Meal planning values impacted by the cancer experience in families with school-aged survivors- a qualitative exploration and recommendations for intervention development

Abstract

Purpose:

Increased cardiovascular disease and second cancer risks among childhood cancer survivors (CCS) makes them and their families important audiences for nutrition intervention. Family meals and home cooking practices have been associated with improved diet and health, but there is a gap in the literature on understanding these behaviors and their motivating values among CCS families. This study qualitatively explores family meal values and behaviors in a sample of CCS parent-child dyads.

Methods:

This observational and qualitative study recruited a convenience sample of 11 parent-CCS dyads. Data collection included audio and video recording of food preparation events in participant homes, which were analyzed with an inductive coding technique to examine meal related values in CCS families.

Results:

Analyses revealed four major categories of meal values. Effort, including time and difficulty, as well as budget, healthfulness and family preferences emerged as recurrent values impacting meal preparation. These values were impacted by the cancer experience upon diagnosis, during treatment and into survivorship.

Conclusions:

A better understanding of CCS family meal planning values, the impact of the cancer experience on these values, and the inclusion of CCS in food preparation reveals potential intervention targets, facilitators, and barriers for future interventions to improve dietary behaviors among CCS.

Introduction

Childhood cancer survivors (CCS) and their families, are an important target population for nutrition intervention. CCS have increased risk of developing and dying from a cardiovascular disease compared to siblings and the general population. [1,2] Common cancer treatments, including anthracyline-class chemotherapeutics can cause cumulative cardiotoxicity in pediatric patients and increase risk for future cardiovascular disease. [3] Although treatment-related late effects are difficult to avoid, diet is a modifiable risk factor for cardiovascular disease, and good nutrition supports CCS well-being and heart health. [2] However, many CCS have demonstrated poor adherence to dietary guidelines through survivorship and into adulthood. [4,5]

A survey of 170 CCS found that the majority were “very” or “extremely” interested in diet-related interventions including weight control programs, learning to eat more nutritiously, and getting in shape. [6] A complementary study including 114 parents of CCS found similarly high rates of interest in diet-related programs among parents, and most CCS favored interventions in which they could partner with a parent. [7] Although nutrition interventions have the potential to benefit patients and survivors throughout the cancer care continuum [8], a recent review of existing interventions found no evidence that current approaches improved CCS dietary intake or reduced cardiometabolic risk. [9] Moreover, few nutrition interventions for CCS include parent involvement. [10]

Various behaviors related to meal patterns and habits are associated with improved diet and health. The consumption of fast food and commercially-prepared meals is linked to increased body mass index (BMI) and weight. [15–17] In contrast, frequent home cooking and family meals support increased nutrient intake, fruit and vegetable consumption, and better dietary choices. [18,19] Children also eat more vegetables and have better diet quality when they participate in food preparation tasks. [20–22]

Interventions that include food preparation components may benefit CCS, but there is little extant data on the meal planning and preparation habits of CCS families and their underlying values that motivate these practices. A deeper understanding of CCS family habits and values will help inform the adaptation or development of practical nutrition interventions for this group. The current study qualitatively identifies family meal values and behaviors in a sample of CCS parent-child dyads and explores the related impact of the cancer experience.

Methods

This study was approved by the institutional review board of the University of Texas MD Anderson Cancer Center (PA16-0995). All adult participants completed an informed consent and minor participants completed child assent. Participants were compensated for their time with $50 gift cards.

