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Galati PC, Rocha PRS, Gruezo ND, Amato AA. Body mass trajectory from diagnosis to the end of treatment in a pediatric acute lymphoblastic leukemia cohort. Sci Rep 2023; 13:13590. [PMID: 37604919 PMCID: PMC10442422 DOI: 10.1038/s41598-023-39287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/22/2023] [Indexed: 08/23/2023] Open
Abstract
The advances in pediatric acute lymphoblastic leukemia (ALL) care have substantially increased survival, and the late effects of treatment are a growing concern. Obesity development is frequent following ALL therapy and may significantly contribute to long-term morbidity and mortality. We examined the body mass trajectory of 208 children with ALL, from the diagnosis to the completion of therapy. We found that 7.2% of children were overweight or obese at diagnosis, which increased to 19.7% at the end of induction therapy and 20.8% after completion of treatment. In a multivariable linear regression model, age at ALL diagnosis, the type of chemotherapy regimen, and body mass index (BMI) z-score at diagnosis were significant predictors of BMI z-score after induction therapy, whereas BMI z-score at diagnosis was the only significant predictor of BMI z-score at the completion of treatment. In a subgroup of 120 children, we found no association between nutrition status at diagnosis and the risk of ALL relapse or poorer overall survival. Our findings indicate that weight gain occurs early during ALL therapy and is predicted by weight status at diagnosis. Therefore, nutritional status should be assessed throughout treatment, and weight management interventions should be considered early, particularly for patients with higher weight at diagnosis.
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Affiliation(s)
- Paula Cristina Galati
- Laboratory of Molecular Pharmacology, School of Health Sciences, University of Brasilia, Brasilia, Brazil
- Children's Hospital of Brasilia José Alencar, Brasilia, Brazil
| | | | | | - Angélica Amorim Amato
- Laboratory of Molecular Pharmacology, School of Health Sciences, University of Brasilia, Brasilia, Brazil.
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2
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Park H, Uhlemann AC, Jacobs SS, Mowbray C, Jubelirer T, Kelly KM, Walters M, Ladas EJ. Title: Obesogenic microbial signatures and the development of obesity in childhood acute lymphoblastic leukemia. Leuk Res 2023; 126:107017. [PMID: 36641874 DOI: 10.1016/j.leukres.2023.107017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/28/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023]
Abstract
Childhood acute lymphoblastic leukemia (ALL) is the most common childhood cancer with survival exceeding 90% for standard-risk groups. A debilitating side-effect of treatment is the development of overweight/obesity (OW/OB), which develops in approximately 40% of children by the end of treatment. The microbiome has been associated with the development of OW/OB. We examined fluctuations in the microbiome with the development of OW/OB during the first six months of treatment at diagnosis, and two subsequent timepoints (N = 62). Shotgun metagenomic sequencing was performed on Illumina Nextseq system, and taxa and functional pathways were extracted from sequences using kraken2 and humann2, respectively. An association of increased presence of several species (e.g., Klebsiella pneumoniae, Escherichia coli) was observed in children with OW/OB, while lean-promoting species (Veillonella, Haemophilus, and Akkermansia) were increased in children who maintained a normal weight. Pathway analysis revealed purine nucleotide biosynthesis, sugar nucleotide biosynthesis, and enzyme cofactor biosynthesis were positively correlated with Bacteroides spp. among children with OW/OB. We identified several taxa and functional pathways that may confer increased risk for the development of OW/OB. The associations observed in this pilot are preliminary and warrant further research in the microbiome and the development of OW/OB in childhood ALL.
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Affiliation(s)
- Heekuk Park
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA; Microbiome and Pathogen Genomics Collaborative Center, Columbia University, New York, NY, USA
| | - A C Uhlemann
- Department of Medicine, Division of Infectious Diseases, Columbia University Irving Medical Center, New York, NY, USA; Microbiome and Pathogen Genomics Collaborative Center, Columbia University, New York, NY, USA
| | - S S Jacobs
- Division of Oncology, Children's National Medical Center, Washington, DC, USA
| | - C Mowbray
- Division of Oncology, Children's National Medical Center, Washington, DC, USA
| | - T Jubelirer
- Children's Hospital of Philadelphia, Division of Oncology and Center for Childhood Cancer Research, Philadelphia, PA, USA; University of Pennsylvania Perelman School of Medicine, Department of Pediatrics, Philadelphia, PA, USA
| | - K M Kelly
- Department of Pediatrics, Roswell Park Comprehensive Cancer Center and University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - M Walters
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Irving Medical Center, New York, NY, USA
| | - E J Ladas
- Division of Pediatric Hematology/Oncology/Stem Cell Transplant, Columbia University Irving Medical Center, New York, NY, USA; Institute of Human Nutrition, Columbia University, New York, NY, USA.
