Research on Longitudinal change trends and influencing factors of eating behaviour in patients with nasopharyngeal carcinoma undergoing radiotherapy

doi:10.21203/rs.3.rs-3213670/v1

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Research Article

Research on Longitudinal change trends and influencing factors of eating behaviour in patients with nasopharyngeal carcinoma undergoing radiotherapy

https://doi.org/10.21203/rs.3.rs-3213670/v1

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Background: Currently, the longitudinal changes in eating behaviour during radiotherapy and the effect of these changes on dietary intake in patients with nasopharyngeal carcinoma remain unclear. The purpose of the study was to observe the longitudinal changes in eating behaviour in patients with nasopharyngeal carcinoma undergoing radiotherapy, and to explore the key factors affecting dietary intake.

Methods: A total of 107 patients were enrolled. Data were collected at eight time points during radiotherapy. Results: After the commencement of radiotherapy, the eating behaviour of patients changed as expected. The intake of calories decreased gradually from 1180.86 ±545.28 kcal to 753.73 ±315.83 kcal. The mixed effect model showed that simultaneous chemotherapy (β =-243.62, P< 0.0001) and a high symptom score (β =-12.1618, P< 0.0001) decreased food intake, while the consumption of a general diet (β = 193.61, P< 0.0001) and oral nutritional supplements (β = 157.7, P< 0.0001) increased food intake.

Conclusions: The results of this study underline the importance of early identification of changes in eating behaviour in nasopharyngeal carcinoma patients undergoing radiotherapy. Patients who are unable to consume a general diet or soft foods may ensure stable intake by increasing the frequency of meals and using oral nutritional supplements.

Nasopharyngeal carcinoma

Radiotherapy

Eating behaviour

Influencing factors

According to the data released by the International Cancer Research Center^[1], there were 133,354 new cases of nasopharyngeal carcinoma (NPC) worldwide in 2020, with 80,008 new deaths, accounting for 0.7% of new cancer cases and 0.8% of new deaths that year. Radiotherapy and chemotherapy are the most effective treatments for NPC^[2–4], but they have obvious adverse consequences for patients in addition to their therapeutic effects. Due to the particularity of the anatomical location of NPC, local oropharyngeal symptoms inevitably occur when patients are receiving high-dose radiation, such as radiation oral mucositis, changes in taste and smell, and dry mouth, which seriously affect their normal eating behaviour. Finally, changes in eating behaviour leads to deficient dietary intake and poor nutritional status. Severe malnutrition not only reduces the sensitivity of radiotherapy and chemotherapy and increases the economic burden of patients but also affects the survival of patients in the later stage^[5–7]. The management of nutritional support for patients with NPC undergoing radiotherapy is of great significance to the smooth progress, effectiveness and safety of treatment. Currently, research on factors affecting patient dietary intake mainly focuses on the impact of treatment-related symptoms on patient dietary intake^[8–11]. The role of eating behaviour changes in patients' dietary intake during radiotherapy is not clear. Eating behaviour, also known as feeding behaviour, refers to "eating activities dominated by relevant food and health concepts", including the selection and purchase of food and the type, quantity, frequency, time, place, and method of food intake^{[12, 13]}. At present, research on the eating behaviour of patients with NPC mainly focuses on the characteristics of their eating behaviour after treatment^[14–16]. Although clinicians are aware that patients usually have difficulty maintaining normal eating habits as the number of radiotherapy sessions increases, it is not clear how dietary behaviour changes over time, such as dietary types, eating frequency and the use of oral nutritional supplements, as well as the impact of these changes on dietary intake. Therefore, this study adopted a longitudinal method to closely observe the changes in the eating behaviour in NPC patients undergoing radiotherapy, and to analyse the effect of the changes in eating behaviour on the level of dietary intake in patients to provide a reference for a clinical targeted increase in patients’ dietary intake.

