View metadata, citation and similar papers at to you byCOREprovided by University of Kufa: UOK Journal Hosting ServiceKUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Association between Nutrient Contents of Foods andOccurrence of Breast Cancer, A Case –Control Study دراسة ارتباط ما بين مكونات الغذاء واالصابة بمرض سرطان الثدي مقارنة باألشخاص االصحاء Jwan Ibrahim Jawzali *Dr. Jangi Shawkat Salai **: الخالصة . تهدف الدراسة إلى مقارنة محتوى الغذاء ما بين مرضى سرطان الثدي واالشخاص االصحاء : هدف البحث حالة سالمة من جميع انواع االمراض السرطانية يترددون على المستشفى التعليمي 69 مريضة بسرطان الثدي و 95 شملت هذه الدراسة : المنهجية والمعلومات عن نمط الحياة واالغذية بواسطة استبيان , النسائية , تم جمع المعلومات الديموغرافية . العراق / الجمهوري ومستشفى رزكاري في اربيل .1311 تموز سنة 03 اذار الى 1 من , مكون أربعة أجزاء وزيادة اخذ , وتاريخ العائلة لإلصابة بمرض السرطان , أظهرت الدراسة زيادة معنوية في اإلصابة بسرطان الثدي نتيجة قلة الوعي والدخل : النتائج , والمعادن (فوسفور ,)D, و الكوليسيفيرول , B1 االغذية الغنية بالطاقة و كربوهيدرات بسيطة و شحوم مشبعة و كوليسترول و فيتامينات ( ثايمين و اخذ , مع سلينيوم) تأثيرات وقائية من االصابة بسرطان الثدي وجدت ضمن االشخاص ذات مستويات التعليم المتوسطة , منغنيز , زنك , صوديوم . والبقوليات و الشاي , و الياف غير الذائبة K. الكميات المقررة من العناصر الصغرى و فيتامين ك اخذ . نستنتج بان االطعمة الغنية بالطاقة والملح يؤدي الى االكسدة الكامنة و عدم توازن الهورمونات وبالتالي زيادة اإلصابة بسرطان الثدي : االستنتاج . كميات محدودة من العناصر الصغرى و بالمستويات المتوازنة في الدم يحمي االنسجة من السرطان توصي الدراسة بتطبيق تقييم الحالة التغذويه وبرنامج التثقيف الغذائي من قبل ممرضين مختصين بالتغذية وأخصائيي التغذية : التوصيات AbstractObjective: The study conducted to identify association of nutrient contents of foods with occurrence ofbreast cancer compares to control group.Design: It is descriptive (analytic case-control study). Interview questionnaire was used to collect data of;socio-demographic properties, reproductive history, familial cancer history, and life style factors includedindices of obesity, and diet history data to calculate intake of; energy, macronutrient, vitamins and mineralsby quantitative food frequency questionnaire.Methodology: The study included (59) women with diagnosed breast cancer, and (65) controls womenfree from all types of cancer attending Rizgary and Hawler teaching hospital / Erbil / Iraq , from the periodof 1st April to 30 July 2011. Statistical analysis included Descriptive statistic, and logistic regression analysisResults: The results showed significant increase in the risk of breast cancer by; low income and lowawareness, family history of cancer, and higher intake than controls of; energy, digestible and high glycemicload carbohydrates, saturated fats, cholesterol, vitamins; thiamin, and cholecalciferol and minerals;phosphors, sodium zinc, manganese, and selenium. While primary education level act as significantprotective factor in addition to slight protective effect of; vitamins K (naphthoquinones), insoluble fiber and(beans and tea) as foods.Conclusion: High dietary intake of rich energy nutrients, and salty foods could cause; oxidative stress,hormone disturbance and associate with breast cancer risk. Low and safe levels of dietary micro-nutrientsand their blood homeostasis may decrease tissues damage and risk of breast cancer.Recommendations: The study recommended implementation nutritional status assessment andnutritional educational program by nutritional specialized nurses, and nutritionists.Keywords: Dietary habit, nutrient intakes, risks of breast cancer. ـــــــــــــــ * PhD. In Clinical Biochemistry, Lecturer in Nursing Department / College of Nursing- Erbil/Iraq.E-mail: [email protected]** Ph.D. in Molecular Biology, Lecturer in Pharmacology Department/ College of MedicineErbil/ Iraq, Oncologist and Internist, in Rizgary Teaching Hospitals - Erbil/ IraqE-mail: [email protected]