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3
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Iijima M, Stall M, Wang L, Panetta JC, Triplett BM, Pui CH, Ribeiro RC, Rubnitz JE, Pounds SB, Inaba H. Changes in body mass index, weight, and height in children with acute myeloid leukemia and the associations with outcome. Blood Adv 2022; 6:2824-2834. [PMID: 35196375 PMCID: PMC9092412 DOI: 10.1182/bloodadvances.2021006090] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/14/2022] [Indexed: 11/20/2022] Open
Abstract
Little is known about body composition changes in patients with acute myeloid leukemia (AML) during and after treatment or their associations with outcomes. Z-scores for body mass index (BMI), weight, and height at diagnosis, their longitudinal changes from diagnosis to 5 years off therapy, and their associations with adverse effects and outcomes were evaluated in 227 pediatric patients with AML enrolled in the AML02 and AML08 trials at St. Jude Children's Research Hospital between 2002-2017. The median Z-scores for baseline weight, height, and BMI were 0.193, 0.209, and 0.170, respectively, and those for weight and height decreased significantly during therapy to -0.038 and -0.163, respectively, at off-therapy (P < .001 for both). At 5 years off therapy, the Z-scores for weight and BMI had increased significantly to 0.492 (P = .003) and 0.911 (P < .001), respectively, whereas the height Z-score remained significantly lower at -0.066 (P < .001) compared with baseline. The height Z-score of transplant recipients decreased further from -0.211 at transplant to -0.617 12 months later (P < .001). Baseline BMI category and Z-score were not associated with outcomes, but higher weight Z-scores were associated with lower incidences of refractory or relapsed disease (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-0.99) and higher incidences of death in remission (HR, 1.31; 95% CI, 1.01-1.70). Furthermore, weight Z-score decrease during induction therapy was associated with gastrointestinal, hepatic, and infection toxicities during subsequent therapy and with death in remission (HR, 2.66; 95% CI, 1.11-6.45). Multidisciplinary monitoring for weight changes and short stature is required from diagnosis to the off-therapy period.
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Affiliation(s)
- Mayuko Iijima
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Melanie Stall
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | | | | | - Brandon M. Triplett
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children’s Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Raul C. Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jeffrey E. Rubnitz
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Stanley B. Pounds
- Department of Pediatrics, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
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Dushnicky MJ, Nazarali S, Mir A, Portwine C, Samaan MC. Is There A Causal Relationship between Childhood Obesity and Acute Lymphoblastic Leukemia? A Review. Cancers (Basel) 2020; 12:E3082. [PMID: 33105727 PMCID: PMC7690432 DOI: 10.3390/cancers12113082] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022] Open
Abstract
Childhood obesity is a growing epidemic with numerous global health implications. Over the past few years, novel insights have emerged about the contribution of adult obesity to cancer risk, but the evidence base is far more limited in children. While pediatric patients with acute lymphoblastic leukemia (ALL) are at risk of obesity, it is unclear if there are potential causal mechanisms by which obesity leads to ALL development. This review explores the endocrine, metabolic and immune dysregulation triggered by obesity and its potential role in pediatric ALL's genesis. We describe possible mechanisms, including adipose tissue attraction and protection of lymphoblasts, and their impact on ALL chemotherapies' pharmacokinetics. We also explore the potential contribution of cytokines, growth factors, natural killer cells and adipose stem cells to ALL initiation and propagation. While there are no current definite causal links between obesity and ALL, critical questions persist as to whether the adipose tissue microenvironment and endocrine actions can play a causal role in childhood ALL, and there is a need for more research to address these questions.
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Affiliation(s)
- Molly J. Dushnicky
- Department of Pediatrics, McMaster University, Hamilton, ON L8N 3Z5, Canada; (M.J.D.); (S.N.); (A.M.); (C.P.)
- Division of Pediatric Endocrinology, McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
| | - Samina Nazarali
- Department of Pediatrics, McMaster University, Hamilton, ON L8N 3Z5, Canada; (M.J.D.); (S.N.); (A.M.); (C.P.)
- Division of Pediatric Endocrinology, McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Adhora Mir
- Department of Pediatrics, McMaster University, Hamilton, ON L8N 3Z5, Canada; (M.J.D.); (S.N.); (A.M.); (C.P.)
- Division of Pediatric Endocrinology, McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
| | - Carol Portwine
- Department of Pediatrics, McMaster University, Hamilton, ON L8N 3Z5, Canada; (M.J.D.); (S.N.); (A.M.); (C.P.)
- Division of Pediatric Hematology/Oncology, McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
| | - Muder Constantine Samaan
- Department of Pediatrics, McMaster University, Hamilton, ON L8N 3Z5, Canada; (M.J.D.); (S.N.); (A.M.); (C.P.)