1.1 Participants and Sample size

Patients with NPC who received antitumour therapy in a grade 3A cancer hospital from 02.2021 to 12.2021were enrolled in this study. The inclusion criteria were as follows: (1) patients aged ≥ 18 years old; (2) patients with a Karnofsky score ≥ 80; (3) patients who had been pathologically diagnosed with NPC for the first time and were receiving radiotherapy; (4) patients with no history of mental illness or disturbed consciousness; and (5) patients who volunteered to participate in this study and signed the informed consent form. The exclusion criteria were as follows: (1) patients with distant metastasis and other malignant tumours within the last five years; (2) patients with communication disorders; and (3) patients who could not eat by mouth. The sample size was calculated with reference to the sample content estimation table for the single-group repeated measures design. For a mean correlation coefficient r = 0.5, f = 0.14 (weak effect), and α = 0.05 and under the condition of ensuring 1-β = 0.8, the sample size required for 7 measurements according to the sample content estimation scale was 106 patients. The higher the number of measurements is, the smaller the required sample size, and the total number of measurements in this study was 8; therefore, a sample size of 106 patients was used for this study.

1.2 Research tools

1.2.1 General information questionnaire

The questionnaire collected demographic data and disease-related data. Demographic data included age, sex, occupational status, main caregivers, place of residence, marital status, education level, monthly family income, medical insurance payment methods, smoking history, etc. Disease-related data included past history, treatment regimen, tumour stage, immunotherapy status, etc.

1.2.2 24-hour dietary questionnaire

A 24-hour dietary questionnaire was used for 3 consecutive days to investigate the eating behaviour of patients with NPC undergoing radiotherapy. Weighing tools and food models were used to quantitatively calculate the dietary intake, and the daily intake of calories, carbohydrates, protein and fat was calculated with the help of peppermint nutrition software. At the same time, in addition to the purpose of this study, we investigated other components of patients' eating behaviour: dietary intake mode, eating place, eating frequency, diet type, and the use of oral nutritional supplements.

1.2.3 The Head and Neck Patient Symptom Checklist

The Head and Neck Patient Symptom Checklist (HNSC) is an assessment tool developed by Schmidt et al.^[17], specifically for treatment-related symptoms of head and neck cancer patients in the past 3 days. The tool has a total of 17 symptom items, including 12 items for local symptoms and 5 items for systemic symptoms. Each symptom item is evaluated by a 5-point Likert scale: scores of 1–5 represent "not at all", "a little bit", "average", "more serious" and "very serious", respectively. The higher the total score is, the more serious the symptom. The Cronbach's α coefficient of the scale was 0.92. Compared with the Patient-Generated Subjective Global Assessment (PG-SGA), for the HNSC, the sensitivity, specificity, positive prediction rate and negative prediction rate for nutritional risk screening are 79%-98%, 99%-100%, 92%-100% and 94%-100%, respectively.

1.3 Data collection

Date on head and neck symptoms and dietary questionnaire data were collected at 8 time points: before radiotherapy (T0) and at the 5th (T1), 10th (T2), 15th (T3), 20th (T4), 25th (T5), 30th (T6) and 35th (T7) radiotherapy sessions. Before data collection, the purpose of this study was explained to the patients, and the patients signed informed consent forms after providing consent. At the same time, we established WeChat and telephone contact with patients to answer their questions in a timely manner and gain their trust and cooperation. After the eating behaviour survey data were collected face to face, the researchers distributed the dietary questionnaire and food scale to the patients and collected them after the patients completed the questionnaire.

1.4 Ethical Approval

This study obtained ethical approval (SCCHEC-02-2022-043)

1.5 Statistical Analysis

The data obtained in this study were repeated measurements obtained at different time intervals, and data were unbalanced due to loss to follow-up; therefore, a general linear mixed model was used for analysis, which takes into account the internal relationship between time points and the internal correlation between observations. Even if there are missing data, reliable conclusions can still be drawn^[18]. Due to the uncertainty of the data structure, Unstructured (UN) was used for the covariance structure. Enumeration data are percentages, and quantitative data are reported as the mean ± standard deviation. The MIXED module of SAS 9.4 software was used to analyse the influencing factors of caloric intake in patients with NPC with the level of caloric intake as the dependent variables, the general demographic data of patients as the fixed independent variable, and the content of other aspects of eating behaviour as covariates.

In this study, 115 patients with NPC undergoing radiotherapy were investigated; 8 patients withdrew from the study after providing baseline data, and 107 patients were included in the effective sample size, all of whom completed 3 or more follow-up visits. A total of 105 patients completed 4-8 surveys, 2 patients completed only 3 surveys (all dropped out of the study after the T2 follow-up due to serious side effects), and 59 patients completed treatment after the T6 follow-up. The “missing data” in the enrolment flowchart refers to instances where patients were absent for various reasons, resulting in the noncompletion of follow-up. It should be noted that this does not indicate that these patients withdrew from the study, nor does it affect their subsequent follow-ups (Figure 1).

