b
Clínica Santa María, Chile

a r t i c l e i n f o s u m m a r y

Article history: Background: In Chile there is a high risk profile of developing cancer which is associated, among other
Received 15 September 2022 factors, to eating behaviors and, in this line, it is essential for cancer survivors to have access to nutri-
Accepted 30 April 2023 tional advice that includes aproppriate food safety practices. The objective of this study is to characterize
the level of adherence of cancer survivors to safe food-handling practices and dietary patterns in a
Keywords: Chilean National Health Survey.
Cancer
Methods: Secondary analysis study, conducted using the National Health Survey 2016e2017 database.
Survivor
The association between adherence to dietary patterns and safe food-handling practices was conducted
Dietary patterns
Safe food handling
by means of a logistic regression analisys, considering a p value of <0.05 as statistically significant.
Results: 2765 participants, females, 5.8% were cancer survivors who adhered twice more to the safe food-
handling practice “wash your hands with soap and water before preparing food and before eating”, and
1.5 times more to the practice “keep raw meat separate from other foods when preparing food or
cooking”. In both groups, it was observed a low adherence to achieve the recommendations on healthy
weight, physical activity, fruits and vegetables consumption, and alcohol and sugar-sweetened beverages
consumption of the WCRF/AICR.
Conclusions: Partial adherence to the safe food-handling recommendations and low adherence to the
WCRF/AICR recommendations were observed among cancer survivors and subjects without cancer.
© 2023 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights
reserved.

1. Introduction
Cancer is one of the leading causes of death worldwide [1], and
due to epidemiological transitions and the modernization of
detection techniques, survival has improved considerably [2]; un-
derstood as the number alive among people with cancer [3];
however, survivors often have long-term sequelae that must be
treated along with other chronic conditions, and, in addition, are at
risk of developing other primary cancers because of shared etio-
logic risk factors or as a consequence of radiotherapy and/or
chemotherapy [4], reason why the diet, considered an important
modifiable factor, could reduce these risks [5], with nutritional
advice being fundamental in all the stages of the disease [6],
particularly because survivors who are on immunosuppressive
therapies are more affected than those who have been in remission
* Corresponding author. Lota 2565 Providencia, Santiago, Chile.
E-mail address: samuel.duran@uss.cl (S. Duran-Aguero).
for a longer period of time [7,8]. It has been demonstrated that
certain behaviors and food choices reduce the risk of contracting
diseases transmitted by food [9], therefore, appropriate food safety
practices are vital for this population [8]. These practices include
preventing cross-contamination during food handling, safely
monitoring temperature during food storage, employing the
adequate heat treatment during cooking, and avoiding foods that
pose high risks to public health [10]. This demonstrates the urgent
need to promote consistent and evidence-based food safety
guidelines, as well as to identify their levels of compliance. More-
over, the impact of diet and nutrition on health is generally deter-
mined by dietary patterns, defined as the quantity, variety, or
combination of different foods and beverages in a diet, and the
frequency with which they are habitually consumed, instead of
individual foods and beverages or specific dietary components [11].
In Chile, at a population level there is a high risk profile of devel-
oping cancer, associated to eating behaviors, sedentary lifestyle,
smoking habit, alcohol consumption, and high rates of obesity
incompatible with health [12]. When comparing the food