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017IntroductionBreast cancer is a cancer of the glandular breast tissues. Incidence of female breastcancer in most Asian countries is much lower than that in western countries, and has beenshown to be rising due to changes in lifestyle(1). It is caused by heredity, environmentpollution, biomechanics, dietary intake (which are mainly consisting of fats and starches)and the way of living. Recent Iraq wars affect the aggressiveness of disease and began toselect its victims within young ages of women (thirties and twenties) (2).In Erbil governorate breast cancer has been shown to be the most common canceramong women attending outpatients clinics of hospitals; Rizgary, Maternity and Hawlerteaching hospitals and Nanakly according to statistical data from ministry of Health, 2006(3,4). Breast cancer is predominantly a disease of pre-menopausal Kurdish Iraqi women inSulaimaniyah (5). Almost all cancers (80 – 90%) are caused by environmental factors andof these (30-40%) of cancers are directly linked to the diet and there is significant relationbetween lifestyle (including food consumption) and cancer (6). Much of the internationalvariation is due to difference in established genetic risk factors but diet might alsocontribute to risk and provide a potentially modifiable target for prevention. Recentefforts have focused on identifying dietary risk modulators (2) .Comparison studies of foodintake and its nutrient content association with breast cancer patients in Iraq and Erbilare rare. Therefore we compared nutrient content of foods consumed between breastcancer patients and controls and risks associated with demographic properties,reproductive history, and history of familial cancer, obesity, and physical activityMethodology:Case-control study was carried out in Rizgary and Hawler teaching hospital in Erbilgovernorate, Kurdistan region/Iraq. The patients (cases) included a purposive sample of(69 women and 6 dropped out because they didn’t complete the interview questionnaire),they were diagnosed with breast cancer (after mastectomy), at different stage, attendingoutpatient unit of chemotherapy of Rizgary teaching hospital (2 days/ week) from theperiod of (1st April to 30 July 2011) and frequency age matched ( 5 years) controlsincluded (65) available sample of women attending the same outpatient clinics of bothRizgary and Hawler teaching hospital of Erbil city from 1st September to 30 November2011. They were free from all types of cancer. All patients and controls were interviewedby questionnaire. (After their consent had been taken) and composed of three parts ofquestions. The first part of questions included socio-demographic properties; age,educational level, residency, occupation and marital status. The second part of questionswere about risk factors associated with reproductive property; age at menarche, age atmenopause status, age at first pregnancy, number of children, type of breast feeding, oralcontraceptive use, and hormonal therapy. The third part of questions included life stylerisks; family history of cancer with relationships to affected family members, physicalactivity, measurement of obesity by body mass index (BMI) and waist to hip ratio anddietary intake data by quantitative food frequency questionnaire to estimate (type andquantity) of food intake during the two years before the diagnosis for cases and beforeinterview for controls.Indexes of obesity were measured for controls and patients (whose weighs notchanged after disease) and included recording the anthropometric measurements whichwere; weight and height to calculate body mass index (BMI), waist and hip circumferencesmeasurement to calculate waist to hip ratio. BMI classified according to the world HealthOrganization (WHO), which defined abdominal obesity as a waist–hip ratio above 0.90 formales and above 0.85 for females, or a body mass index (BMI) above 30.0 (7). Physical-67-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017activity levels (PAL) were calculated by asking the study population