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Chemoprotective effect of the MD against breast cancer seemed to depend on individual's characteristics and potential risk factors, such as obesity, physical activity, smoking, age at menarche, and menopausal status. Diet and nutritional status are not only important factors in the etiology of breast cancer, but they are—major determinants of prognosis and treatment outcome in breast cancer patients.

Furthermore, scientific observations support the idea that dietary supplement can prevent breast cancer recurrences. Not limited only to breast cancer, malnutrition is frequently manifested in cancer patients, even at the time of diagnosis. In cancer patients, undernutrition may be due to various factors. Inflammation and catabolism created by the tumor can result in muscle wasting and weight loss, 48 whereas tumor gastrointestinal obstruction can impair food intake and absorption, as a result of dysphagia, pain, and vomiting.

In addition to this, the side effects of anticancer treatment, such as anorexia, nausea, vomiting, oral and intestinal mucositis with dysphagia, diarrhea, hemorrhoids, anal fissures, and modifications in smell and taste affect not only the total energy intake, but also the nutrient absorption, compromising nutritional status. Furthermore, the poor psychological state of cancer patients can affect their energy intake.

Substantial studies have shown that weight loss in cancer is associated with poor prognosis, poor quality of life, lower activity level, increased treatment-related adverse symptoms, and reduced tumor response to therapy. However, when patients stop losing weight they have better OS.

Socioeconomic development is usually associated with increasing wealth, changing lifestyle, and disease pattern leading to increase in life expectancy. This association of changes, known as epidemiological transition, is very well demonstrated in the Middle East, especially in the Gulf States, which have experienced rapid socioeconomic changes during the last four decades. As food habits trail changes in lifestyle, there has been a dramatic shift from the indigenous traditional healthy diet, which was based on whole wheat flour, fish, milk, and dates toward an affluent diet, which is rich in total calories, meat, saturated fat.

This change in dietary habits, taking place in parallel with reduced physical activity, may have contributed to the increase in the number of breast cancer cases in the regions. The findings reported in the literature are not conclusive enough to establish a pattern for the real cause of the disease. Globally there is sufficient evidence to strongly support the notion that overweight, obesity, and reduced physical activities have direct causal relationship to breast cancer.

Although very few studies are available to directly document such a relationship in the Arab world, circumstantial evidence clearly points to the possible role of the epidemic obesity in this population and the startling rise in cases of breast cancer. Well-designed and systematic studies are urgently needed to establish these associations.

Cancer-Fighting Foods

Although this review has shown that dietary habits and lifestyle have an influence on the incidence of breast cancer, it is still evident that the main etiological factors are hormone related. McDonald et al. Strong and persistent efforts are also needed to promote an overall healthy lifestyle with special emphasis on diet that is rich in fruit and vegetables and whole grains and low in red meat and saturated fats. Continued and expanded research on diet, lifestyle and breast cancer risk is urgently needed to build the foundation for future progress in evidence-based public health efforts in this region of the world.

The authors are grateful to Ms. Dhuha Abdulla Naser for her assistance with the literature search. They acknowledge the funding of S. Conception and design: Z. No competing financial interests exist.

Nutrition and Cancer From Epidemiology to Biology

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Nutritional Epidemiology

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