https://doi.org/10.1016/j.clnesp.2023.04.030
2405-4577/© 2023 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.
 n-Pincheira and S. Duran-Aguero
P. Huanca, C. Guzma
consumption profile with the World Health Organization (WHO)
and the Food & Drug Administration (FDA) recommendations, it
was noted that the Chilean consumption pattern exceeds the con-
sumption of foods associated to greater risk of cancer, and is below
the recommendations of consumption for foods with protective
effects [12]. Nevertheless, there are no data in Chile about the
adequate behavior regarding food safety or about dietary patterns
in cancer survivors. The objective of this study is to characterize the
level of adherence of cancer survivors to safe food-handling prac-
tices and dietary patterns recommended by the World Cancer
Research Fund/American Institute for Cancer Research and US Food
& Drug Administration Center for Food Safety & Applied Nutrition
recommendations (2020) in a Chilean National Health Survey.
2. Materials and methods
2.1. Study design and population
Secondary analysis study, conducted using the National Health
Survey 2016e2017 database (available on: http://epi.minsal.cl/
bases-de-datos/). For this cross-sectional population survey, it
was conducted a random, stratified, multistage, and cluster sam-
pling of households including 6234 people over 15 years of age,
who live in Chile. The survey protocol was approved by the
Research Ethics Committee of the School of Medicine of the Pon-
tificia Universidad Cato lica de Chile [13]. For the purpose of this
research, selection criteria included adults aged 18 years and older,
cancer survivors or subjects without cancer; those who left ques-
tions unanswered or gave incomplete answers to the questions
about safe food-handling practices, dietary patterns and data on
Fig. 1. Participant flowchart and questions on Adherence to healthy dietary patterns and safe food-handling practices.
136
Clinical Nutrition ESPEN 56 (2023) 135e141
anthropometric, clinical, sociodemographic and lifestyle factors
were excluded (Fig. 1). Details are available at Fig. 1.
2.2. Adherence to healthy dietary patterns and safe food-handling
practices
In order to know the level of adherence to healthy dietary pat-
terns, the World Cancer Research Fund/American Institute for
Cancer Research (WCRF/AICR) recommendations [14] were used as
a benchmark, while so as to know the level of adherence to safe
food-handling practices, the US Food & Drug Administration Center
for Food Safety & Applied Nutrition recommendations (2020) [9]
were used.
2.3. Statistical analysis
The STATA 15 software was used for conducting all the analyses.
Significance level was defined as p < 0.05. The normality of
continuous variables was assessed via the Shapiro-Francia test; in
order to compare two groups with normal variables, the Student's t
test was used, and the ManneWhitney test was used in the case of
non-normally distributed data. Categorical variables were dis-
played as numbers and percentages, and analyzed using the Chi-
square test with the Pearson correlation or the Fisher's test. Logi-
ctic regression analyses were conducted with the aim of assessing
the level of adherence to healthy dietary patterns and the level of
adherence to safe food-handling practices. The independent vari-
able was being a survivor or not having cancer, and dependent
variables were adherence to safe food-handling practices and to the
World Cancer Research Fund/American Institute for Cancer
 n-Pincheira and S. Duran-Aguero
P. Huanca, C. Guzma Clinical Nutrition ESPEN 56 (2023) 135e141