Design and Participants

This observational and qualitative study utilized a convenience sample of 11 parent-CCS dyads. One parent with one CCS were recruited for each dyad. Inclusion criteria were: CCS between 5 and 17 years old, of any cancer diagnosis and at least one year off all cancer treatment; parents self reported preparing at least one meal for their child per week; and being able to speak and read in English. The broad age range was selected to maximize study recruitment, and school aged children were deemed likely to eat evening meals in the home. Exclusion criteria included anyone in the household with severe food allergies. Recruitment was conducted through the MD Anderson Children’s Cancer Hospital Survivorship Network, providers, hospital events through presentations, telephone calls, mailed letters, and posted flyers. Before enrollment, participants completed a screener to ensure compliance with eligibility criteria. A total of 109 CCS families were contacted for participation in this study and 45 (41%) responded to our inquiry. Of those who responded, 7 were ineligible due to food allergies (n=1) or inability to speak English (n=6). Thirty-eight declined to participate due to discomfort with home visits (n=3), general disinterest (n=11), or recovery from recent hurricane damage (n=13). Recruitment occurred primarily in Houston, TX, between October 2017 and June 2018. Hurricane Harvey impacted Houston in August 2017 and impacted potential participant response due to continued recovery from extensive city-wide flood damage.

Data Collection Procedure

Data collection was conducted in participant homes during a normal evening meal preparation event, either weekday or weekend. Existing qualitative research suggests variability in how individuals define both cooking as a concept and specific cooking-related behaviors.^34,36 This study used in-home observations of cooking events to contextualize participants’ reported experience. Each dyad completed one meal preparation observation session. Sessions were scheduled according to participant availability and lasted approximately 45 minutes to 2 hours, depending on the meal prepared. During recruitment, potential participants were asked to report their five most commonly made meals. Parents were then encouraged to prepare one of these reported meals or select an alternative typical meal to prepare for the session. One to two observers, trained in observational assessment and guided by a general data collection script, were present during the sessions to set up equipment, take notes and ask questions. The sessions were recorded using a digital camcorder (Canon VIXIA HFR800), situated on a tripod and oriented to capture the entire kitchen environment. Parents were fitted with a wireless lapel microphone (MOVO WMIC70) that fed directly into the camera to supplement the image. During the session, observers asked for clarification as needed and prompted participants to discuss their motivation for using certain ingredients, cooking methods, and other factors relating to meal planning and preparation. Participants were instructed to describe their actions into the microphone as they performed them.

Family Characteristics

Demographic information was collected through a self-report questionnaire that included items on parent age and education, child age and race, as well as socioeconomic factors. Time off treatment and primary diagnosis were collected from parents and confirmed through the medical record.

Data Analysis Procedure

Video and audio data from meal preparation sessions were analyzed with an inductive coding technique utilized in other studies of CCS parent behavior. [24] All qualitative analyses used qualitative analysis software (QSR International NVivo 10 Software). This software allows users to embed video files with audio for storage, retrieval and coding. Parent or child mentions of factors that influenced family meal preparation including food shopping, cooking or eating behavior were coded. After initial review, codes were reviewed and aggregated into parent codes representing specific themes. These parent codes were then reviewed and aggregated into broader overarching themes, forming a coding hierarchy. [24] Mind mapping was used to graphically explore the relationships within the coding hierarchy. [25] The mind map was created around the main parent codes, which branched into child and sibling codes, gaining specificity on outer branches. Two separate mind maps were developed, one focusing on CCS parent meal values, and the other focused on the cancer experience. The intersectionality of these topics was explored through the selection and presentation of representative participant quotes.

CCS involvement in food preparation was assessed by the first author (MR) and classified into four categories informed by previous research [26]: 1) no involvement, 2) involvement in mainly non-food preparation meal related tasks (i.e. setting table, cleaning, plating) 3) child helped parent prepare meal component (e.g. chopped nuts for salad) and 4) child independently prepared meal component (e.g. made pasta). Descriptive statistics were completed for demographic and family characteristic data, including medians and ranges for continuous variables, and percentages for discrete variables. All quantitative analysis was completed using SPSS (IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.)

