Weight management is a well-documented challenge for survivors of childhood cancer. This includes both being underweight and being obese. Dietary Guidelines for Americans, 2010 provides basic information readily available to all that can serve as a foundation for dietary health promotion. When available, individualized dietary recommendations from a registered dietician can help minimize the many risk factors associated with obesity or being underweight in the childhood cancer survivor.

Dietary Guidelines for Americans, 2010 has three major goals that can assist in preventing and/or treating obesity:

The USDA recommends using a Daily Food Plan to optimize food consumption and caloric intake that promotes a healthy weight. A Daily Food Plan summarizes what and how much to eat within a specific calorie allowance that is based on age, sex, height, weight, and physical activity level [29]. The five recommended food groups are fruit, vegetables, grains, protein, and dairy. For the 2,000 calorie per day level, recommended intakes include 2 cups fruit, 2.5 cups vegetables, 6 oz grains, 5.5 oz protein foods, and 3 cups dairy [30]. Just as an exercise scientist or physical therapist can create a personalized exercise regimen or physical activity plan, a registered dietician can create a personalized nutrition plan that can best help the survivor manage their weight.

Like obesity, hypertension is a significant risk factor for heart disease, but can be modified with dietary changes. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) calls for an aggressive approach to treating hypertension including lifestyle modifications with an emphasis on dietary changes before the initiation of drug therapy. The JNC 7 recommends adopting an eating plan that is rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat [31]. These dietary modifications have been shown to reduce systolic blood pressure by 8–14 mmHg [32, 33]. Blood pressure classifications are summarized in Table 24.3.

An appropriate dietary plan should serve as the mainstay of heart health promotion, along with weight loss and physical activity.

Appropriate amounts of dietary calcium and vitamin D are necessary to maintain proper levels of calcium and bone mass. Physiological vitamin D also comes from synthesis in the skin through sunlight exposure. In 2010, the Institute of Medicine (IOM) was commissioned to assess the current data on health outcomes associated with calcium and vitamin D [4]. Their exhaustive review of the evidence determined that calcium and vitamin D have a role in bone health but not in other health conditions. It was concluded that Americans are receiving adequate amounts of both calcium and vitamin D. Additionally, the IOM report indicated that too much of these nutrients may be harmful. The recommended amounts of intake for the general population were based on age and assumed minimal sun exposure. Recommended dietary intake for calcium and vitamin D are summarized in Table 24.4.

It has been hypothesized that in addition to treatment-related risk factors, sedentary lifestyle and inflammation may play a role in bone deficits in childhood cancer survivors [6]. While lifestyle changes are possible, appropriate dietary guidelines should be followed for calcium and vitamin D supplementation to optimize bone health.

Evidence-based guidelines now exist for calcium and vitamin D supplementation. Given the concern for low BMD in both child and adult survivors of childhood cancer, it is prudent to use the IOM recommendations (see Table 24.4 above) regarding calcium and vitamin D as a foundation for supplementation therapy. It is advisable to consult with a registered dietician or endocrinologist for the optimal calcium and vitamin D doses needed by the childhood cancer survivor based on the individual risk for poor bone health. Special attention must be paid to women on hormonal therapy as that also can affect bone health. In conjunction with the appropriate physical activity regimen, such supplementation can maintain optimal bone health and help prevent low BMD and its serious sequelae such as ON.

Tobacco use is the leading cause of preventable illness and death in the United States [36–44]. More than 600,000 middle school students and three million high school students smoke cigarettes [37–45]. In the CCSS, 28 % reported ever smoking with 17 % being current smokers [40]. Adolescent survivors had rates of tobacco use similar to their cancer-free siblings [35, 38–45]. This is still concerning as survivors used tobacco at higher rates than expected given their increased risk of cardiac and pulmonary complications [35, 39–46]. When compared to the general population, survivors of childhood cancer were, in fact, more likely to report being a current smoker than their noncancer peer controls [35, 40–47]. In countries outside the United States, tobacco use among survivors has varied. For example, in Great Britain, the prevalence of smoking among adult survivors of childhood cancer is substantially less overall than that in the general population [35, 40, 42–48]. Given the multiple risks associated with tobacco use, survivorship care should routinely screen for its use and have accessible smoking cessation resources readily available [35, 40, 43–49]. Multiple options exist for smoking cessation, but interventions designed to build self-efficacy may be specifically beneficial for this population [35, 40, 44–50]. Data from the CCSS showed that >69 % of survivors studied engaged in two or more other health-risk behaviors [51]. Reducing other risk behaviors might also encourage survivors to quit smoking [51].