Research (WCRF/AICR) recommendations. Data were displayed as
Odds ratio, with 95% confidence intervals (CI).
3. Results
3.1. Characteristics of the study population
The final sample size consisted of 2765 individuals (160 cancer
survivors and 2605 without cancer), all of them females (Table 1).
The median age in the group of survivors was significantly different
from the median of the population without cancer (p ¼ 0.0000). The
most prevalent cancer diagnosis was cervical cancer (44.7%), fol-
lowed by breast cancer (20.5%), and thyroid cancer (13.8%). The
median for BMI, geographic area of residence, physical activity, and
alcohol consumption among the survivors and the population
without cancer did not show significant differences, in contrast to
the variables related to tobacco consumption, which reported that
20.6% of survivors, as well as 19.5% of women without cancer, re-
ported having smoked one or more cigarettes per day (p ¼ 0.010).
3.2. Level of adherence to food-handling good practices
The level of adherence to food-handling good practices is shown
in Table 2. Significant differences were only noted in the item “I
wash my hands with soap and water before preparing food and
before eating”. A percentage of 92.5% of cancer survivors adhered to
this practice (p ¼ 0.041). When conducting a logistic regression
analisys, it was found that survivors' adherence to the practice
“wash your hands with soap and water before preparing food and
before eating” was almost twice more frequent than in the popu-
lation without cancer, OR ¼ 1.97 (95% CI: 1.06e3.66) (p ¼ 0.031).
When adjusting by type of cancer, it was observed that more than
90% of survivors of breast cancer, cervical cancer, bile duct cancer,
gastric cancer, thyroid cancer and other types of cancer adhere
significantly more to the hand washing practice, when compared to
survivors of colon, rectal and other types of cancer, including cer-
vical cancer. Similarly, survivors adhere 1.5 times more frequently
and significantly to the practice of appropriate handling related to
the proper cooking of meat and eggs, when compared to the pop-
ulation without cancer (p ¼ 0.042) with OR ¼ 0.69 (95% CI:
0.482e0.986). In the case of questions number 3, 4 and 5, no sig-
nificant differences were observed, however, when adjusting by
type of cancer it was noted that more than 96% of survivors of
breast cancer, bile duct cancer, gastric cancer, thyroid cancer, and
other types of cancer have not consumed well water, spring water
or rural tap water during the last week, whether for drinking or
cooking (supplementary material). Additionally, it is important to
consider conditions such as socioeconomic and educational levels
when it comes to safe food-handling behaviors, since more than
60% of the participants had a low income level and about 30% had a
low educational level, in both study groups.
3.3. Level of adherence to lifestyle recommendations,
sociodemographic and clinical characteristics (WCRF/AICR)
Adherence to these recommendations is shown in Table 3.
Recommendations related to BMI, physical activity, fruits and
vegetables consumption, and alcohol and sugar-sweetened bever-
ages consumption were included. There were only significant dif-
ferences regarding the consumption of sugar-sweetened beverages
(the consumption of sugar-sweetened juices was also included).
Survivors had a significantly lower consumption of sugar-

Table 1
Characteristics of the participants of the NHS 2016e2017a.

Characteristics Survivors Without cancer p

n ¼ 160 (5.8%) n ¼ 2605 (94.2%)

Age4 (years) 58.8 50.5 0.000*

Median [95% Confidence Interval] [56.5e61.0] [49.8e51.2]
Weight4 (kg) 70.0 69.4 0.781
Median [95% Confidence Interval] [66.0e72.8] [68.7e70.0]
BMI4 (kg/m2) 29.4 28.9 0.255
Median [95% Confidence Interval] [28.3e30.6] [28.7e29.2]
Nutritional status3
Underweight (IMC<18.5 kg/m2) 0 (0%) 18 (0.7%) 0.692
Normal weight (IMC 18.5e24.9 kg/m2) 26 (16.2%) 532 (20.4%)
Overweight (IMC 25e29.9 kg/m2) 62 (38.8%) 929 (35.7%)
Obesity (IMC 25e29.9 kg/m2) 72 (45%) 1126 (43.2%)
Geographic area2
Urban 138 (86.3%) 2124 (81.5%) 0.134
Rural 22 (13.7%) 481 (18.5%)
Physical activity >30 min per day3
Yes, three or more times a week 15 (9.4%) 213 (8.2%) 0.733
Yes, once or twice a week 6 (3.7%) 138 (5.3%)
Yes, less than four times a month 4 (2.5%) 51 (1.9%)
The subject did not engage in sports during the last month 135 (84.4%) 2203 (84.6%)
Do you currently smoke cigarettes?3
Yes, one or more cigarettes per day 33 (20.6%) 507 (19.5%) 0.010*
Yes, occasionally (less than 1 per day) 2 (1.3%) 169 (6.5%)
No, I quitted smoking 45 (28.1%) 568 (21.8%)
No, I have never smoked 80 (50.0%) 1361 (52.2%)
Alcohol consumption. How often do you drink an alcoholic beverage?3
Never 81 (50.6%) 1144 (43.9%) 0.183
Once or twice a month 55 (34.4%) 1000 (38.4%)
2 - 4 times a month 16 (10%) 362 (13.9%)
2 - 3 times a week 4 (2.5%) 68 (2.6%)
4 or more times a week 4 (2.5%) 31 (1.2%)
a
Values are presented as mean and median [95% CI] for continuous variables, and as numbers (percentage) for categorical variables. Continuous measurements were
compared between groups using the ManneWhitney test, and categorical measurements were compared by means of the Chi-square test and the Fisher's exact test. (*)
statistical significance p < 0.05. Abbreviation: BMI; body mass index.