about their habitualactivities as house work, office work, sleeping, watching TV, chatting, and walking per daythen calculating energy costs and (PAL) using tables adapted from human energyrequirement of FAO/ WHO/ UNU 2001 (8) .The questionnaire of dietary intake data included (35) food items which were; Mostfrequency food item and Food items consumed in greatest amounts. Selected food itemswere categorized according to food groups and subdivided by source content and types.Food items in each category were cereals (cereal were differentiated to white bread,whole bread and whole grain), meats (red meats, chicken meats and fish), egg, legumes,milk and dairy products, vegetables and fruits most consumed by season, oils and fats,sweat snack, hot beverage (coffee and tea) and soft drinks (orange juice and cola).Subjects asked to state the average frequency of consumption of each food item accordingto the categories of frequency varying from; never or less than once per month, once permonth, to 6 or more times per day. The food portion sizes were standard householdmeasures and food models and photographs of the standard portion sizes of foods werecommonly eaten. The subject was asked to refer to those portions when selecting theamounts of foods consumed. Once food intake data had been collected the quantities offoods reported in household measures were converted into quantities in grams for oneday manually. Then data of foods intake in grams were analyzed for nutrient intake by acomputer aided nutrient analysis program for Mosby's Nutitric Nutrition AnalysisSoftware, version IV (CD-ROM). Daily macronutrients intakes were categorized to low,normal and high levels according to recommended amounts by the Institute of Medicine(IOM) National Academy Dietary Reference Intakes of 2002 Normal category of energyrepresents women's energy intake levels based on Estimated Energy Requirements (EER)which had taken in consideration age and activity of women. While the low and highcategories represent women's with lower or higher intake of energy than (EER). The sameprinciple was used for categories of macronutrient depending on the range of AcceptableMacronutrient Distribution Ranges (AMDRS) of; carbohydrates (45% - 65%), protein(10% - 35%), and fat (20% - 35%) of total energy and their energy value in one gram offood. The mid of total energy intake 2100) kilocalorie/day (Kcal/day) among the studiedwomen was used in calculation (9). Saturated, fat intake categorized to three levelscomparing to normal recommended levels which ranges between (7 – 10% of totalenergy) for saturated (European Food Safety Authority (EFSA), 2010) (10).A maximum healthy level of cholesterol was limited to (200-300) mg/day asrecommended by Dietary guideline of American, while the healthy low levels were lowerthan 200 mg/day and higher levels were regarded as unhealthy level (11). Dietary fiberintakes categorized into low, normal, and high intakes. Normal was 20-30 g/daydepending on caloric intake (20g for 2000 calories) recommends by Academy of Nutritionand Dietetic previous (ADA) (12). Daily caffeine intake categorized to low ( 0.2) g/day andmoderate healthy levels which is equal to 3.0 g/day (Sata, 2005) and abnormal levels 0.3 g /day (13). Vitamins and minerals were categorized depending on recommendedDietary Allowance (RDA) and Tolerable Upper Intake Levels (UL) of Dietary ReferenceIntakes (DRIs) Food and Nutrition Board, Institute of Medicine, National Academies, andUpper Safe Levels of Intake for Adults: Vitamins and Minerals (Judy,2009) (14). All datawere analyzed by SPSS version 18.0. Include descriptive statistic independent samples ttest, Chi-square test Adjustment odds ratio (OR) value inclusion confounders; residency,occupation, and education levels were calculated to test risk of diseases or associationbetween different risk factors and breast cancer. For binominal (yes and No) Cochran'sand Mantel Haenszel descriptive test and binary logistic regression analysis for