Results:

Participant Characteristics

Demographic characteristics of participants are shown in Table 1. Parent participants were mostly mothers over 35 years old, well educated, married and home-owners. CCS participants were majority female and ranged from 6 to 16 years old. A range of diagnoses were reported among participants, including acute lymphoblastic leukemia (4), germ cell tumor (n = 2), osteosarcoma (1), liver tumor (1), neuroblastoma (1), neuroendocrine tumor (1), and rhabdomyosarcoma (1). Information about family meals and child involvement is shown in Table 2. Several meals were noted as commonly prepared by multiple parents. The majority of meals prepared during the data collection observation sessions used chicken as the main protein. Over one third of CCS were not involved in food preparation during the observation session (n= 4, 36.4%). Non-involvement did not appear to be impacted by age, as those with no involvement ranged in age from 6 – 16 years old).

Table 1:

Demographics and Family Meal Characteristics of Participants (n=11)

Parent female %(n)	90.9 (10)
Parent age median (range)	41 (34 – 51)
# of children median (range)	2 (1 – 5)
CCS age median (range)	11 (6 – 16)
CCS gender %(n)
Male	36.4 (4)
Female	63.6 (7)
CCS race %(n)
White	45.5 (5)
Hispanic	36.4 (4)
Asian	18.2 (2)
Years off treatment %(n)
1 – 3	63.6 (7)
3 – 5	9.0 (1)
5 – 10	18.2 (2)
More than 10	9.0 (1)
Parent married %(n)	90.9 (10)
Income > $60,000 %(n)	63.6 (7)
Owns home %(n)	100 (11)

Self-reported demographics from parent participants

Table 2:

Commonly reported and prepared family meals and CCS involvement

Most commonly reported evening mealsa	% (n)
Chicken with sides	90.9 (10)
Tacos (tostadas etc)	72.7 (8)
Pasta with sauce	63.6 (7)
Fish with sides	54.5 (6)
Soups / Stews	45.5 (5)
Level of CCS Involvement % (n)
None	36.4 (4)
Meal-related tasks	18.2 (2)
Helped prep meal component	27.3 (3)
Independently prep meal component	18.2 (2)
Dish prepared during observed meal preparation sessionb
Beef tacos	18.2 (2)
Chicken with pasta and salad	18.2 (2)
Chicken with rice and asparagus	9.1 (1)
Chicken with salad	9.1 (1)
Beef Enchiladas with rice and beans	9.1 (1)
Pasta and salad (vegetarian)	9.1 (1)
Chicken Curry with rice	9.1 (1)
Shrimp Sinigang with rice (stew)	9.1 (1)
Chicken tostadas	9.1 (1)

^a)parent-reported during study screening, requested to report up to 5 most commonly made evening meals

^b)actual dishes prepared during the observation session for each participant (n=11)

CCS Family Meal Values

Meal preparation values and the impact of the cancer experience on these values was qualitatively explored through analysis of the CCS meal preparation audio/video tapes (n=11). Four major themes emerged form the data (Figure 1) including effort, budget, health and preferences.

Fig 1.

Mind map of overarching categories of meal values and hierarchy of parent and child codes. The mind map diagram is used to represent concepts arranged around a central research topic of interest. Each square represents a child or parent (aggregated) code. The top branches represent major themes, and gain in specificity on lower branches.

Effort.

Effort as a meal value encompasses time, difficulty, and child effort. When asked why parents chose to make certain dishes, 8 out of 11 parents noted it was because the dish was “easy”. Flexibility was also mentioned as an attractive quality in a recipe or meal idea, in the sense of being able to add “whatever is in the fridge” to a dish (n=4). Time was important to CCS parents with several noting time-saving shortcuts during cooking (n=5), and the need to prepare dishes in one evening that would yield leftovers for school lunches, work lunches and second meals (n=9). Time pressure was relieved by the use of convenience or store prepared foods (n=3), pre-prepping dinner during the day (n=3) and cooking more on weekends (n=2). Time impacted family meals and child involvement in food preparation, as dinners needed to be coordinated around multiple schedules (n=4). Child effort was also considered by parents, as several participants assigned children tasks to complete in order to help in meal preparation (n=8), although the level of involvement varied widely (Table 2), and the child involved was not necessarily the CCS. For example, in one family of four children, three of the four helped prepare dinner, but their CCS sibling did not.