137
 n-Pincheira and S. Duran-Aguero
P. Huanca, C. Guzma Clinical Nutrition ESPEN 56 (2023) 135e141

Table 2
Food-handling practicesc.

How often do you follow these practices? Adherence Non-adherence p

Survivor Without cancer Survivor Without cancer

N 1 I wash my hands with soap and water before preparing 148 2265 12 340 0.041*
food and before eating (92.5%) (86.9%) (7.5%) (13.1%)

N 2 I keep raw meat and poultry (beef, chicken, and fish) separate 140 2257 20 348 0.756
from other foods while preparing them or cooking (87.5%) (86.6%) (12.5%) (13.4%)
N 3 I cook or eat fully cooked meat and eggs (until the 112 1980 48 625 0.086
center is cooked and the yolk and white are firm) (70%) (76%) (30%) (24%)
N 4 I keep food refrigerated or frozen 156 2478 4 127 0.246
(97.5%) (95.1%) (2.5%) (4.9%)
N 5 I consume foods past their expiration datea 132 2281 28 324 0.062
(82.5%) (87.6%) (17.5%) (12.4%)

N 6 I have consumed well water, spring water or rural tap water 146 2253 14 352 0.084
during the last week, whether for drinking or cookingb (91.3%) (86.5%) (8.7%) (13.5%)
a
Adherence ¼ It is understood that the subject does not consume foods past their expiration date.
b
Adherence ¼ It is understood that the subject has not consumed well water, spring water or rural tap water during the last week, whether for drinking or cooking.
c
In order to know the level of adherence to safe food-handling practices, the US Food & Drug Administration Center for Food Safety & Applied Nutrition recommendations
(2020) were used asa benchmark (US Food & Drug Administration (2020) nd). Measurements were compared using the Chi-square test and the Fisher's exact test. (*)statistical
significancep < 0.05.

Table 3
Adherence scores to the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations on lifestyle; sociodemographic and clinical
characteristicsa.

WCRF/AICR recommendations Operationalization of recommendations Score Survivors Without cancer Total p

n % n % n %

Keep a healthy weight BMI (kg/m2) 18.5e24.9 0.5 26 16.3 532 20.4 558 20.2 0.419
25e29.9 0.25 62 38.7 929 35.7 991 35.8
<18.5 or 30 0 72 45.0 1144 43.9 1216 44.0
Be physically active (min/week) 150 1 0 0 0 0 0 0 0.593
75 - <150 0.5 15 9.4 213 8.2 228 8.3
<75 0 145 90.6 2392 91.8 2537 91.7
Eat a diet rich in whole grains, vegetables, 400 0.5 18 11.2 274 10.5 292 10.6 0.952
fruits, and beans (g/day) 200 - <400 0.25 58 36.3 941 36.1 999 36.1
<200 0 84 52.5 1390 53.4 1474 53.3
Limit the consumption of sugar-sweetened 0 1 76 47.5 938 36.0 1014 36.7 0.013*
beverages (g/day) >0 e 250 0.5 51 31.9 1053 40.4 1104 39.9
>250 0 33 20.6 614 23.6 647 23.4
Limit alcohol consumption (g/day) 0 1 156 97.5 2496 96.2 2652 96.3 0.465
>0e28 (2 drinks) men and 14 (1 drink) women 0.5 3 1.9 87 3.4 90 3.3
>28 (2 drinks) men and >14 (1 drink) women 0 1 0.6 12 0.4 13 0.4
Total score range 0 points 0 5 3.1 154 5.9 159 5.8 0.100
0.3e1.0 1 85 53.2 1462 56.1 1547 56.0
1.3e2.0 2 65 40.6 954 36.6 1019 36.8
2.3e3.0 3 5 3.1 35 1.4 40 1.4
a
Adherence to the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations on lifestyle; sociodemographic and clinical
characteristics. Measurements were compared using the Chi-square test and the Fisher's exact test. (*)statistical significance p < 0.05.