other-68-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017variables were used. The P- value was considered significant when P 3.39 and wasconsidered as highly significant when P 3.31.Results:Table1: Socio-demographic characteristics for study populationSocio-demographic DataAge Groups(years)ResidencyMarital StatusOccupationEducationalLevelsF.Cases% 1530-3940-4950-59 leNot workingWorking3227527491032105183IlliterateRead& WritePrimary schoolIntermediateschoolSecondary schoolCollege & aboveMean SDF.Control%Mean SD71016221010.715.4 46.5 24.6 10.3P-valueORNs.First as referenceNs.Ns(95% CI1.630.- 8.60.640.900.580.550.2- 2.30.3 - 2.90.19 -1.80.24- 1.250.780.24 -2.57.8**2.4 - 25.6 .001**First referenceNs0.280.12*0.6001.5000.2250.07 - 1.10.02- 0.70.11 – 3.20.1 – 18.40.04 -1.2P 0.001** High significant difference between cases and controls. F. Frequency, OR. Odds Ratio, CI. Confidentinterval**Table 1 shows the socio-demographic properties for cases and controls. Age meanswere 47.2 10.3 year for cases and 46.5 11.9 years for controls. Chi square analysisshowed no significant difference between breast cancer and the control group in;residency, marital status and education levels. There was a high significant differencebetween cases and controls in occupation status, 50.8% of controls had official work,while 83.1% of breast cancer patients were housewife with no income. Not working wasfound to increase significantly the risk of breast cancer by more than seven fold (OR 7.8,95% CI 2.4 – 25.6). In spite of no significant difference in educational levels, primaryschool level significantly decrease breast cancer risk by 88% (OR 0.12, 95% CI, 0.020.7).-69-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Table 2: Reproductive characteristic of study populationReproductive factorsCasesF.%Age ofMenarche 12 years12 -14 years 19 years6391410.266.123.7Age at firstpregnancyNo pregnancy 13 years20-29 years 03 years13162372227.13911.9Means SD13.5 1.717.3 10.6ControlF.%7481011.973.815.31029188P-value13.4 1.34Ns15.444.627.712.318.9 9.97Ns.112623516.94035.47.74 2.9Number ofchildren0 (No children)1-45-8 5132318521.337.729.58.23.9 3.2MenopausestatusNo menopause (No)Menopause (yes)312852.547.539.1 6.1362955.444.638.8 8.8Ages atmenopause 49 years46-50 years 93 yearsNo feedingBreast feedingFormula .33.435.672.927.147.7 32.348.9 5.6NoYes312852.447.539266040Baby feedingstatusUsing oralcontraceptiveHormoneintakeOR95% CI)Means SDNs.Ns.Ns.Ns.Ns.First reference1.60.4- reference0.670.18- 2.51.690.51- 5.60.660.2- 2.15First reference0.850.2- - – reference1.20.3 – 4.70.830.3 – 2.8First reference1.10.39 - -– 2 shows reproductive characteristic of study population associated withbreast cancer risk. Majority 66.1% of cases and 73.8 % of controls had menarche age at(12-14) years, and there was no significant difference between categories of menarcheage. According to age of first full term pregnancy; the high percentage 34% of cases hadfull term pregnancy at age (20-29) years, while high percentage 44.6% of controls ages atfull term pregnancy were less than 20 years. There was no significant difference betweencategories of two groups. There was no significant difference between two groups innumber of children, breast feeding status, oral contraceptive and hormone intake.Regarding menopause status, 52.5 % of cases and 55.4% of controls were not atmenopause stage. Highest percentage 37.9% of cases were menopause at age (46-50)year compared to (50) years of menopause age for majority of controls.-70-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Table 3: Life style factors associated with breast cancerLife style factors (A)Family historyNo relation (No)Family relation (Yes)First degree relativeFatherMotherBrotherSisterSecond degreePhysical activity levelsSedentary (1.4-1.69)Moderate (1.7-1.99)Active (2.0-2.3) valueBody Mass Index 1925-29 03Waist to hip ratio 3.80.8-0.85 272118.645.835.6Controls%P-values ofChi square 0.001**OR0.14**Ns.Mean SD31.6 5.40.84 0.1ControlNo%622379.233.856.915242623.136.940Mean SD30.5 4.9%95 CI0.04—0.49First as reference0.490.07—3.340.770.34 – 1.73PORvalueNs.First as reference0.61.20.84 0.1Ns.