Budget.

Budget played an important role in family meal planning. Although our sample had higher income than the average family in Texas (average family income in Texas is $56,565) [27], participants noted sale items were important considerations when grocery shopping and planning meals (n=3). This appeared to be especially important for parents with more than one child in the home. Budget concerns were noted as restricting one parent’s willingness to buy organic products and other produce. Another parent mentioned purchasing meat on sale that was close to the expiration date and cooking or freezing it immediately as a strategy to save on grocery costs.

Health.

Healthfulness of meals was consistently mentioned by parent participants (n=7), although the definition of healthful meals varied from promoting vegetables (n=7) to reducing processed foods (n=4), sodium (n=7) or dairy (n=3). The resources that fueled these beliefs centered around the Internet and social circles (n=5). These two resources would sometimes collide, with family and friends posting recipes or nutrition related articles on social media, or in person advice being verified by the Internet. Parent beliefs about healthful eating were communicated to CCS through conversation (n=3) and through teaching children to prepare meals (n=5). Despite a perceived knowledge of healthy eating, many parents noted a measure of flexibility in the diet (n=6), to allow children to explore different foods and experiences. For example, one parent followed a strict no-dairy diet, but allowed her child to add cheese to a taco as part of the traditional meal experience.

Preferences.

Preference was the most commonly given reason parents noted for preparing certain dishes (n= 10). These preferences tended to be influenced by culture and tastes. Cultural preferences and norms (especially by immigrant families) were mentioned as being important influences on their cooking habits (n=4). Flavor preferences included the likes and dislikes of the family (n=9) including parents, their children, and their partners. Saltiness, spiciness and strongly flavored foods, such as olives, were avoided or added by different parents. ‘Pickiness’ among CCS ranged, with some very willing to try new foods (n=3), and others more particular about which foods they wanted to eat (n=4).

Cancer Experience Impact on Meal Values

CCS parents were not asked directly about the cancer experience during the cooking video sessions. However, all eleven participant dyads naturally discussed the experience while preparing meals. Many described the experience in the past tense, through recollections of CCS’ diets during treatment, as well as in the present tense (post treatment or current diet) (Figure 2). Example quotes of how the cancer experience intersected meal values is shown in Table 3.

Fig 2.

Mind map of cancer experience related codes and hierarchy of parent and child codes. The far left branches represent major themes, and gain in specificity on branches moving to the right.

Table 3:

Selected codes and quotes^a on cancer experience on meal values during diagnosis, treatment and survivorship (current)