sweetened beverages/juices than women without cancer; 47.5%
versus 36%, respectively (p ¼ 0.013). When conducting the logistic
regression analisys, it was observed that the probability of a sur-
vivor to consume sugar-sweetened beverages and juices is 38.5%
lower than the probability of consumption in the population
without cancer, OR ¼ 0.615 (95% CI: 0.445e0.850, p ¼ 0.003).
consumed dairy products, and nearly half of them preferred to
consume half-skimmed, skimmed or low-fat products. Only 35.6%
of survivors consumed full-fat dairy products, as compared with
47.2% of the population without cancer (p ¼ 0.004).
4. Discussion

3.4. Other associations with foods 4.1. Interpretation of the main results

It was possible to establish associations with certain character-
istics of the diet that are shown in Table 4. Survivors showed a
significantly lower frequency of consumption of pulses; only 20%
consumed pulses twice or more a week, compared to 25.5% of the
population without cancer; it was also observed that 20% of sur-
vivors consumed pulses less than once a month or never, compared
to 12.5% of the population without cancer (p ¼ 0.03). Similarly,
13.8% of survivors and 8.2% of the population without cancer never
138
As far as we know, this is the first study to investigate the
adherence of cancer survivors to the recommendations of safe
food-handling practices and to the lifestyles recommendations for
cancer prevention of the World Cancer Research Fund/American
Institute for Cancer Research, WCRF/AICR and US Food & Drug
Administration Center for Food Safety & Applied Nutrition rec-
ommendations in a Chilean population. A significant association
was found only in three of the six items that assessed the
 n-Pincheira and S. Duran-Aguero
P. Huanca, C. Guzma Clinical Nutrition ESPEN 56 (2023) 135e141

Table 4
Type and frequency of food consumption, according to the presence of cancer.a.

Variable Survivors n (%) Without cancer n (%) Total n (%) p

Type of cooking oil 0.04*

None 2 (1.3%) 12 (0.5%) 14 (0.5%)
Vegetable oil (sunflower, corn, grape seed) 136 (85%) 2358 (90.5%) 2494 (90.2%)
Olive oil 20 (12.5%) 195 (7.5%) 215 (7.8%)
Lard 0 (0%) 3 (0.1%) 3 (0.1%)
Butter 1 (0.6%) 15 (0.6%) 16 (0.6%)
Margarine 0 (0%) 20 (0.7%) 20 (0.7%)
Other 1 (0.6%) 2 (0.1%) 3 (0.1%)
Frequency of consumption of pulses: beans, lentils, peas, chickpeas 0.03*
Twice or more a week 32 (20.0%) 663 (25.5%) 695 (25.2%)
At least once a week 77 (48.1%) 1342 (51.5%) 1419 (51.3%)
Between one and three times a month 19 (11.9%) 275 (10.6%) 294 (10.6%)
Less than once a month or never 32 (20.0%) 325 (12.4%) 357 (12.9%)
Frequency of consumption of wholegrain cereals: bread or food containing wholemeal flours. 0.73
More than once a day 1 (0.6%) 58 (2.2%) 59 (2.1%)
Daily 24 (15%) 360 (13.8%) 384 (13.9%)
Every other day 12 (7.5%) 212 (8.2%) 224 (8.1%)
At least once a week 18 (11.3%) 333 (12.8%) 351 (12.7%)
At least once a month 17 (10.6%) 225 (8.6%) 242 (8.8%)
Never 88 (55%) 1417 (54.4%) 1505 (54.4%)
Frequency of consumption of milk, cheese, fresh cheese, or yogurt 0.09
Three or more times per day 13 (8.1%) 176 (6.8%) 189 (6.8%)
Less than three times per day 15 (9.4%) 189 (7.3%) 204 (7.4%)
Once a day 59 (36.9%) 934 (35.9%) 993 (35.9%)
Every other day 21 (13.1%) 457 (17.5%) 478 (17.3%)
At least once a week 21 (13.1%) 496 (19.0%) 517 (18.7%)
At least once a month 9 (5.6%) 139 (5.3%) 148 (5.4%)
Never 22 (13.8%) 214 (8.2%) 236 (8.5%)
Type of dairy products consumed (milk, cheese, or yogurt) 0.004*
Half-skimmed, skimmed or low-fat 81 (50.6%) 1162 (44.6%) 1243 (45%)
Full-fat dairy 57 (35.6%) 1229 (47.2%) 1286 (46.5%)
Does not consume 22 (13.8%) 214 (8.2%) 236 (8.5%)
Frequency of consumption of fish or seafood 0.33
More than once a week 17 (10.6%) 251 (9.6%) 268 (9.7%)
Once a week 60 (37.5%) 814 (31.3%) 874 (31.6%)
Less than three times a week 32 (20.0%) 573 (22.0%) 605 (21.9%)
Less than once a month or never 51 (31.9%) 967 (37.1%) 1018 (36.8%)
a
Type and frequency of food consumption. Measurements were compared using the Chi-square test and the Fisher's exact test. (*)statistical significance p < 0.05.

