Progresses accomplished in childhood cancer treatment, diagnosis, and management in the past decades have led to survival rates exceeding 80% [1,2]. Despite these encouraging statistics, it is estimated that about two-thirds of childhood cancer survivors (CCS) will be affected by treatment-related long-term complications [3], including cardiovascular and metabolic diseases [4,5]. Lifestyle practices such as healthy eating and physical activity are well-recognized modifiable factors that contribute to lower the risk of cardiometabolic complications [6]. Particularly, adherence to a Mediterranean dietary pattern has been associated with reduced risk factors related to the metabolic syndrome in survivors of childhood acute lymphoblastic leukemia [7]. In addition to the prevention of long-term sequelae, good nutrition is essential to ensure children’s requirements for growth and development during cancer treatments. Adequate nutritional status is also associated with increased tolerance to cancer treatments, better prognosis, and enhanced quality of life [8]. Side effects of cancer treatments such as nausea, mucositis, taste disorders, poor appetite, or increased appetite secondary to steroids intake can impact children’s eating behaviors and nutritional status [8]. Furthermore, it is known that eating habits acquired in childhood are likely to persist in adulthood [9,10] and after completion of cancer treatments [11].

Studies on CCS have described similar dietary habits to those of the general population, reflecting a suboptimal diet for the prevention of metabolic syndrome components such as obesity, insulin resistance, arterial hypertension, or dyslipidemia [12]. So, involving families of children with cancer to adopt or maintain healthy habits during and after cancer treatment is essential. Moreover, given that parents often experience time constraints [13] and economic burden related to transportation, accommodation, or loss of work income [14], practical advice for meal preparation should be provided to meet families’ needs. Design and evaluation of family-based nutrition and cooking education programs are increasingly reported in the literature, mainly related to the prevention or management of childhood obesity [15-19]. Nutritional interventions for young CCS and their families have been described in the literature [20-22], but, to our knowledge, only few were developed for children undergoing cancer treatment and those that were targeted patients in the maintenance phase of therapy [23-25]. As there is a need to develop and evaluate the feasibility of an early intervention during the course of pediatric cancer treatments, we have developed 6 nutrition and cooking education workshops that aim to increase knowledge relative to the following: (1) children’s nutrition during and after cancer treatments; (2) healthy, quick, and economical food preparation, cooking techniques, and food safety specific for children with cancer; and (3) development of food preferences during childhood and parental feeding practices. Here, we describe the following: (1) the development and validation of the workshops; (2) the elaboration of an evaluation tool; and (3) the study protocol to implement the workshops and to measure their impact.

We have developed a protocol for a nonrandomized controlled study. This study has been developed within the VIE (Valorization, Implication, Education) Program at the Sainte-Justine University Health Center (SJUHC) in Montreal, Canada. This research program consists of a 4-year family-oriented multidisciplinary interventional program integrating physical activity, nutrition, and psychosocial clinical and research teams. The nutritional intervention includes personalized assessment, goal setting, and counseling for behavioral changes with a registered dietitian (RD) as well as group nutrition education and cooking workshops providing complementary information. The SJUHC Institutional Review Board approved the study, and investigations will be carried out in accordance with the principles of the Declaration of Helsinki.

The research- and practice-based curriculum consists of 6 lessons developed by a team of researchers and RD and validated by the hematology-oncology clinical nutrition team at SJUHC. The workshops are designed to provide reliable, up-to-date nutritional information geared to address specific themes and associated to cooking demonstrations facilitated by a RD and a chef.

To develop the curriculum, evidence for common nutritional and behavioral eating problems related to side effects of childhood cancer treatment and their management has been reviewed in the scientific literature published between 2000 and 2017 contained in Medline, PubMed, and Scopus databases. A few core papers published before 2000 have also been considered. Gray literature was searched for Canadian governmental guidelines and family-oriented documentation related to children’s diet while on cancer treatment published by recognized organizations, such as the Children Oncology Group and the Canadian Cancer Society. Insight from the SJUHC Centre de cancérologie Charles-Bruneau (CCCB) clinical nutrition team has also been sought. Recipes for demonstration were developed and standardized to match each of the 6 lesson themes. Nutritional value of recipes was analyzed based on general (for protein, lipid, and sodium content) and theme-specific criteria and was inspired by those of the SJUHC institutional food service, of early childhood nutrition reference [26], and of the Heart and Stroke Foundation program [27].

The curriculum was validated concurrently with its development within an 8-step process (Figure 1). The first 6 steps have already been completed. Subsequent to the literature review, primary themes and specific lesson objectives were elaborated and submitted to a steering committee, composed of SJUHC CCCB clinical RD (n=2) and the Department head of the Clinical Nutrition Services, representing, respectively, 19, 15, and 10 years of experience in pediatric oncology. A consensus on improvements to be made was obtained, and a detailed content of the lessons was then elaborated based on current scientific evidence and common practices by the clinical nutrition team. The modified and detailed content was submitted to the clinicians for a second validation, followed by a final revision of the curriculum. Workshops were pretested with nonparticipants, including CCCB health care professionals, leading to further refinements.