%95 CI0.3- 3.20.5 –2.5First as reference1.10.70.42-2.90.3-1.6P 0.001** High significant difference between cases and controls using Chi squared testTable 3 represents categories of life style factors. There was no significantdifference between cases and controls in; physical activity (most had sedentary life stylewith physical activity values less than 1.5), and obesity indexes. Majority of both groupswere obese with body mass index more than 30 and waist to hip ratio between (0.8- 0.85)in cases and more than 0.85 in controls.Family history with cancer showed high significant difference between breastcancer and controls. High percentage 93.8% of controls had no family history of cancercompared to cases 40.7% had family history of cancer which composed of 11.9% withfirst degree relatives and 28.8% with second degree relatives. No familial history caused86% (95% CI 0.03-0.38) decrease in risk of breast cancer.-71-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Table 4: Levels and categories of daily intake of energy and macronutrientLevels andcategories of Kcal &Macronutrients(g/d)Kcal/dLow ( 1333)Normal (2000- 2200)High ( 1133)Carbohydrates (g/d)Low ( 106 )Normal (236-345)High ( 049)Dietary fiber (g/d)Low ( 11)Normal (21-27.5)High ( 17.9)Protein (g/d)Low ( 90 )Normal (53-184)High ( 184 30.540.728.82724845.840.713.5Total Fat (g/d)Low ( 46.7)Normal (46.7-81.7)High ( 81.7)14202523.733.942.4Saturated Fats lligram/day)Healthy ( 133)Limited (200- 300)High ( 033)Caffeine (gram/day)Low ( 3.1)Moderate ( 0.2- 0.3)High ( 3.0)Insoluble Fiber (g/d)Means SD4858.1 8958.5788.4 472.7*70.6 158.5156.2 131852.32027.74217664.626.29.2139.6 354.156.19 230.34040203915116023.111.9386.9 1392.4371484810162.723.713.681.416.91.75762.095 0.0744192Ns.2828.9 4402522.5 1036*54.0 . 167.8 80.8Ns.15.7 59.2%95 CI)Low as reference2.5*1.1- as reference2.5*1.1- 6.11.450.6-3.9Low as reference 0.05*Ns0.67- as reference0.33 0.05*17.2 20.5 0.001*124.1 126. 0.01* SD79.3 95.6262613P- value0.300.05-1.98Low as reference4.03 0.22-72.84.86 0.46-51.4Low as reference5.2*1.2- as reference5.96*0.2 0.67Ns.Ns.1.2-30.31.990.3-12.8Low as reference0.5222.8 60.90.05-2.291.460.04- 6.50.1-20.4*significant difference by independent samples T- test between cases and controls in the mean levels ofcarbohydrates (P 0.03) and the mean levels of poly unsaturated fats (P 0.008) , (gram/day) g/dTable 4 shows daily dietary energy and macronutrient intake of cases and controls.There was no significant difference between cases and controls in categories of; energy,carbohydrates, proteins, insoluble fiber and caffeine intake. (High energy andcarbohydrates caused significant increase risk of breast cancer by 2.5 times among caseswith 95% CI 1.1-5.9 and 1.1- 6.1 respectively). While significant differences were foundbetween categories of; dietary fiber, total fat, saturated fats, and cholesterol intake. Mostbreast cancer patients had high level intake of saturated fats (increased risk of cancersignificantly by 5.2 times, 95% CI 1.2-22.7) and normal intake of, dietary fiber compare tocontrols which had low intake of energy and all macro-nutrients. Majority of controls(87.7%) had healthy level (( 133) mg/d intake of dietary cholesterol while B-cancerpatients had higher levels intake of dietary cholesterol which caused significant increasecancer risk (5.9 times (95%1.2-30.3).-72-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Carbohydrates in cases had significant higher mean levels compare to controls. Alsoinsoluble fibers and caffeine in controls showed higher mean levels of intake than 5: Levels and categories of daily water soluble vitamins intakelevels of watersoluble VitaminsCategoriesVitamin B1 (mg/d)Low (( 1.1 )Safe ( 1.1-1.5)High ( 1.5)Vitamin B2 (mg/d)Low ( 1.1)Safe (1.1-1.7)Abnormal ( 1.7)Vitamin B3 (mg/d)Low ( 14)Safe (14-35)High ( 35)Vitamin B6 (mg/d)Low ( 1.3)Safe (1.3 - 2)Upper safe (3 - 100)Vitamin B9 (mcg/d)(microgram/day)Low ( 400)Safe (400- 1000)High ( 1000)P 8173413.628.857.616232027.13933.94.23 8.134.5 15.24ControlsMeans SDF.