adherence of survivors and population without cancer to safe
food-handling practices; this could constitute a risk of contracting
a foodborne illness. The consumption of food products contami-
nated with Campylobacter, Escherichia coli (O157:H7), Toxoplasma
gondii, Salmonella, Listeria monocytogenes, and Vibrio vulnificus,
can lead to mild to moderate gastrointestinal disease and even
death [15]. Additionally, it is important to consider conditions
such as socioeconomic and educational levels when it comes to
safe food-handling behaviors, thus creating the need for health-
care teams to identify risk factors, since this would allow the
development of social and educational support networks, in order
to obtain an improved adherence and a lower risk of contracting a
disease. With respect to the handling practice related to the type
of water consumed, only when adjusting by type of cancer it was
observed that more than 96% of survivors of breast cancer, bile
duct cancer, gastric cancer, thyroid cancer, and other types of
cancer adhere to this behavior, compared to survivors of cervical
cancer and colon or rectal cancer who do not adhere to this
practice. It is worth mentioning that around 40% of colon/rectal
cancer survivors lived in rural areas, which highlights the need for
the identification of these high-risk groups and the recommen-
dation of consuming bottled or treated drinking water as a reli-
able, quality alternative when the water from the supply network
is unavailable or when water tanks and pipes have not been
monitored [15]. Currently available studies try to promote the
adoption of these food safety guidelines and demonstrate the
absence of any benefit when following the neutropenic diet,
however, there is little research [16] exploring the level of
adherence of cancer survivors to these practices. For this reason,
this research provides relevant information regarding what to
emphasize when designing education models for cancer survi-
vors, and identifies what could be the major barriers affecting the
compliance of safe food-handling measures. It has been estimated
that between 30% and 50% of all cases of cancer can be prevented
by adopting appropriate diets and engaging in regular physical
activity [14]. Furthermore, the failure to comply with the WCRF/
AICR recommendations demonstrates the need to inform and
educate the population about lifestyles modifications. Our results
are well above those obtained by Kaluza et al. [17], who studied
two prospective Swedish cohorts over a period of 15 years and
found that 51% of the subjects did not meet the recommendation
on maintaining a healthy weight, and 54% of the subjects were not
physically active. Moreover, the role of diet in cancer prevention
has been widely documented [18]. Our study, similarly to Kaluza
et al., found that nearly 90% of the subjects did not meet the
recommendation on fruits and vegetables, therefore demon-
strating an eating behavior of high risk for cancer in the Chilean
population. Regarding alcohol consumption, there is strong evi-
dence indicating that its consumption increases the risk of cancer
of the mouth, pharynx, and larynx, oesophagus cancer, and breast
cancer [14]. Our data is in line with the results of the National
Health Interview Survey (NHIS) 2000e2017 [19], which examined
alcohol prevalence and alcohol consumption patterns in 34,080
adult cancer survivors and found that 56.5% reported themselves