Table 1 describes the sociodemographic characteristics, clinical characteristics, living habits and types of treatment of the patients. Among the total sample, males accounted for 76.6%, females accounted for 23.4%, the ratio of males to females was approximately 3.3:1, and the age ranged from 21 to 70 years, with an average age of 47.30±11.01 years. A total of 64.5% of the people had a low level of education, and 60.7% had a history of smoking. In this study, 98.1% of the patients had stage III and IV cancer. In addition, 94 patients received neoadjuvant therapy plus concurrent radiotherapy and chemotherapy (87.9%), and 13 patients received concurrent radiotherapy and chemotherapy (12.1%).

Table 1 General data of patients with nasopharyngeal carcinoma (n=107)

Content	Classification	No .of patients(n)	Percentage(%)
Gender	Male	82	76.6
	Female	25	23.4
Age	≤40	29	27.1
	41-60	66	61.7
	≥61	12	11.2
Ethnic group	Ethnic Han	104	97.2
	Ethnic Minority	3	2.8
Occupation	Peasant	15	14.0
	Worker	41	38.3
	Individual business or other	51	47.7
Primary companions	Spouse	75	70.1
	Parents or offspring or other	32	29.9
Residence	Countryside	31	29.0
	Boomhill Village	47	43.9
	City	29	27.1
Marital status	Have spouse	95	88.8
	No spouse	12	11.2
Educational level	Primary school and below	19	17.8
	Junior high school education	50	46.7
	High school and technical secondary school education	17	15.9
	College degree or above	21	19.6
Family monthly earning(¥)	＜3000	31	29.0
	3000-5000	32	29.9
	＞5000	44	41.1
Payment mode	Full self-payment plus new rural cooperative medical insurance	53	49.5
	Employee medical insurance	37	34.6
	Urban medical insurance	17	15.9
History of smoking	No	42	39.3
	Yes	65	60.7
History of drinking	No	63	58.9
	Yes	44	41.1
Basic Disease	Hypertension	9	8.4
	Diabetes	3	2.8
	Others (such as coronary heart disease, myocardial infarction, hepatitis, etc.)	24	22.4
	No	71	66.4
Therapeutic regimen	Neoadjuvant plus concurrent chemoradiotherapy	94	87.9
	Concurrent chemoradiotherapy	13	12.1
Cancer classification	Stage Ⅱ	2	1.9
	Stage III	43	40.2
	Stage Ⅳ	62	57.9
Immunotherapy	Yes	77	72.0
	No	30	28.0

The percentage of diet-type changes in NPC patients at different time points is presented in Figure 2. The proportion of patients on a general diet decreased from 83.8% before radiotherapy(T0) to 3% at the later stage of radiotherapy (T6); the proportion of patients receiving soft food increased rapidly from 12.4% (T0) to 53% and then gradually decreased to 30.3%; the proportion of patients on a semifluid diet increased from 3.8% (T0) to 53.5% (T6); and the proportion of patients on a fluid diet showed an overall upward trend from preradiotherapy to late radiotherapy (0% vs. 13.1%).

As shown in Table 2, the vast majority of patients maintained oral feeding during radiotherapy, with only 5.1% using tube feeding. Oral nutritional supplements (ONS) were used by 34% of patients before radiotherapy, and the proportion of patients receiving ONS was maintained between 32.4% and 44.0% during radiotherapy. Patients primarily dined at the hospital or at home while undergoing radiotherapy.

Table 2 Statistical description of eating patterns, places and use of ONS in patients with NPC at different time points (n(%))

Items	Eating pattern		ONS		Eating place
Time	Tube feeding	Oral feeding	NO	YES	Hospital	Home etc
T0	0(0.0)	107(100)	71(66.0)	36(34.0)	69(77.5)	20(22.5)
T1	0(0.0)	102(100)	69(67.6)	33(32.4)	19(21.6)	69(78.4)
T2	1(1.0)	99(99.0)	56(56.0)	44(44.0)	21(26.6)	59(73.4)
T3	3(3.1)	95(96.9)	57(58.0)	41(42.0)	39(47.0)	44(53.0)
T4	3(3.0)	98(97.0)	63(63.0)	37(37.0)	29(36.3)	51(63.7)
T5	4(4.0)	97(96.0)	57(57.0)	43(43.0)	23(27.1)	62(72.9)
T6	5(5.1)	94(94.9)	62(63.3)	36(36.7)	37(42.5)	50(57.5)
T7	0(0.0)	35(100)	22(64.7)	12(35.3)	19(57.6)	14(42.4)