- Division of Pediatric Endocrinology, McMaster Children’s Hospital, Hamilton, ON L8N 3Z5, Canada
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, ON L8S4L8, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON L8S 4K1, Canada
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Trends in age- and sex-adjusted body mass index and the prevalence of malnutrition in children with cancer over 42 months after diagnosis: a single-center cohort study. Eur J Pediatr 2020; 179:91-98. [PMID: 31659466 PMCID: PMC6942564 DOI: 10.1007/s00431-019-03482-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 01/06/2023]
Abstract
The adequate nutritional status of pediatric cancer patients is particularly important to enable them to cope with the demands of the disease and its treatment and to maintain normal growth. Malnutrition and obesity have both been associated with reduced survival and increased drug toxicity. We investigated trends in the age- and sex-adjusted body mass index (ISO-BMI) and the prevalence of malnutrition in a Finnish cohort of 139 consecutive children receiving chemotherapy for cancer, with a follow-up period of 42 months after diagnosis. In total, 28% (39/139) of the patients experienced malnutrition (ISO-BMI < 17 or > 10% weight loss), and 12% (16/139) had a nasogastric tube or underwent gastrostomy. Patients with acute or chronic myeloid leukemia (5/10), central nervous system (CNS) tumors (5/13), or solid tumors (13/31) most frequently suffered from malnutrition. There was a significant increase in the ISO-BMI of patients with acute lymphoblastic leukemia (ALL) (+ 2.1 kg/m2) and lymphomas (+ 2.4 kg/m2) during the first 6 months, and the ISO-BMI of patients with ALL remained higher at 42 months compared to baseline (+ 1.9 kg/m2).Conclusion: The cumulative incidence of malnutrition in Finnish pediatric cancer patients is comparable to that reported in other populations. The nutritional status of patients with acute myeloid leukemia, CNS tumors, or solid tumors should be monitored with extra care to facilitate early intervention in the case of impending malnutrition.What is known:• Both malnutrition and obesity are associated with reduced survival and increased drug toxicity in pediatric cancer patients.What is new:• Overall, 28 % of Finnish children receiving chemotherapy for cancer suffer from malnutrition during the first 42 months following the initial cancer diagnosis. • ISO-BMI curves from initial diagnosis to 42 months after diagnosis are provided for patients with different types of cancer.
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Browne EK, Zhou Y, Chemaitilly W, Panetta JC, Ness KK, Kaste SC, Cheng C, Relling MV, Pui CH, Inaba H. Changes in body mass index, height, and weight in children during and after therapy for acute lymphoblastic leukemia. Cancer 2018; 124:4248-4259. [PMID: 30358906 DOI: 10.1002/cncr.31736] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 07/28/2018] [Accepted: 07/30/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Children with acute lymphoblastic leukemia (ALL) have an increased risk of obesity and short stature. To the authors' knowledge, data regarding patients treated on contemporary protocols without cranial irradiation are limited. METHODS Changes in z scores for body mass index (BMI), height, and weight from the time of diagnosis to 5 years off therapy were evaluated using multivariable analysis in 372 children with ALL who were aged 2 to 18 years at the time of diagnosis and were enrolled on the St. Jude Children's Research Hospital Total XV protocol from 2000 through 2007. RESULTS The percentage of overweight/obese patients increased from 25.5% at the time of diagnosis to approximately 50% during the off-therapy period. Median BMI z scores increased significantly during glucocorticoid therapy (induction: ∆0.56; 95% confidence interval [95% CI], 0.29-0.64 [P<.001]; and reinduction II: ∆0.22; 95% CI, 0.13-0.49 [P=.001]) and during the first year after therapy (∆0.18; 95% CI, 0.08-0.46 [P=.006]). Among patients who were of healthy weight/underweight at the time of diagnosis, those aged 2 to <10 years at diagnosis had a significantly higher risk of becoming overweight/obese during or after therapy compared with those aged ≥10 years (P=.001). Height z scores declined during treatment and improved after therapy. Being aged 2 to <10 years at the time of diagnosis, being of low-risk status, having a white blood cell count < 50×109 /L at the time of diagnosis, and having negative central nervous system disease were associated with significantly better improvements in z scores for height during the off-therapy period compared with being aged ≥10 years, being of standard-risk/high-risk status, having a white blood cell count ≥ 50×109 /L, and having positive central nervous system disease, respectively. CONCLUSIONS The results of the current study demonstrate that obesity is prevalent, and height growth, especially in patients with identified risk factors, appears compromised. Multidisciplinary intervention should begin during induction therapy and continue during the off-therapy period.
