Dietary Intake Among Breast Cancer Survivors in East Coast of Peninsular Malaysia

Background and Context

Breast cancer is the most common cancer among Malaysian women, with an age-standardised incidence rate that has been rising steadily over the past several decades. In Malaysia, approximately one in twenty women will be diagnosed with breast cancer during their lifetime. Advances in early detection and treatment have improved survival rates significantly, resulting in a growing population of breast cancer survivors who face long-term health challenges including the risk of cancer recurrence, cardiovascular disease, metabolic syndrome, and impaired quality of life.

Dietary intake is a modifiable factor that plays a critical role in cancer survivorship. The World Cancer Research Fund and American Institute for Cancer Research (WCRF/AICR) have concluded that dietary patterns characterised by increased intake of whole grains, vegetables, fruits, and legumes, combined with reduced intake of processed foods, red meat, sweetened drinks, and alcohol, can reduce the risk of cancer recurrence and improve overall health outcomes. For breast cancer survivors specifically, maintaining a healthy body weight, consuming a nutrient-dense diet, and limiting intake of saturated fats, refined carbohydrates, and sodium are considered important elements of survivorship care.

The East Coast of Peninsular Malaysia — comprising the states of Kelantan and Terengganu — has distinct cultural, dietary, and socio-economic characteristics that differentiate it from the more urbanised west coast. The predominantly Malay population in these states has traditional dietary patterns that are rich in rice, fish, coconut-based preparations, and fermented foods, but may also include high sodium content from traditional condiments and preserved foods. Understanding the dietary intake of breast cancer survivors in this specific context is essential for developing culturally appropriate nutritional interventions.

Study Design and Population

This cross-sectional study recruited 125 breast cancer survivors aged 37 to 72 years from two main referral hospitals in the east coast region: Hospital Sultanah Nur Zahirah in Terengganu and Hospital Raja Perempuan Zainab II in Kelantan. Eligible participants were women who had completed their primary cancer treatment (surgery, chemotherapy, and/or radiotherapy) at least six months prior to recruitment. Dietary intake was assessed using a validated semi-quantitative food frequency questionnaire (FFQ) designed to capture habitual dietary patterns over the preceding year.

The study population was predominantly Malay (94.4%), consistent with the ethnic composition of the east coast region. The majority (66.0%) had been diagnosed with stage II breast cancer. The mean BMI of 27.7 ± 5.07 kg/m² indicated that the study population was predominantly overweight, a finding that aligns with the growing prevalence of overweight and obesity among Malaysian women generally and among breast cancer survivors specifically.

Macronutrient Intake

The mean daily energy intake of 1,764 ± 378 kcal/day was within the range typically recommended for adult women of this age group with moderate physical activity levels. The proportional contribution of macronutrients to total energy intake — 55% from carbohydrates, 16.5% from protein, and 28% from fat — was broadly consistent with the Malaysian Dietary Guidelines and WHO recommendations.

However, closer examination of fat subtypes revealed concerning patterns. Saturated fatty acid intake averaged 26.9 ± 14.2 g/day, approximately 167% of the recommended maximum. This finding is particularly relevant for breast cancer survivors, as epidemiological evidence suggests that high saturated fat intake may be associated with poorer cancer outcomes and increased cardiovascular risk — both important considerations in the survivorship period. Conversely, intake of cardio-protective monounsaturated and polyunsaturated fatty acids fell below recommended levels.

Micronutrient Concerns

The analysis revealed several micronutrient inadequacies with important clinical implications for breast cancer survivors. Calcium intake was below recommended levels — a concern given that breast cancer treatments (including aromatase inhibitors and chemotherapy-induced premature menopause) can accelerate bone loss and increase fracture risk. Iron intake was also below recommendations, which is relevant in the context of cancer treatment-related anaemia and fatigue. Potassium intake was inadequate, potentially contributing to the blood pressure elevation associated with high sodium intake.

The high sodium intake observed in this population likely reflects traditional east coast Malay dietary practices that incorporate substantial amounts of fermented fish paste (belacan), fish sauce, soy sauce, and salt in food preparation. Addressing sodium intake in this population requires culturally sensitive approaches that acknowledge the importance of traditional flavourings while offering practical strategies for gradual reduction.

Duration of Survivorship and Dietary Patterns

An important secondary finding was the comparison of dietary intake between survivors diagnosed within the past five years and those diagnosed more than five years previously. No significant difference was observed for most nutrients (p > 0.05), with the notable exceptions of total fat (p < 0.001), saturated fatty acid (p = 0.006), monounsaturated fatty acid (p = 0.005), and polyunsaturated fatty acid (p = 0.003). These findings suggest that fat intake patterns may change over the course of survivorship, though the cross-sectional design precludes determination of the direction or cause of these changes.

Implications for Survivorship Care

The findings highlight the need for targeted nutritional counselling and dietary intervention programmes for breast cancer survivors in the east coast region. Key intervention targets include reducing saturated fat and sodium intake, increasing dietary fibre through greater consumption of vegetables, fruits, and whole grains, improving calcium intake to support bone health, and addressing the high prevalence of overweight and obesity through comprehensive lifestyle modification programmes.

Culturally appropriate dietary interventions that respect traditional Malay food practices while guiding survivors towards healthier preparation methods and ingredient substitutions are more likely to achieve sustained behaviour change. Integration of nutritional counselling into routine oncology follow-up care would ensure that dietary assessment and intervention become standard components of breast cancer survivorship care in Malaysia.

Limitations

The study relied on a food frequency questionnaire, which is subject to recall bias and may not capture day-to-day variation in dietary intake. The predominantly Malay sample from two hospitals in the east coast region limits generalisability to other ethnic groups and geographic settings within Malaysia. The cross-sectional design does not permit causal inferences about the relationship between dietary patterns and health outcomes. Biomarker-based validation of dietary intake was not performed.

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