ONS: oral nutrition supplements

Before radiotherapy (T0), 1% of the patients ate less than or equal to 2 times a day, 81.9% ate 3 times a day, and only 17.1% ate more than 3 times a day. After 5 rounds of radiotherapy (T1), the constituent eating frequency ratio changed, and the proportion of patients who ate 3 times a day decreased gradually. The proportion of patients who ate more than 3 times a day increased from 17.1% before radiotherapy to 48.5% at the later stage of radiotherapy (T5), but the highest proportion of patients who ate 5 or more meals per day was only 17.3% (Figure 3).

Figure 4 shows the changing trajectory of calorie intake during treatment. During treatment, calorie intake showed an overall downward trend, decreased rapidly during T1-T3, and decreased slowly after T3. The average calorie intake was 1180.86 kcal at T0 and 753.73 kcal at T7, representing a decrease of approximately 36%.

Taking the calorie intake level of patients as the representative index of food intake, univariate analysis and multivariate analysis were carried out. The assignment of variables is shown in Table 3.

Table 3 Assignment of variables

Items	Assignment mode
Sex	0=Male; 1=Female
Age	≤40 =(0, 0, 0); 41-60 =(0, 1, 0); ≥61 =(0, 0, 1)
Ethnic group	0=Ethnic Han; 1=Ethnic Minority
Occupation	Peasant =(0, 0, 0); Worker =(0, 1, 0); Individual business or other =(0, 0, 1)
Companion	0=Spouse; 1=Parent or offspring plus other
Residence	Countryside =(0, 0, 0); Boomhill Village =(0, 1, 0); City =(0, 0, 1)
Marital status	0=with partner; 1=without partner
Education Level	Primary or less =(0, 0, 0, 0); Middle school =(0, 1, 0, 0); High school and technical secondary school =(0, 0, 1, 0); College or above =(0, 0, 0, 1)
Income(¥)	＜3000=(0, 0, 0); 3000-5000=(0, 1, 0); ＞5000=(0, 0, 1)
Payment mode	Full self-payment or new rural cooperative medical insurance plus other =(0, 0, 0); Employee medical insurance =(0, 1, 0); Urban medical insurance =(0, 0, 1)
Smoking history	0=No; 1=Yes
Drinking history	0=No; 1=Yes
Diseases history	Hypertension or Diabetes =(0, 0, 0); Other diseases =(0, 1, 0); No=(0, 0, 1)
Therapeutic regimen	0=Neoadjuvant therapy plus concurrent chemoradiotherapy; 1=Concurrent chemoradiotherapy
Clinical stages	0=Ⅱ、Ⅲ; 1=Ⅳ
Immunotherapy	0=Yes; 1=No
Events (chemotherapy)	0=No; 1=Yes;
Total symptom score	Raw data
diet type	Liquid diet =(0, 0, 0, 0); Soft diet=(0, 1, 0, 0); Semi-fluid =(0, 0, 1, 0); General diet=(0, 0, 0, 1)
Eating pattern	0=Oral feeding ; 1=Tube feeding
Eating frequency	Raw data
ONS	0=No; 1=Yes
Intravenous Nutrition	0=No; 1=Yes
Eating place	0=Hospital; 1=Home or other
Time	0=Before radiotherapy; 1= 5th radiotherapy ; 2=10th radiotherapy; 3=15th radiotherapy; 4= 20th radiotherapy; 5= 25th radiotherapy; 6= 30th radiotherapy; 7=35th radiotherapy

ONS: oral nutrition supplements

The results of the univariate analysis indicate that sex, education level, smoking history, drinking history, whether chemotherapy was received, head and neck symptom score, diet type, eating pattern, eating frequency, eating place and the use of ONS were the influencing factors of calorie intake in patients with NPC treated with radiotherapy (Table 4).

According to the standard of α = 0.05, the statistically significant variables, the interaction terms between the variables and time and the variables corresponding to the interaction items in the single factor analysis were incorporated into the mixed effect model for multifactor analysis, and the first model was obtained. Then, based on professional knowledge and statistical significance, we gradually eliminated the variables in the model, developed follow-up model in turn, and fit the optimal model after screenings. Among the models, the eating place was not statistically significant, but after elimination, diet type became statistically insignificant, so it was retained based on professional knowledge (Table 5).