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Affiliation(s)
- Emily K Browne
- Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yinmei Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wassim Chemaitilly
- Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - John C Panetta
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Sue C Kaste
- Department of Diagnostic Imaging, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Mary V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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Srivastava R, Batra A, Dhawan D, Bakhshi S. Association of energy intake and expenditure with obesity: A cross-sectional study of 150 pediatric patients following treatment for leukemia. Pediatr Hematol Oncol 2017; 34:29-35. [PMID: 28287332 DOI: 10.1080/08880018.2016.1272025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Increased obesity in leukemia survivors has been attributed to chemotherapy and radiation. Data on total energy intake (TEI) and total energy expenditure (TEE) are lacking in obese childhood leukemia patients after completion of therapy from India. We conducted a cross-sectional study in pediatric acute leukemia patients after completion of therapy wherein energy intake was assessed by 24-hour recall method. TEE was calculated using Harris-Benedict equation, by assessing the physical activity level using Physical Activity Questionnaire for children and basal metabolic rate by World Health Organization equation. Indian Academy of Pediatrics 2015 guidelines for BMI were used for defining overweight and obesity. Nutritional status was assessed in 150 leukemia patients after completion of therapy. Twenty-five percent of leukemia patients after completion of therapy were overweight and obese versus 11% of healthy controls (p = 0.042). The mean ratio of TEI/required energy intake (REI), TEE/required energy expenditure (REE), and (TEI:REI)/(TEE:REE) were significantly higher in overweight and obese group versus nonobese survivors (p < 0.001, p = 0.091, p < 0.001, respectively). Multivariate analysis showed higher income (HR-2.3, p = 0.04), increased TEI/REI (HR-4, p = 0.049) and higher (TEI:REI)/(TEE:REE) (HR-3.1, p = 0.039) to be significant factors predicting obesity. Obesity in leukemia patients after completion of therapy is associated with increased energy intake, causing imbalance between energy intake and TEE in these patients.
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Affiliation(s)
- Richa Srivastava
- a Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital , All India Institute of Medical Sciences , Ansari Nagar, New Delhi , India
| | - Atul Batra
- a Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital , All India Institute of Medical Sciences , Ansari Nagar, New Delhi , India
| | - Deepa Dhawan
- a Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital , All India Institute of Medical Sciences , Ansari Nagar, New Delhi , India
| | - Sameer Bakhshi
- a Department of Medical Oncology, Dr. B. R. A. Institute Rotary Cancer Hospital , All India Institute of Medical Sciences , Ansari Nagar, New Delhi , India
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Prevalence and Predictors of Overweight and Obesity Among a Multiethnic Population of Pediatric Acute Lymphoblastic Leukemia Survivors: A Cross-Sectional Assessment. J Pediatr Hematol Oncol 2016; 38:429-36. [PMID: 26989911 PMCID: PMC4955650 DOI: 10.1097/mph.0000000000000555] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
As previous studies of obesity in survivors of pediatric acute lymphoblastic leukemia (ALL) have primarily been conducted among non-Hispanic white survivors or children treated on older protocols, our objective was to describe the prevalence and correlates of overweight status among an ethnically diverse population of pediatric ALL survivors, largely treated with more contemporary therapies. We evaluated the overweight/obesity status of pediatric ALL survivors (n=406) followed in the Texas Children's Cancer Center between 2004 and 2014. Survivors were classified as underweight, normal weight, overweight, or obese on the basis of their body mass index at their most current follow-up visit. Our results showed that Hispanic ethnicity (39% of the subjects) was associated with being overweight (adjusted odds ratio=1.88; 95% confidence interval, 1.13-3.14) or obese (adjusted odds ratio=2.84; 95% confidence interval, 1.59-5.06) at follow-up, even after adjusting for cranial radiotherapy (CRT) exposure. Body mass index z-score at diagnosis was also associated with overweight/obesity at follow-up. In addition, there was a statistically significant interaction between younger age at diagnosis and CRT, indicating that younger age at diagnosis was associated with obesity among patients who received CRT. These findings may help identify pediatric ALL patients that are at increased risk of being overweight or obese after treatment.