Subsequent steps will be performed before official implementation and intervention evaluation. A validation meeting will be conducted with a committee composed of family members and CCS to better tailor the curriculum regarding the length of the workshop, the timing, and the amount of information delivered. After implementation, we will continually monitor the curriculum and evaluation tools to fine-tune and optimize content delivery.

The developed curriculum consists of 6 themed workshops with specific objectives and key messages (Table 1). The 6 lessons are independent from one another, and there is no specific sequence to attend the workshops. This will increase convenience and allow flexibility according to participants’ schedule and needs for information. The nutritional criteria of the recipes are presented in Table 2.

The curriculum will promote a liberalized diet that reinforces food safety guidelines for immunocompromised patients based on Health Canada food safety guidelines for people with a weakened immune system [61] and in line with the SJUHC CCCB standard clinical practices. Patients receiving hematopoietic cell transplantation will be referred to the hematology-oncology RD for personalized diet and food safety guidelines.

With this study, we have developed a family-oriented nutrition education and cooking workshop curriculum specific to pediatric oncology. The elaboration based on scientific evidence and on years of clinical experience, combined with an 8-step validation process, are strengths and features of interest of this study [64,66]. There is a consensus on the value of including field actors and representatives of the target population in the development of lifestyle interventions. Including clinicians in the development process offers precious insight to enhance the curriculum content and ensures coherence with the medical team. In CCS overweight children, a group lifestyle intervention used interviews and focus groups with health care providers and CCS parents to adapt a curriculum previously shown to be effective in non-CCS overweight children [67].

Some authors suggested that adding a cooking component to nutrition education is a good way to enhance participants’ skills and increase application of knowledge [68,69]. In our curriculum, cooking demonstrations will allow observational learning [68] and may enhance participants’ familiarity with specific foods [70], cooking techniques, and food safety practices. Moreover, the nutrition education content will focus on practical application as several ideas to apply recommendations and tips to overcome barriers to healthy eating and home cooking will be presented. Furthermore, the developed content aims at reinforcing the messages conveyed by the clinical and research RD during individual follow-up. Therefore, the workshops may serve as a complementary intervention tool to facilitate behavioral change.

The curriculum was developed based on the social-ecological model, considering that individuals’ eating behaviors are influenced by determinants of their environment [71]. Family, as part of their social environment, is one of the most influent determinants of healthy eating in children. Indeed, parents play a crucial role as they usually are responsible for food selection, serve as role models, and use parental feeding practices that impact children’s eating behaviors [72]. According to studies designed for obesity prevention or management in children, family-oriented lifestyle interventions are the most effective in noncancer and in CCS populations [15,73]. Therefore, our curriculum targets patients and their families. It will address the use of positive parental feeding practices [74,75] to promote healthy eating behaviors in children during and after cancer treatments, for example, healthy eating role modeling and avoidance of restrictions or control over eating [9,76].

The curriculum will put forward a positive and total diet approach to healthy eating that considers the whole eating pattern, suggests adding healthy foods instead of forbidding specific foods (apart from those restricted for food safety), and avoids categorization of food as “good” or “bad” [77]. The Mediterranean diet pattern is associated with the prevention of cardiovascular diseases [49] that are frequent long-term complications of CCS [4,5]. Therefore, coupled with Canadian Dietary Guidelines [78], this pattern has guided the development of nutrition education content and recipe criteria.

Food safety is a major concern during pediatric cancer treatment due to weakened immune system. It will be addressed throughout all cooking demonstrations when facilitators will model safe food handling practices. Only little evidence support a neutropenic diet to prevent infection for patients undergoing chemotherapy or radiotherapy, as the only few randomized control trials performed used variable methodologies and presented several limitations [79,80]. Indeed, a neutropenic diet may impose unnecessary food restrictions on patients who often consume insufficient dietary intakes [80,81].

Further studies need to evaluate the feasibility of implementing workshops for pediatric oncology patients undergoing cancer treatments. The moment surrounding the diagnosis and treatment of cancer has been described as a teachable moment for a healthier lifestyle in adult cancer [82]. However, this opportunity window is not well documented in children. Families overwhelmed with the diagnosis might be less interested or find it too challenging to adopt healthy habits while experiencing a distressing life event [83]. However, focus groups with parents of overweight CCS testing a 6-lesson curriculum after completion of their child’s treatment revealed that some would have preferred to receive the intervention earlier in the process [67], supporting that the timing of our intervention might be optimal.

The heterogeneity of the target population, which comprises children of various ages, diagnoses, and treatments, was a challenge in the development of the curriculum. Evaluating the implementation of the workshops will inform us on participation rate and will allow to calculate sample size of future nutrition education and cooking program in pediatric oncology. The nonrandomized design is also a limitation of this study. Our study was designed to ensure that every newly diagnosed patient could participate and benefit from this novel lifestyle study. Therefore, control participants will only be recruited among patients who completed the standard treatment before the VIE Program was implemented.

We are confident that this intervention will contribute to increase knowledge about nutrition and cooking in the context of childhood cancer. Hopefully, it will improve children’s diet quality while promoting long-term healthy eating habits to prevent cardiometabolic complications. This research- and practice-based nutrition education and cooking demonstration curriculum will be a valuable complement to the VIE Program lifestyle intervention for the prevention of cardiometabolic long-term complications.