Table 4 The results of univariate analysis of the changes of calorie intake in patients with NPC

Factors	Estimated value （β）	Standard error（SE）	t-value	P-value
Sex (female)	-170.16	60.1793	-2.83	0.0049
Time	-56.8652	8.5677	-6.64	<0.0001
Education level (primary school education and below)	Reference	-	-	-
Junior high school education	118.47	72.0670	1.64	0.1008
High school and technical secondary education	57.4502	89.8795	0.64	0.5230
College degree or above	183.65	84.4297	2.18	0.0301
Time	-56.7239	8.5743	-6.62	<0.0001
Smoking history (Yes)	122.67	52.6585	2.33	0.0202
Time	-56.5026	8.5808	-6.58	<0.0001
Drinking history (Yes)	121.28	52.3034	2.32	0.0208
Time	-56.6301	8.5928	-6.59	<0.0001
Event (chemotherapy)	-297.31	60.2200	-4.94	<0.0001
Event * time	39.1871	15.0656	2.60	0.0096
Time	-64.7643	9.2493	-7.00	<0.0001
Total symptom score	-15.7769	1.8174	-8.68	<0.0001
Time	-5.6112	10.3183	-0.54	0.5877
diet type (fluid)	Reference	-	-	-
Semi-fluid	-123.78	60.6952	-2.04	0.0419
Soft food	2.1945	61.4075	0.04	0.9715
General diet	206.76	71.0849	2.91	0.0038
Time	-24.3229	9.8952	-2.46	0.0156
Eating pattern (tube feeding)	344.84	113.62	3.03	0.0025
Time	-59.8172	8.7051	-6.87	<0.0001
Eating frequency	105.64	18.7933	5.62	<0.0001
Time	-65.4067	8.7621	-7.46	<0.0001
ONS (Yes)	140.35	33.7726	4.16	<0.0001
Time	-57.0300	8.5282	-6.69	<0.0001
Eating place (at home, etc.)	74.8274	30.6036	2.45	0.0149
Time	-57.6472	9.6368	-5.98	<0.0001

ONS: oral nutrition supplements

Table 5 Final model of multivariate analysis of calorie intake in patients with NPC

Factor	Estimated value （β）	Standard error（SE）	t-value	P-value
Intercept	1058.81	127.45	8.31	<0.0001
Gender (female)	-197.12	60.1557	-3.28	0.0011
Event (chemotherapy)	-243.62	59.4545	-4.1	<0.0001
Total symptom score	-12.1618	2.0419	-5.96	<0.0001
diet type (fluid)	Reference	-	-	-
Semi-fluid	-23.27	58.3594	-0.4	0.6903
Soft food	34.7159	59.8377	0.58	0.5621
General diet	193.61	72.4267	2.67	0.0078
Eating frequency	102	18.297	5.57	<0.0001
ONS	157.7	33.6665	4.68	<0.0001
Eating place	13.9536	31.5162	0.44	0.6582
Event * time	37.9423	13.9935	2.71	0.007
Time	-15.6192	11.8448	-1.32	0.1903

ONS: oral nutrition supplements

The results showed that compared with male patients, female patients had lower calorie intake (β =-197.12, P=0.0011), lower calorie intake during chemotherapy (β =-243.62, P< 0.0001), and a faster decrease in calorie intake while undergoing chemotherapy (β = 37.9423, P=0.007). The patients with higher head and neck symptoms scores had lower calorie intake (β =-12.1618, P< 0.0001). At the same time, compared with patients on a liquid diet, patients who ate a general diet (β = 193.61, P=0.0078), patients who ate more frequently (β = 102, P< 0.0001), and patients who used ONS had higher calorie intake (β = 157.7, P< 0.0001).