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Zhang FF, Liu S, Chung M, Kelly MJ. Growth patterns during and after treatment in patients with pediatric ALL: A meta-analysis. Pediatr Blood Cancer 2015; 62:1452-60. [PMID: 25808413 PMCID: PMC4482769 DOI: 10.1002/pbc.25519] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 02/25/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Survivors of pediatric acute lymphoblastic leukemia (ALL) have a significantly higher body mass index (BMI) than their peers. Understanding the critical time periods in which patients with pediatric ALL are vulnerable to unhealthy weight gain will lay the groundwork for developing effectively timed interventions. PROCEDURE We determined the growth patterns of patients with pediatric ALL during and after treatment through the conduct of a systematic review and meta-analysis. A search of MEDLINE, Scopus, and Web of Science was performed from its inception through May 2014. Studies met the inclusion criteria if they included at least 10 patients of pediatric ALL, and longitudinally assessed BMI at diagnosis and at least one time point after diagnosis RESULTS Twenty-one studies met the inclusion criteria for the systematic review and 16 were included in meta-analysis. The mean increase in BMI z-score during treatment in 1,514 patients with pediatric ALL was 0.81 (95% CI: 0.25-1.38). Specifically, patients experienced substantial weight gain in early treatment (Δ = 0.41, 95% CI: -0.34, 1.17) and again during maintenance (Δ = 0.34, 95% CI:-0.22, 0.90). The mean increase in BMI z-score ranged between 0.52 and 0.89 beyond treatment completion. Subgroup analyses found unhealthy weight gain occurred regardless of patients' receipt of cranial radiation therapy, sex, and, weight status at diagnosis. CONCLUSIONS Patients with pediatric ALL experience unhealthy weight gain early in treatment, and increases in weight are maintained beyond treatment completion. Preventing early onset of obesity is a priority for improving the care and outcomes for patients with pediatric ALL.
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Affiliation(s)
- Fang Fang Zhang
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA
| | - Shanshan Liu
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, USA
| | - Mei Chung
- Nutrition/Infection Unit, Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Michael J. Kelly
- Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA
- Department of Pediatrics, Tufts University School of Medicine, Boston, MA, USA
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10
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Increased Body Mass Index during Therapy for Childhood Acute Lymphoblastic Leukemia: A Significant and Underestimated Complication. Int J Pediatr 2015; 2015:386413. [PMID: 26101530 PMCID: PMC4458559 DOI: 10.1155/2015/386413] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 04/22/2015] [Accepted: 05/04/2015] [Indexed: 01/09/2023] Open
Abstract
Objective & Design. We undertook a retrospective review of children diagnosed with acute lymphoblastic leukemia (ALL) and treated with modern COG protocols (n = 80) to determine longitudinal changes in body mass index (BMI) and the prevalence of obesity compared with a healthy reference population. Results. At diagnosis, the majority of patients (77.5%) were in the healthy weight category. During treatment, increases in BMI z-scores were greater for females than males; the prevalence of obesity increased from 10.3% to 44.8% (P < 0.004) for females but remained relatively unchanged for males (9.8% to 13.7%, P = 0.7). Longitudinal analysis using linear mixed-effects identified associations between BMI z-scores and time-dependent interactions with sex (P = 0.0005), disease risk (P < 0.0001), age (P = 0.0001), and BMI z-score (P < 0.0001) at diagnosis and total dose of steroid during maintenance (P = 0.01). Predicted mean BMI z-scores at the end of therapy were greater for females with standard risk ALL irrespective of age at diagnosis and for males younger than 4 years of age at diagnosis with standard risk ALL. Conclusion. Females treated on standard risk protocols and younger males may be at greatest risk of becoming obese during treatment for ALL. These subgroups may benefit from intervention strategies to manage BMI during treatment for ALL.
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11
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Iniesta RR, Paciarotti I, Brougham MFH, McKenzie JM, Wilson DC. Effects of pediatric cancer and its treatment on nutritional status: a systematic review. Nutr Rev 2015; 73:276-95. [PMID: 26011902 DOI: 10.1093/nutrit/nuu062] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
CONTEXT Malnutrition in pediatric cancer is common worldwide, yet its prevalence and effects on clinical outcomes remain unclear. OBJECTIVE The aim of this review was to evaluate primary research reporting the prevalence of malnutrition in pediatric cancer patients and to assess the effects of pediatric cancer and its treatment on nutritional status. DATA SOURCES Electronic databases of MEDLINE, CINHAL, and PubMed were searched (January 1990-February 2013). STUDY SELECTION Studies of patients aged <18 years who were diagnosed with and treated for cancer and for whom measurements of anthropometry were reported and included. The primary outcome was the prevalence of malnutrition (undernutrition and overnutrition), expressed as body mass index (BMI), in children diagnosed with and treated for cancer. DATA EXTRACTION Evidence was appraised critically by employing the Critical Appraisal Skills Program tool, and data was extracted from original articles. DATA SYNTHESIS A total of 46 studies were included, most of which were considered to be of low quality on the basis of heterogeneity in both the criteria and the measurements used to define malnutrition. Undernutrition was identified by measuring BMI, weight loss, mid-upper arm circumference, and triceps skinfold thickness, while overnutrition was assessed using BMI. Overall, the prevalence of undernutrition ranged from 0% to 65% and overnutrition from 8% to 78%. Finally, undernutrition in pediatric cancer at diagnosis was associated with poor clinical outcomes in 6 of 9 studies. CONCLUSION The possibility of a high prevalence of malnutrition in childhood cancer, indicated by the studies reviewed, highlights the need for high-quality, population-based, longitudinal studies using standard criteria to identify malnutrition.