According to the Centers for Disease Control and Prevention’s (CDC) 2011 Youth Risk Behavior Surveillance System (YRBSS), 38.7 % of US high school students had at least one alcoholic drink in the 30 days prior to being surveyed, and 39.9 % had used marijuana one or more times during their life [52]. Varying reports exist on the prevalence of alcohol and drug use by survivors of childhood cancer. Some reports have found no significant difference between survivors and their peers in regard to alcohol use [47]. There is still great concern, however, as the rate of alcohol use in long-term survivors was higher than expected given the increased risk of cardiac and pulmonary sequelae [46]. Another study reported that adult survivors of childhood cancer have decreased alcohol consumption compared to their peers [53]. This trend was also seen in a British cohort of childhood cancer survivors [42]. Illicit drugs that have a stimulatory effect on the cardiovascular system may also pose significant health risks. Therefore, survivors at risk for cardiac long-term complications should be specifically counseled regarding the dangers of any drug use that may be associated with cardiac side effects, such as cocaine use or methamphetamine abuse and smoking risk factors with marijuana.

Evidence-based interventions are needed to address substance abuse among survivors. The multiorgan damage associated with excessive alcohol consumption can quickly compound the risks of potential cardiac, pulmonary, hepatic, and endocrine complications for the childhood cancer survivor. Interventions specific to the childhood cancer survivor are currently under investigation and many show promise [54, 55]. If substance abuse is suspected by a survivorship provider, a quick and definitive referral to an addiction specialist is necessary for further evaluation and treatment.

Inadequate sun protection is a health-risk behavior that can have serious consequences for the cancer survivor. The risk of skin cancer as a second malignant neoplasm is especially relevant for those who received radiation therapy for their primary malignancy. The CDC recommends that all people take precautions against sun exposure every day of the year, especially during midday hours. This is the time period when ultraviolet (UV) rays are strongest and can do the most damage. UV rays are not blocked by clouds and can damage unprotected skin in as little as 15 min [56]. The CDC recommends the following sun protection (Table 24.5).

In a study of 75 adolescent survivors of childhood cancer, nonadherence to sun protection was the single most common health-risk behavior reported [57]. An educational intervention for these survivors was found to be efficacious in improving short-term self-reported sun safety practices [58]. Nevertheless, sun protection behaviors are difficult to instill in survivors, as in the general population. Even in a group of primary melanoma survivors, the rates of sun protection were no higher than the estimates for the general population [59]. Survivors should also be cautioned about the use of tanning beds which also increases the risk of skin cancer.

Single kidney health guidelines have been reviewed in the Physical Activity: Special Considerations section of this chapter. The use of a helmet when engaging in physical activities that involve movement at high speeds may prevent head injury. The CDC YBRSS found that 87.5 % of youth who had ridden a bicycle in the last year prior to the survey reported not wearing a helmet [52]. As with the general population, age-appropriate preventive medicine and anticipatory guidance should be communicated to all childhood cancer survivors. This involves reviewing seat belt guidelines, especially when survivors approach the legal driving age. Seat belt laws vary, but most states mandate the use of seat belts for drivers and front seat passengers, while many require that all passengers wear seat belts when riding in a passenger vehicle. This anticipatory guidance is critical as 7.7 % of youth surveyed for the YBRSS rarely or never wore a seat belt when riding in a car driven by someone else [52]. Distracted driving should also be included as a risk-taking behavior that should be avoided by survivors. It is now estimated that 33 % of youth text or email while driving a car [52].

It is imperative that all survivors understand their risks for sexually transmitted infections (STIs). Young people in the United States account for nearly half of all new STIs, yet they represent only 25 % of the sexually active population [60]. Consequently, a sexual history should be obtained on all adolescent and young adult survivors of childhood cancer as part of routine survivorship health promotion. In the CCSS cohort, survivors were more likely than their siblings to report being tested for human immunodeficiency virus (HIV) [47]. Furthermore, providers must dispel any survivor misconception that infertility is protective against contracting STIs. Another opportunity for survivor health promotion includes anticipatory guidance regarding human papillomavirus (HPV) infections [61]. A recent study found that the rate of HPV vaccination among female pediatric cancer survivors was not appreciably different than that seen in the general population [62]. Unsafe sexual practices and their associated significant health risks must be addressed as part of childhood cancer survivor health promotion.