In this longitudinal investigation, we utilized calorie intake as the primary outcome metric to investigate the crucial factors influencing the dietary intake of nasopharyngeal carcinoma (NPC) patients undergoing radiotherapy. The findings showed that patients with NPC experienced a swift progression from general and soft food diets to semifluid and liquid diets after the initiation of radiotherapy. Furthermore, after 20 rounds of radiotherapy, the proportion of patients on semifluid and liquid diets reached approximately 50%, indicating that these patients modulated their eating habits by opting for easily swallowed foods, such as porridge and soup, in response to the exacerbation of symptoms engendered by increased radiation doses^{[19, 20]}. The results revealed that there was a change in the dietary types of patients after 5 rounds of radiotherapy, and the intake significantly decreased after 10 rounds, indicating that changes in dietary types occurred earlier than the decrease in intake. This suggests that the assessment of dietary types can serve as an important indicator for the nutritional evaluation of nasopharyngeal cancer patients undergoing radiotherapy. Although some patients adopted tube feeding, increased their meal frequency, and supplemented their intake with ONS during radiotherapy, the proportion of patients who did so did not increase substantially with the progression of radiation therapy: from T2-T6, the proportion of patients with tube feeding was only 1.0%-5.1%, and the proportion of patients with a meal frequency ≥5 times/day was only 4.1%-17.3%, while the proportion of patients using ONS did not show a significant difference before and after radiotherapy (34%-44%). Inadequate eating frequency and the use of ONS after changes in dietary types may be a key reason for the decrease in intake during radiotherapy (1180.86 ±545.28 kcal vs. 753.73 ±315.83 kcal). Hence, in clinical practice, not only should the management of radiation-related symptoms be emphasized, but changes in eating behaviour should also be given due regard. Specifically, the eating frequency and intake of patients on semiliquid and liquid diets, as well as the use of ONS, should be carefully evaluated to ensure that the impact of changes in dietary types on intake can be mitigated through other feeding behaviour. Furthermore, the interactions between different means of feeding behaviour should be further explored to more accurately regulate meeting the intake requirements.

At the same time, the results also found that female patients had lower calorie intake, which may be related to the different body target needs of the different sexes; on the other hand, it may also be because female patients face higher dietary risks ^[21]. Women receive less life care than men. It is important for clinicians to consider sex when providing nutritional support to patients. Furthermore, NPC patients undergoing radiotherapy and chemotherapy simultaneously had lower calorie intake, which is consistent with the results of related studies^[22]; that is, chemotherapy aggravates the decrease in dietary intake. This is related to gastrointestinal reactions, such as nausea, vomiting and loss of appetite, caused by platinum chemotherapeutic drugs used in patients with NPC^[23]. According to international guidelines, dietary intake should be increased through intensive nutritional counselling (NC) and ONS in patients receiving radiotherapy or chemoradiotherapy for head and neck cancer^[24-26]. Several randomized controlled trials^{[25, 27]} have shown that patients receiving radiotherapy for head and neck cancer have significantly higher intakes after intensive nutritional counselling than patients who do not receive or receive standard nutritional advice. Nutritional support is an important part of the treatment of patients with head and neck cancer. Nutritional intervention should be carried out during treatment to prevent weight loss, increase food intake and reduce treatment interruption^[28]. In fact, however, nutritional support is considered part of palliative care for patients with advanced cancer, with the sole aim of improving quality of life, neglecting its potential to enhance the efficacy of aggressive anticancer treatments and improve disease outcomes.

This study showed that when the symptom score increased by 1 point, the calorie intake decreased by 12.1618 kcal (β =-12.1618, P < 0.0001). A study by Farhanghar et al.^[8] showed that patients with multiple nutritional impact symptoms (NIS) or higher total symptom scores were more likely to have reduced dietary intake and weight loss. Radiotherapy, with or without combined chemotherapy, aggravates NIS, further reducing dietary intake and increasing the risk of malnutrition^[29], which is the reason why clinical attention has been given to symptom management in patients with NPC for a long time. However, this study found that the effect of symptoms on calorie intake is lower than that of treatment and eating behaviour factors such as the combination of radiotherapy and chemotherapy, diet types and eating frequency. This suggests that the management of eating-related symptoms caused by radiotherapy in patients with NPC is better, and the influence on intake is reduced, but the effect of changes in eating behaviour on intake is increased, which is worthy of attention.