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Affiliation(s)
- Raquel Revuelta Iniesta
- R. Revuelta Iniesta, I. Paciarotti, and J.M. McKenzie are with the Department of Dietetics, Nutrition and Biological Health Sciences, Queen Margaret University, Edinburgh, United Kingdom. R. Revuelta Iniesta, I. Paciarotti, and D.C. Wilson are with the Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom. F.H.M. Brougham is with the Department of Haematology and Oncology, Royal Hospital for Sick Children, Edinburgh, United Kingdom.
| | - Ilenia Paciarotti
- R. Revuelta Iniesta, I. Paciarotti, and J.M. McKenzie are with the Department of Dietetics, Nutrition and Biological Health Sciences, Queen Margaret University, Edinburgh, United Kingdom. R. Revuelta Iniesta, I. Paciarotti, and D.C. Wilson are with the Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom. F.H.M. Brougham is with the Department of Haematology and Oncology, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Mark F H Brougham
- R. Revuelta Iniesta, I. Paciarotti, and J.M. McKenzie are with the Department of Dietetics, Nutrition and Biological Health Sciences, Queen Margaret University, Edinburgh, United Kingdom. R. Revuelta Iniesta, I. Paciarotti, and D.C. Wilson are with the Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom. F.H.M. Brougham is with the Department of Haematology and Oncology, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - Jane M McKenzie
- R. Revuelta Iniesta, I. Paciarotti, and J.M. McKenzie are with the Department of Dietetics, Nutrition and Biological Health Sciences, Queen Margaret University, Edinburgh, United Kingdom. R. Revuelta Iniesta, I. Paciarotti, and D.C. Wilson are with the Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom. F.H.M. Brougham is with the Department of Haematology and Oncology, Royal Hospital for Sick Children, Edinburgh, United Kingdom
| | - David C Wilson
- R. Revuelta Iniesta, I. Paciarotti, and J.M. McKenzie are with the Department of Dietetics, Nutrition and Biological Health Sciences, Queen Margaret University, Edinburgh, United Kingdom. R. Revuelta Iniesta, I. Paciarotti, and D.C. Wilson are with the Department of Child Life and Health, University of Edinburgh, Edinburgh, United Kingdom. F.H.M. Brougham is with the Department of Haematology and Oncology, Royal Hospital for Sick Children, Edinburgh, United Kingdom
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12
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Abu-Ouf NM, Jan MM. Metabolic syndrome in the survivors of childhood acute lymphoblastic leukaemia. Obes Res Clin Pract 2015; 9:114-24. [DOI: 10.1016/j.orcp.2014.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 06/21/2014] [Accepted: 06/26/2014] [Indexed: 12/28/2022]
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Kauhanen L, Järvelä L, Lähteenmäki PM, Arola M, Heinonen OJ, Axelin A, Lilius J, Vahlberg T, Salanterä S. Active video games to promote physical activity in children with cancer: a randomized clinical trial with follow-up. BMC Pediatr 2014; 14:94. [PMID: 24708773 PMCID: PMC4234290 DOI: 10.1186/1471-2431-14-94] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 03/21/2014] [Indexed: 01/14/2023] Open
Abstract
Background Low levels of physical activity, musculoskeletal morbidity and weight gain are commonly reported problems in children with cancer. Intensive medical treatment and a decline in physical activity may also result in reduced motor performance. Therefore, simple and inexpensive ways to promote physical activity and exercise are becoming an increasingly important part of children’s cancer treatment. Methods The aim of this study is to evaluate the effect of active video games in promotion of physical activity in children with cancer. The research is conducted as a parallel randomized clinical trial with follow-up. Patients between 3 and 16 years old, diagnosed with cancer and treated with vincristine in two specialized medical centers are asked to participate. Based on statistical estimates, the target enrollment is 40 patients. The intervention includes playing elective active video games and, in addition, education and consultations for the family. The control group will receive a general recommendation for physical activity for 30 minutes per day. The main outcomes are the amount of physical activity and sedentary behavior. Other outcomes include motor performance, fatigue and metabolic risk factors. The outcomes are examined with questionnaires, diaries, physical examinations and blood tests at baseline and at 2, 6, 12 and 30 months after the baseline. Additionally, the children’s perceptions of the most enjoyable activation methods are explored through an interview at 2 months. Discussion This trial will help to answer the question of whether playing active video games is beneficial for children with cancer. It will also provide further reasoning for physical activity promotion and training of motor skills during treatment. Trial registration ClinicalTrials.gov identifier: NCT01748058 (October 15, 2012).
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Affiliation(s)
- Lotta Kauhanen
- Department of Nursing Science, University of Turku, Lemminkäisenkatu 1, FI-20014 Turku, Finland.