	Effort	Health	Preferences
During Diagnosis and Treatment	E1. Code: Reliance on Social Circle	H1. Source Advice from Friends	P1. CCS Taste Changes
	Quote: When you (re child) are first diagnosed everyone is like “what can I do? what can I do?. I told people just stick with us because we are going to need help 5 months from now not just this month. (female, 11 years old)a	I (got nutrition information)…notfrom the doctors, mostly other parents, our family maybe or we heard, we read and then I would go and check (the internet) (female, 15 years old)	I don’t know how things tasted to him, when he was on steroids but he was very definitive about what he did and didn’t want…at one point he ate two dozen eggs, just the egg whites, and asparagus every single day. (male, 6 years old)
	E2. Parent Responsibility	H2. Frustration with Diet Advice of HCP	P2. Balance Diet and Preferences
	When (redacted) was in treatment, that’s all I did…that was my full time job was just making sure he could eat well (male, 10 years old)	I called Dr. (name redacted) in a panic… I said I can’t get him to eat real food, I said he’s only eating beige food. He said, what do you mean? And I said he is eating cheese and (cheese crackers) and (chips) with mustard, like it was disgusting. And I said what can we do? And he said, there is nothing you can do just feed him what he wants (male, 6 years old)	We try to do the (low) histamine diet as much as possible with her just because of the carcinoid syndrome… So she can’t have spinach… we didn’t realize until they put her on it that that was one of the ones and she was eating a lot of it… and she really liked it, now she can’t have it (female, 16 years old)
	E3. CCS Interest in Food	H3. Control	P3. Giving In
	Mom: She wasn’t really interested in cooking really until after she was in treatment… (CCS name redacted) what changed? CCS: I think it is because I couldn’t do as many like sports and athletic things, and it (cooking) was something that I was able to do (female, 11 years old)	If you walked into that room you would think we were the most horrible parents ever because we were very forceful with her and we said this (eating) has to happen because she needed to survive this. Her body had to be healthy enough, robust enough to survive getting the chemo, and that included getting protein in you and keeping her calories up so she wouldn’t lose weight (female, 11 years old)	So I just gave in… that’s what she (CCS) is asking for so I just have to buy onion ring…hot Cheetos, hot dog, oh my. I’m like, I can’t take in those things but, that is what she would askfor (female, 13 years old)
Current (Post Treatment)	E4. Safety Concerns CCS Cooking	H4. Special Diets	P4. Blacklisted Foods
	I got really scared when I was cooking one day and (CCS name redacted), when she was little, she was behind me and I dropped something on her and after that I’m like, go away (from the kitchen), go play, let me do my thing (female, 15 years old)	It was (CCS name redacted) who had us go paleo, not that she knew it, but just with everything that her health encompasses and that she’s gone through I started paying a little bit more attention to what we were putting the body through (female, 10 years old)	There is some stuff he used to eat that he just doesn’t touch now. Like he used to eat salsa by the fistfuls, especially during treatment he would just pound salsa and now… it nauseates him (male, 11 years old)
	E5. CCS Autonomy Cooking	H5. Protectiveness	P5. Avoid Conflict Regarding Food
	It was a scary thing (CCS cutting), but then when we started seeing those kid challenges shows and they are like 8 years old and just cutting away like anything I was like, ok I’ll teach you (female, 7 years old)	We never let him (CCS) buy school lunch because they serve like pasta and pancakes and spaghetti…there is not a lot of balance as far as nutrition goes there (male, 10 years old)	Bottom line, he doesn’t like to eat a lot of good food. We have to force him to eat… I told him, whatever you like, you can have it. If you want something else just let us know we can go grab something for you, and we can always give it to you (male, 10 years old)

E = Effort

H= Health

P= Preferences

^a)all quotes are by parents unless indicated, sex/age at end of quote refers to CCS current sex/age for context

Treatment.

Parents noted taste changes during cancer treatment (n=4) (Table 3, P1), which often led to stress around feeding (n=4). For example, two parents recalled that interactions with physicians regarding CCS’ diet were a source of parent frustration. Physicians would generally respond to parent dietary concerns by encouraging parents to feed CCS whatever they wanted during treatment (Table 3, H2), leading to a loss of control for parents and conflict with regard to the parent’s understanding of food healthfulness. All parents expressed feeling responsible for their child’s eating during treatment (Table 3, E2). This responsibility sometimes manifested as controlling feeding behaviors (Table 3, H3) such as force-feeding (n = 2), or in one case threatening insertion of a feeding tube as a deterrent to not eating. Other parents noted succumbing to CCS’ preferences as a perceived “giving in”, making dietary adjustments to achieve a sort of balance between CCS wants and parent perceived needs (n=3) (Table 3, P2 & P3).

Parents also mentioned reliance on their social circle for help and dietary/nutrition advice during their child’s cancer treatment (n=5) (Table 3, E1 & H1). One mother noted friends made meals for her family twice a week through nine months of treatment. Friends, family, and other CCS parents are important resources for nutrition and diet advice during and after treatment. While several parents noted their child’s interest in cooking (n=9), one participant noted a growing interest in food and cooking specifically after cancer diagnosis (Table 3, E3). When asked about this by observers, the CCS mentioned her interest in cooking as a hobby increased after she was unable to participate in more active sports during treatment.