%18212627.732.340.022261733.84026.243.3 437.320.344123Vitamin C (mg/d)Low( 75)Safe (75-2000)High ( 2000)0.05*%3.65 5.261197.1 0.812.33.3 7.1P- valueORNs.Low as reference.2.94*1.11- 7.81.622.3 3.6Ns22.7 29.9Ns4.94 14.2 0.05*Ns.0.71- 3.7Low as reference.1.620.65- 4.01.33 0.6 – 3.1Low as reference2.91 0.91- 9.31.16 0.36 3.74Low used as ref2.41069.3 3293.195% CI0.90 – 6.40.790.3 – 1.9Low as reference2.220.79 – 6.21.360.46 – 4.0Low as referenceVitamin B12(mcg/d)Low ( 2.4)Safe (2.4-6)High ( 6)*CasesMeans SDF.351574.620. 40. 6589.5 1123.36041751792.36.21.510.878.410.81.6 2.8749.9 2733.6 0 .05*Ns.Significant difference between cases and controls using Chi squared test.4.10.41- -12.6High used as ref.1.670.28 – 9.80.710.21 -2.4Table 5 shows daily intake of water soluble vitamins. There was significantdifference between cases and controls in categories of vitamins; pyridoxine (B6), &cobalamin (B12), intake. Most of cases 42.4% and 56.9% of controls had low intake ofdietary vitamin folate (B9).While intake of vitamin B12, was low in more than half (74.6%)of cases compared to majority (92.3%) of controls. Cases had mean levels of (B12) 7.86 40.6 mcg/d, higher than safe levels and mean level of controls 1.6 2.8 mcg/d. Vitamin B6& B3 (Niacin) intake were in safe levels by most of cancer patients but these vitaminswere low in controls. Most of cases and controls had high intake of vitamin thiamine (B1)particularly in cases which caused significant increase risk of breast cancer by (2.94)times with (95% CI 1.11- 7.8). Both cases and control were in safe level intake of vitamins;Riboflavin (B2) and ascorbic acid (C).-73-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Table 6: Levels and categories of daily intake of fat soluble vitaminsCategories of fatsoluble vitaminslevelsVitamin A ( mcg/d)(microgram/day)Low( 700)Safe (700-1500)Upper safe (1500-3000)Abnormal ( 3000)Vitamin D (mcg/d)Low ( 3.369)Low ( 3.16)Low ( 3.76)Safe ( 9)Vitamin E (mg /d)Low ( 15)Safe (15-22)Upper safe ( 23-1000)Vitamin K (mcg/d)Low ( 80)Safe (80-90)Abnormal ( 86581.310.28.5552293.23.43.4CasesMeans SD3763.3 150440.8 1.0216.34 47.8447.5 .5573587.74.67.7552884.63.112.3ControlsMeans SD978.8 1813.40.51 0.9P-valueNs. 0.0510. 23.4Ns.126.8 539.3Ns.OR95% CILow as reference1.950.4- 9.40.910.18- 4.62.670.3- 25.6low level asreference1.60.58- 4.22.97*1.04- 8.50.700.3- 1.96Low as reference2.70.3- 4.34Low as reference0.250.05- 6 shows the daily intake of fat soluble vitamin. Majority of both groups hadlow intake of fat soluble vitamin. There was significant difference between cases andcontrols in categories of vitamin D (cholecalciferol) intake that caused significant increaserisk by 2.97 times with (95% (1.04 – 8.5). There was higher intake of vitamin A (retinol)than Tolerable Upper Intake levels, (UL). Lower mean level than RDA of vitamin K(naphthoquinones) in cases.Table 7: Levels and categories of daily macro minerals intakeLevels of macromineral categoriesCalcium (mg/d)Low ( 1000)Safe (1000- 2500)Abnormal ( 2500)Magnesium (mg/d)Low ( 310 )Safe (310-350)Abnormal ( 350)Phosphorus (mg/d)Low ( 700)Safe (700-1000)Upper safe(1000- 4000)Potassium(mg/d)Low ( 3500)Safe (3500-4700)Abnormal ( 4700)Sodium (mg/d)Low ( 1300)Safe (1300-2300)Abnormal ( Means SD2833.1 13203.4792.53 1550.93027.4 10482.59719.7 23374.53541.4 alueORMeans SD1110.9 2188.8NsLow as reference1.10.4- 3.1579.95 1181.9Ns1.00.12- 8.7Low as reference1.40.62-3.20.941320.7 1990.9Ns95% CI0.24-3.7Low as reference2.7*8350.5 20818Ns1.1 –6.82.7*1.03-7.0Low as reference1.311900.9 3964.3 0.05*0.5- 3.1.490.15- 1.6Low as reference4.6**1.6-13.13.9**1.411.0P 0.05* Significant difference between cases and controls using independent Chi squared test.Table 7 shows daily of macro mineral intake. All study populations had low levelsof macro mineral intake and there was no significant difference in categories of intakebetween cases and controls except sodium and phosphorus which were safe and low incontrols while cases intake were safe, upper safe for phosphorus and safe and abnormal.Cases had higher level of mean than UL for sodium. Phosphorus and sodium intake causedsignificant increase in risk by 2.7 times, (95% CI, 1.1 – 6-8) and 4.6 times, (95% CI 1.6213.1) respectively.