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Zhang FF, Kelly MJ, Saltzman E, Must A, Roberts SB, Parsons SK. Obesity in pediatric ALL survivors: a meta-analysis. Pediatrics 2014; 133:e704-15. [PMID: 24534408 PMCID: PMC3934345 DOI: 10.1542/peds.2013-3332] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Previous studies of survivors of pediatric acute lymphoblastic leukemia (ALL) have drawn heterogeneous conclusions regarding the prevalence of obesity and risk factors for developing obesity in pediatric ALL survivors. We sought to determine the prevalence of obesity in pediatric ALL survivors and examine risk factors for obesity through a systematic review and meta-analysis. METHODS A MEDLINE search was performed from its inception through 2013. Studies met the inclusion criteria if they (1) included at least 10 survivors of pediatric ALL; (2) assessed the prevalence or indicators of obesity; and (3) compared obesity among ALL survivors to a reference population or external control group. Extracted data included patient and treatment characteristics, study design, population used for comparison, and prevalence of obesity. RESULTS Forty-seven studies met the inclusion criteria. Despite significant heterogeneity among the studies (I(2) = 96%), the mean BMI z score in 1742 pediatric ALL survivors was 0.83 (95% confidence interval: 0.60-1.06), which corresponds to the 80th BMI percentile, indicating a significantly higher BMI in pediatric ALL survivors than the reference population. Subgroup analyses found a high prevalence of obesity in ALL survivors regardless of survivors' receipt of cranial irradiation, gender, or age at diagnosis. CONCLUSIONS Obesity is prevalent in pediatric ALL survivors and is independent of patient- and treatment-related characteristics. Clinicians need to screen for obesity and its associated health conditions early in survivorship.
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Affiliation(s)
- Fang Fang Zhang
- Department of Nutrition Sciences, Friedman School of Nutrition Science and Policy and,Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Michael J. Kelly
- Division of Pediatric Hematology/Oncology, The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts;,Departments of Pediatrics
| | - Edward Saltzman
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Aviva Must
- Public Health and Community Medicine, and
| | - Susan B. Roberts
- Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
| | - Susan K. Parsons
- Departments of Pediatrics,,Medicine, Tufts University School of Medicine, Boston, Massachusetts; and,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
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Hansen JA, Stancel HH, Klesges LM, Tyc VL, Hinds PS, Wu S, Hudson MM, Kahalley LS. Eating behavior and BMI in adolescent survivors of brain tumor and acute lymphoblastic leukemia. J Pediatr Oncol Nurs 2014; 31:41-50. [PMID: 24451908 DOI: 10.1177/1043454213515548] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Elevated body mass index (BMI) has been reported in pediatric cancer survivors. It is unclear whether this is related to altered energy intake (via disordered eating), decreased energy expenditure (via limited exercise), or treatment-related direct/indirect changes. The aims of this study are to describe the occurrence of overweight and obesity, exercise frequency, and the extent of disordered eating patterns in this sample of survivors, and to examine relationships among BMI, eating patterns, exercise frequency, and demographic and disease and treatment-related variables to identify those survivors most at risk for overweight/obesity. METHODS This cross-sectional study recruited 98 cancer survivors (50 acute lymphoblastic leukemia [ALL], 48 brain tumor [BT]), aged 12 to 17 years and ≥12 months posttreatment from a large pediatric oncology hospital. Survivors completed health behavior measures assessing disordered eating patterns and physical activity. Clinical variables were obtained through medical record review. Univariate analyses were conducted to make comparisons on health behaviors by diagnosis, gender, treatment history, and BMI category. RESULTS Fifty-two percent of ALL survivors and 41.7% of BT survivors were classified as overweight/obese. Overweight/obesity status was associated with higher cognitive restraint (odds ratio = 1.0; 95% confidence interval = 1.0-1.1). Only 12% of ALL survivors and 8.3% of BT survivors met Centers for Disease Control and Prevention guidelines for physical activity. Males reported more physical activity, t(96) = 2.2, P < .05. CONCLUSIONS Overweight/obese survivors may attempt to purposefully restrict their food intake and rely less on physiological cues to regulate consumption. Survivors should be screened at follow-up for weight-related concerns.
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Tuckuviene R, Christensen AL, Chan AKC, Athale U. Body mass index and thromboembolism in children with hematological malignancies. Pediatr Blood Cancer 2012; 59:320-2. [PMID: 22223230 DOI: 10.1002/pbc.23355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 08/30/2011] [Indexed: 01/03/2023]
Abstract
We evaluated the effects of body mass index (BMI) on the risk of thromboembolism (TE) in children (<18 years) with hematological malignancies during the period 1990-2009 (n = 359). Obesity was prevalent in 12% of patients: 6% versus 17% prior to and after the year 2000 (P = 0.02). Sixty-one (17%) patients developed TE; increasing BMI was associated with increased, but statistically insignificant risk of TE [adjusted odds ratios (OR): 0.75 (95%CI 0.32-1.77), 0.93 (95%CI 0.38-2.30), and 1.01(95%CI 0.42-2.41) for underweight, overweight, and obese group]. A large prospective study is needed to define the impact of BMI on the risk of TE in children.
