Purpose: The aim of this study was to investigate the associations between nutrition, physical activity,
fatigue, and quality of life (QoL) among childhood cancer survivors. The specific purpose was to examine
whether nutrition mediated and physical activity moderated the relationship between fatigue and QoL in
this population.
Methods: A pooled sample of 120 childhood cancer survivors was recruited at pediatric oncology wards
and ambulatory settings between August 2020 and May 2021. We collected data on participants’ deꠓmographic characteristics, fatigue, nutritional status, physical activity, and QoL. We then adapted Hayes
Process Macro to examine the mediating and moderating effects of nutrition and physical activity on the
relationship between fatigue and QoL.
Results: In models adjusted for age and sex, (1) the simple mediation analysis identified the mediating
effect of nutrition on the relationship between fatigue and QoL; and (2) the mediation and moderation
analysis identified that the direct effect of nutrition between fatigue and QoL was significant when
adding (a) physical activity and (b) fatigue ꠑ physical activity. There were significantly decreasing trends
in physical activity at 1 standard deviation below the mean and at the mean, but not at 1 standard
deviation above the mean.
Conclusions: Our findings demonstrate that nutrition mediated and physical activity moderated the relaꠓtionship between fatigue and QoL. This highlights an opportunity to enhance QoL among childhood cancer
survivors through healthy lifestyle interventions. To ensure that future interventions address children's
needs and promote the greatest impact, such interventions should include nutrition and physical activity
components that involve nurses, pediatric oncology physicians, nutritionists, and physical therapists.