Post Treatment.

Several parents expressed a level of protectiveness, often expressed as worry, over their child with regard to the current eating habits and child cooking autonomy (n=10) (Table 3, H5). The root of this protectiveness appeared to revolve around future risk of cancer, and other health concerns. Cancer risk concerns led some parents to avoid microwaving foods (n=2), baking potatoes (n=1), and drinking tap water (n=2). Other health concerns included CCS consuming excessive sugar and refined grains (n=10). Two parents were particularly worried about neurological disease and inflammation in their child as a result of excessive sugar intake. Parent protective behavior also impacted CCS’ cooking autonomy, as parents had concerns regarding allowing children near heat or knives (n=8). For some parents, these concerns were alleviated through modeling cooking practices with their child, formal cooking classes for children, and exposure to child cooking shows (n=3). However, some parents still preferred their children completely separated from food preparation (n=2) (Table 3, E4 & E5).

Parents also noted adhering to various special diets while preparing meals (n=3). These tended to stem from popular diet trends, current CCS preferences and the continuation of diets from treatment. With regard to popular diet trends, one parent noted moving her family into a completely paleo diet (derived from the term “Paleolithic”, followers of a paleo diet claim to eat only foods available during the Paleolithic era approximately 10,000 to 2. 5 million years ago), avoiding sugar, dairy, legumes and grains (Table 3, H4). Another parent had a more relaxed approach to a paleo diet, noting general avoidance of sugar, refined grains and highly processed foods.

CCS preferences were often incorporated into meals, with parents cooking child favorites. However, parents also noted some food aversions among CCS or “blacklisted” foods (n=3). These were foods that were eaten during treatment but were no longer palatable to CCS (Table 3, P4). To avoid conflict, parents noted making dishes with components pickier CCS could eat around, purchasing foods the CCS expressly requested, or in one case making completely separate meals (Table 3, P5). In some cases, parents continued the diets from when their child was on treatment.

Discussion

This study examined the meal preparation habits of 11 CCS-parent dyads through audio/video observation and recording. Qualitative analyses revealed four major categories of meal values, several of which were impacted by the cancer experience both during and post treatment. Our findings offer insight into CCS family meal practices and elucidate potential areas for practical, family-based nutrition intervention in this population.

Effort, including time and difficulty, emerged as recurrent values impacting meal preparation that should be considered in intervention development. Parents noted that meals prepared one evening were often used for school lunches and subsequent evening meals, or as a component in a subsequent meal. This highlights the importance of home cooking practices as home-prepared foods may represent both dinner and lunch for some CCS. Our group recently created a cooking curriculum that focused on the repeated use of leftovers as a strategy for healthy meal planning, which was piloted among Hispanic overweight and obese children aged 6 to 11. The pilot study included 10 cooking demonstrations of “mother” recipes, which were then utilized as the main component of 3 “daughter” recipes. [28] This concept of “mother” (base) and daughter recipes may be attractive to CCS’ parents hoping to minimize time and effort in food preparation, and could form the base recipe curriculum for survivor-targeted cooking classes.

Health was noted as an important factor in meal planning by many participants. Refined carbohydrates, including added sugars, were a concern of several parents, with fat (particularly butter) being less of a concern. Two parents in particular noted trying to reduce grains (including whole grains) overall to improve meal healthfulness. Recommendations regarding fat and refined carbohydrates have shifted in recent years due to continually emerging evidence that healthy fats are part of a balanced diet. [29] However, many CCS are at increased risk of cardiovascular disease, and the evidence linking the consumption of saturated fats, such as those found in beef and butter, with cardiovascular risk factors remains strong. [30] The Mediterranean or DASH (Dietary Approaches to Stop Hypertension) diets, which improve cardiometabolic risk factors, could be utilized as guidelines for CCS intervention development. [31,32]