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Affiliation(s)
- Ruta Tuckuviene
- Department of Clinical Biochemistry, Centre of Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Denmark
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Auxological changes in UK survivors of childhood acute lymphoblastic leukaemia treated without cranial irradiation. Br J Cancer 2011; 104:746-9. [PMID: 21326239 PMCID: PMC3048209 DOI: 10.1038/bjc.2011.16] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND As most children with acute lymphoblastic leukaemia (ALL) achieve long-term survival, minimising late effects of treatment is a priority. Acute lymphoblastic leukaemia survivors treated historically with protocols including cranial irradiation demonstrate increased weight gain. METHODS We retrospectively studied all 134 patients treated on the MRC/UKALL97 protocol (without cranial irradiation as standard therapy) at a single centre, with 77 inclusions. Height-, weight- and body mass index (BMI) standard-deviation scores (SDS) were recorded at diagnosis and annually until 3 years out (YO) from end of treatment (EoT); changes across time were explored using a univariate model (significance P ≤ 0.001 to account for multiple comparisons). RESULTS Whole-group height SDS was lower from 1 year into treatment until 2 YO, whereas weight- and BMI-SDS remained higher until 3 YO. In females, height-SDS was lower until EoT, but higher weight- and BMI-SDS persisted until 3 YO. In males, height-SDS was lower at EoT and at 2 YO; differences in BMI-SDS had resolved by 2 YO. By WHO criteria, more patients were overweight or obese at 3 YO than at diagnosis (P=0.01). CONCLUSION Survivors of childhood ALL, particularly females, exhibit adverse changes in height-, weight- and BMI-SDS, which arise during treatment and persist into follow-up. Patients should be supported with appropriate dietary and lifestyle advice during ALL treatment and follow-up, which may minimise these changes and reduce associated long-term morbidity.
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Abstract
Obesity is increasingly prevalent in affluent societies and portends considerable morbidity. This is especially true in children with acute lymphoblastic leukemia (ALL) in whom the metabolic syndrome may begin during therapy, demanding clarification of the trajectory of weight gain so that effective interventions may be developed. In this retrospective study of body mass index from a single institution over a 20-year period, almost 15% of children with ALL were at risk of overweight or frankly overweight (body mass index >85th centile) at diagnosis. This proportion increased steadily, reaching 40% at the end of treatment. Strategies to limit weight gain will have to be instituted early in the management of children with ALL, and will probably have to be maintained throughout and after the completion of active treatment.
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Sonabend RY, McKay SV, Okcu MF, Yan J, Haymond MW, Margolin JF. Hyperglycemia during induction therapy is associated with increased infectious complications in childhood acute lymphocytic leukemia. Pediatr Blood Cancer 2008; 51:387-92. [PMID: 18523991 DOI: 10.1002/pbc.21624] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Children with acute lymphocytic leukemia (ALL) are at high risk for developing hyperglycemia. Hyperglycemic adult ALL patients have shorter remissions, more infections, and increased mortality. No corresponding data are available in children. We hypothesized that children with ALL who become hyperglycemic during induction chemotherapy have an increased risk for infection during their first year of treatment. PROCEDURE We conducted a retrospective chart review of 135 patients diagnosed with ALL during 1999-2001 at Texas Children's Hospital. Infectious outcomes during the first year of therapy were compared in three groups patients based on blood glucose concentrations during induction therapy: euglycemic (<140 mg/dl), mild hyperglycemic (MH) (140-199 mg/dl) and overt hyperglycemic (OH) (blood glucose >200 mg/dl). RESULTS Seventy-five (56%) patients met criteria for either MH (21%) or OH (35%). Hyperglycemia was more prevalent in older children (P < 0.001) and those at risk for being overweight (BMI% >85%) at diagnosis (P < 0.01). Patients with MH and OH were 2.5 times (95% CI 1.0-6.2) and 2.1 times (95% CI 1.0-4.6) more likely to have documented infections, respectively. Patients with OH were 4.2 times (95% CI 1.5-12) more likely to have bacteremia/fungemia, 3.8 times (95% CI 1.2-11.6) more likely to have cellulitis, and 4.0 times (95% CI 1.7-9.3) more likely to be admitted for fever and neutropenia than the euglycemia group. CONCLUSION Hyperglycemia, especially when overt, may be a previously unrecognized risk factor of infectious complications in children with ALL during the first year of treatment.
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Affiliation(s)
- Rona Y Sonabend
- Department of Pediatrics, Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas, USA
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