-74-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017Table 8: Levels and categories of daily micro - mineral intakeLevels of micromineral categoriesmilligram /dayIron(mg/d)Low ( 8)Safe (8-18)Upper safe (18-45)Abnormal ( 45)Zinc (mg/d)Low ( 8)Safe (8- 45)Abnormal ( 45)Cupper (mg/d)Low ( 0.9)Safe (0.9- 2)Upper safe (2-10)Abnormal ( 10)Manganese (mg/d)Low ( 1.8)Safe (1.8- 2)Upper safe (2-11)Abnormal ( 11)Selenium (mcg/d)Low ( 55)Safe (55-70)Upper safe (70-400)F.%CasesMeans .2 70.525.4 68.92.8 5.511.3 25.7100 40.9*%ControlMeans 6.27.73223554.633.953.87.71318342027.752.317.9 26.1P-valueof ᵪ2Ns.OR95% CI2.961.30.79-11.1.42- 4.240.760.15 -3.9High as reference9.1 11.22.3 4.4 0.001**Ns.Low as reference5.3*1.04- 13.4Low as reference0.940.19- 7.13 0.05*Low as reference2.24.8 *1.281.1 30.4* 0.05*0.13-2.70.04-1.90.45 - 11.11.04-21.80.34 – 4Low as reference3.4*1.09- 10.42.330.95- 5.7*significant difference between breast cancer and controls in the mean level of selenium by independent T- test (P 0.003). * P 0.05* Significant difference between categories of cases and controls using Chi squared test.Table 8 shows daily intake of micro-minerals. They had safe or upper safe intakes,except intake of zinc which was lower than RDA particularly in (75.4 %) of controls. Therewas significant difference in categories of zinc, manganese and selenium intake, betweencases and controls. They increased risk significantly by 5.3 times 95% (1.04 – 27.1) forzinc, 4.76 times 95% CI (1.04- 21.8) for manganese, and 3.37 times 95% CI (1.09-10.4) forselenium.Table 9: Means (g/d) of food item in cases (Breast cancer) and controlsFood itemsCerealsAnimal meatsEggTotal BeansDairy ProductFruitVegetablesFatsTeaOrange Juice (softdrink)Cola (soft drink)Sweat snackCasesB- cancerControlsB- cancerControlsB- cancerControlsB- cancerControlsB- cancerControlsB- cancerControlsB- cancerControlsB- cancerControlB- cancerControlsB- cancerControlsB- cancerControlsB- 965596558655965Mean Std. Deviation358.2 200.8269.3 128.659.7 44.533.2 21.615.9 14.911.6 11.936.9 34.443.7 34.5205.4 139.8196.0 160.2572.9 267.6458.1 323.3275.4 155.3262.3 178.214.8 27.40.8 2.8321.2 250.1415.4 328.7110.6 14770.5 89.8114.7 120.662.5 133.943.6 106.411.4 23.6P- values 0.01** 0.001**NsNs.Ns. 0.05*Ns. 0.001**Ns.Ns. 0.05* 0.05*Table 9 shows mean of daily food item intake in gram of cases and controls. Theindependent samples T-test showed that breast cancer patients consumed significantlyat (p 3.331) greater quantities of cereals, meats, fats, and at (p 3.39) for fruit, soft drink-75-

KUFA JOURNAL FOR NURSING SCIENCES Vol. 7 No. 1 January through April 2017and sweat snack. While they consumed lower quantity of bean and tea compared tocontrols.Discussion:Most cancer patients were house wives compare to controls which had official work.This result may be attributed to low income and low awareness to; early detection, factorsaffecting cancer survivors and social and culture barriers, as stated by (15) especially inlow- and middle-income countries (15) .This result in line with previous studies whoobserved that (81% and 72.57%) of cancer patients were house wives (16, 17)Significant decrease in risk of breast cancer after six year education (primary schoolcompare to secondary school) is in consistent that wome

governorate, Kurdistan region/Iraq. The patients (cases) included a purposive sample of (9 women and x dropped out because they didn’t complete the interview questionnaire), they were diagnosed with breast cancer (after mastectomy), at different stage, attending outpatient unit of chemothe