Another major consideration when meal planning was CCS and family preferences. Food preferences vary by both societal norms and individual tastes. [33] Dislike or inexperience with certain foods, textures and flavors may create a powerful barrier to dietary change in families. [34,35] Preferences should be carefully considered when developing interventions to target meal preparation behaviors in CCS as cancer treatment may alter a patient’s sense of taste and smell. [36] One way to help mitigate this potential barrier is the use of a participatory design in intervention development, which engages end users throughout the process. [37] Our group recently examined the feasibility and acceptability of participatory cooking classes targeting CCS. [38] Class participants requested recipes or dishes they wished to make (e.g. pizza, cookies), which were then optimized for nutrition using an evidence-based framework. [39] This approach was well received and may be utilized in future interventions to help ensure program elements are in line with family norms and preferences.

CCS helped prepare meal components in slightly less than half of the sample (45.5%). The main reasons for not involving CCS included disinterest, scheduling, and worry regarding CCS safety. Given that involvement in meal preparation may improve diet quality in children [22], and other studies reporting that CCS prefer participating in interventions with parents [7], future interventions targeting CCS diet should consider promoting healthy cooking and eating through a family-based approach. Interventions should address parent concern with CCS safety, as this may form a barrier to program participation if parents are uncomfortable.

The cancer experience provides important context to meal values noted from parents. The emotional climate surrounding a pediatric cancer diagnosis should be taken into account when planning nutritional resources for patients and their families. Parents in the current study noted feeling frustration with the dietary advice received from medical providers and consistently highlighted their personal networks as a trusted source of nutrition information. Further, parents expressed surprise and alarm as their CCS changed food habits as a result of treatment. CCS families may benefit from a family-based nutritional intervention upon diagnosis that offers an opportunity to discuss healthy eating topics with peers, guided by a nutrition professional. Healthy eating materials can also be integrated into new patient informational documents that provide parents with resources and evidence-based information regarding food habits during cancer treatment and best practices. New technologies, such as phone or wearable applications, may also be helpful for intervention delivery in this group, as patients reduce hospital contact as they transition into longer-term survivorship.

This is the first study of which we are aware to qualitatively examine CCS family meal preparation habits. Limitations to this study include the use of a small convenience sample and reliance on a single coder for data analysis, which was necessitated by limited study resources. Participants were wealthier, more likely to own homes, and more educated than the average family in the region, and may be different than other CCS given their willingness to have researchers record their home food habits. The requirement to include in-home observations may have limited the recruitment of a diverse sample; other methods, such as photography or wearable cameras should be considered in future studies examining CCS home cooking habits. Parents reported their most commonly made meals during recruitment screening, and were asked to prepare one of these or a typical meal during the observation session to reduce demand bias. However, parents may have chosen their most healthful meal option in response to observers being present. Although access to a clinical nutritionist at the provider’s request is standard care at MD Anderson, we did not collect information on parent or CCS exposure to nutrition counseling; such measures could be integrated into future qualitative work on this topic to better contextualize CCS habits. This study focused on CCS, and it was outside the scope of this project to investigate and compare CCS habits with siblings or other children in the same household. This data may be useful to collect in future studies in order to clarify the impact of the cancer experience on the entire family unit. Despite these limitations, this study offered an in-depth examination of participant meal values, CCS involvement in meal preparation, and the impact of the cancer experience on family meals.

Future research should consider pilot testing participatory interventions for CCS and families that focus on fast, easy meals that can be used for leftovers. Several of the main meal values expressed by CCS parents may be consistent with non-cancer families, and thus existing interventions could be explored for use in this population with adaptation. Potential adaptations of existing programs may include targeting therapy-related late effects seen in pediatric cancer survivors (i.e. cardiotoxicity and bone health), which warrant cooking interventions focused on the promotion of specific macro or micronutrients. Further, the impact of the cancer experience must be considered when developing content, particularly with respect to parent stress regarding CCS dietary intake, shifts in CCS preferences, and safety concerns. Changes in the home food environment have the potential future chronic disease in this population.