Moreover, patients with NPC who adhered to a general diet exhibited a higher caloric intake when compared to those who consumed a liquid-based diet. As such, a substitution in dietary habits should be regarded as a preliminary indication of inadequate nutritional consumption. At the same time, the results indicated that the more frequently patients consumed meals, the greater the number of calories they tended to consume. Prior to undergoing radiotherapy, 81.9% of patients adhered to the traditional Chinese three-meals-a-day regimen. As treatment progressed, the patients' dietary habits rapidly evolved from a general diet to soft foods, semiliquid food and liquid substances. Nevertheless, the nutritional provisions furnished by the latter alimentary alternatives are merely suitable for temporary use, necessitating a food intake frequency of 5-6 or 6-7 times a day. In this study, the highest proportion of patients with a meal frequency of ≥5 times/day was only 17.3%; the insufficiency of eating frequency, coupled with the lack of awareness of food and nutrition in cancer patients, and the dietary concepts and beliefs of most cancer patients with specific food restrictions^[30-32] resulted in insufficient calorie intake. This suggests that nurses should urge patients to increase their willingness to eat by increasing the eating frequency to obtain higher food intake, closely monitor dietary composition and perform target intake assessment. In cases where patients have difficulty maintaining a normal eating pattern due to adverse reactions related to treatment, they can be referred to a dietitian for relevant dietary advice and guidance, and dietary health guidance should be given to patients and their family members. The incorrect concept of dietary culture should be corrected, patients should be helped to maintain eating behaviour suitable for their nutritional needs during radiotherapy, and dietary follow-up health support should be provided during radiotherapy.

As part of nutritional treatment, ONS is an effective tool to address cancer-related malnutrition, which is supported by an increasing amount of literature data^[33-36]. The guidelines of the European Society for Parenteral and Enteral Nutrition recommend ONS as a first-line nutritional treatment for patients with insufficient oral intake^[37]. The results of this study showed that the use of ONS increased the calorie intake of patients, which is consistent with the results of related studies^{[38, 39]}. ONS are a nutritional supplement for oral intake of general food to increase the intake of energy and nutrients, which is economical, convenient and easy for patients to accept^[39]. Related studies have also shown that the use of ONS can improve the nutritional status of patients with head and neck tumours^{[40, 41]}. With the development of medical technology, there are many kinds of ONS on the market at present^[42]. In this study, most of the ONS used by patients were products purchased in drugstores, with different prices and types, and patients were subjective and random in the way of use. As shown in Table 3, 34% of patients used ONS prophylactically before radiotherapy; however, the number of patients using ONS did not increase significantly with the progress of treatment. Studies^{[43, 44]} have shown that low compliance, taste fatigue, and high costs are common problems when using ONS in cancer patients. Although the clinical value of ONS has been confirmed, many factors may affect adherence, including clinical environment, the type of ONS, the taste of the ONS, and patient cognition and attitudes, patients who receive various flavors of ONS are more compliant with ONS than those who receive various types of ONS^{[45, 46]}. Therefore, providing patients with various flavors of supplements to help them obtain a better sensory experience may enhance their compliance with ONS. In addition, oral nutritional supplementation is a nutritional therapy given orally, which may also be affected by symptoms. Due to disease and treatment, NPC patients often have symptoms that affect oral intake, such as loss of appetite, nausea and vomiting, which may hinder the use of ONS^[47]. A decrease in the consumption of usual foods when ONS are consumed has been demonstrated^[48]; therefore, patients should be encouraged to take ONS between meals rather than as a substitute for a regular meal.

Although this study provided patients with food scales to ensure the accuracy of dietary intake records, the compliance of some patients was poor, so it may affect the accuracy of the dietary intake surveys. This also suggests that convenient methods or tools for patients' dietary surveys can be developed in the future to provide conditions for patients with NPC to self-evaluate their dietary intake during radiotherapy so that they can quantify their daily dietary intake and improve their compliance with increased dietary intake.

Acknowledgement: The authors would like to express their sincere appreciation to the Ethics Committee of Medical Research and New Medical Technology, Sichuan Cancer Hospital, for approval of this study. Moreover, we thank the patients who participated and contributed to this study

Author contributions: GW provided guidance on the thinking and writing of the whole text. ZY and YR processed part of the data and wrote the full text. All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors, read, and approved the final manuscript.

Ethics approval and consent to participate: The study was approved by the Ethics Committee of Medical Research and New Medical Technology of Sichuan Cancer Hospital (SCCEC-02-2022-043). The patients provided their written informed consent to participate in this study

Data availability: The original contributions presented in this study are included

in the article/supplementary material, further inquiries can be directed to the corresponding author.

Conflict of interest: The authors declare no conflict of interest.

Funding: No funding was received for conducting this study.

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No competing interests reported.

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Research on Longitudinal change trends and influencing factors of eating behaviour in patients with nasopharyngeal carcinoma undergoing radiotherapy

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