139
 n-Pincheira and S. Duran-Aguero
P. Huanca, C. Guzma
as current drinkers. Lyu J et al. characterized alcohol consumption
behaviors among adult cancer survivors and determined how
these behaviors compared with cancer-free individuals using
NHANES data (1999e2016) [20], and found that from a total of
3113 survivors and 39,527 cancer-free individuals, survivors were
less likely to be current drinkers and were more likely to be
former drinkers. Moreover, our data show that it is necessary to
insist on the implementation of public policies and strategies
aimed at reducing alcohol consumption in our population. Farvid
et al. [21] conducted a prospective evaluation of the relation of
post-diagnostic sugar-sweetened beverages and artificially-
sweetened beverage consumption with mortality among women
with breast cancer, and found that women that consumed sugar-
sweetened beverages after diagnosis had higher breast cancer-
specific mortality. Additionally, Hur et al. [22] found that a
higher intake of sugar-sweetened beverages in adulthood and
adolescence was associated with greater risk of early-onset
colorectal cancer among women who participated in the Nurses’
Health Study II (1991e2015). Compared with women who
consumed <1 serving of sugar-sweetened beverages per week,
women whose intake was of 2 servings per day had a two-fold
higher risk of developing colorectal cancer, for this reason, pub-
lic policies should be oriented to minimize the consumption of
sugar-sweetened beverages and should address child population,
including a strong commitment from the industry, schools and
health authorities. This study also helped to characterize other
aspects of the diet. Survivors had a significantly greater con-
sumption of half-skimmed, skimmed or low-fat dairy products
and olive oil, and a lower consumption of pulses in comparison
with the population without cancer. This study contributes to
enhance the knowledge on the compliance of the WCRF/AICR
recommendations for cancer survivors and is oriented to future
directions regarding diet and lifestyles interventions targeted at
this population. The results of this study should be interpreted
considering some limitations. In the first place, causality is not
established, but only association because our study is cross-
sectional and not longitudinal. Secondly, participants who were
cancer survivors represented 5.8% of the total sample, however,
we believe that this low representation does not affect the overall
results of the study. Finally the participants are included in the
definition of cancer survivors, therefore we can have people in
treatment and people who were “medically discharged”.
4.2. Conclusion
Female survivors and women without cancer showed a limited
adherence to safe food-handling recommendations, therefore, it is
necessary to explore the level of knowledge on food-safety prac-
tices, as well as the barriers to compliance, and to identify
healthcare practices aimed at reducing the risk of foodborne dis-
eases in this population. It was also observed that both survivors
and women without cancer presented a low adherence to most of
the WCRF/AICR recommendations. This high risk profile of devel-
oping cancer shows the need for the delineation of public health
strategies geared towards the promotion of healthy lifestyles, In
addition, national and international longitudinal studies are
needed to analyze causality.
Authors' contributions
SD - PH: Conceptualization, Methodology. PH: Statistical anal-
ysis. SD e; PH e CG: Writing, Preparation of the original draft. SD-
CG: Supervision. SD e CG: Validation, revision, editing.
140
Clinical Nutrition ESPEN 56 (2023) 135e141
Funding
The present research has not received any specific grant from
funding agencies in the public, commercial, or not-for-profit
sectors.
Declaration of competing interest
Authors declare no conflicts of interests.
Acknowledgments
Thanks to the Ministry of Health of Chile, for allowing them to
have the database.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.clnesp.2023.04.030.
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