Nutritional intake of long-term survivors of childhood acute lymphoblastic leukemia: evidence for bone health interventional opportunities

The Role of Diet in the Cardiovascular Health of Childhood Cancer Survivors-A Systematic Review

BACKGROUND

Childhood cancer survivors (CCSs) face an increased risk of cardiovascular disease (CVD). This systematic review aims to provide the first synthesis of observational and interventional studies on the relationship between diet and cardiovascular health in CCSs.

METHODS

A comprehensive search was conducted for studies published between 1990 and July 2023 in PubMed, MEDLINE, CINAHL, Child Development & Adolescent Studies, and Cochrane Library. Eligible studies included observational and interventional studies examining the associations or effects of dietary factors on CVD incidence, cardiac dysfunction, or CVD risk factors in CCSs diagnosed before age 25 years.

RESULTS

Ten studies met the inclusion criteria (nine observational and one interventional). Collectively, they comprised 3485 CCSs (male, 1734; female, 1751). The outcomes examined across observational studies included characteristics of obesity, diabetes biomarkers, hypertension indicators, dyslipidaemia biomarkers, and metabolic syndrome. The evidence suggested that greater adherence to healthy diets was associated with lower body mass index, blood pressure, glucose, and triglycerides and higher high-density lipoprotein cholesterol. The 12-week lifestyle intervention study in childhood leukaemia survivors found no impact on obesity indicators.

CONCLUSION

The review results indicate the potentially protective effects of healthy diets. However, the available research remains preliminary and limited, underscoring the need for more rigorous, adequately powered studies.

Health behaviors in adolescent survivors of cancer: An integrative review

PROBLEM

Adolescent survivors of cancer face an increased risk of chronic health conditions that can be improved by healthy behaviors. The purpose of this review is to synthesize the extent/prevalence of health behaviors (physical activity [PA], diet, human papillomavirus [HPV] vaccination, alcohol use, smoking, marijuana use, and unprotected sex) compared to age-matched peers and factors associated with those behaviors.

ELIGIBILITY CRITERIA

Four databases (PubMed, EMBASE, PsycINFO, and CINAHL) were searched for peer-reviewed primary studies published since 2000 including adolescents aged 11-20 years-old, who had completed cancer treatments. Studies reporting at least one behavior were included.

SAMPLE

Of 1979 articles reviewed, 27 studies reporting any of the following health behaviors were included: PA, diet, HPV vaccination, alcohol use, smoking, marijuana use, or unprotected sex.

RESULTS

Adolescent survivors of cancer engaged less in health risk behaviors (alcohol use, smoking, marijuana use, and unprotected sex) or health-promoting behaviors (PA, healthy diet, and HPV vaccination) compared to age-matched peers. Their health behaviors were associated with psychosocial factors including emotional discomfort (e.g., feeling depressed or nervous) and influence of others (family, friends, and healthcare providers).

CONCLUSIONS

Although health risk behaviors in adolescent survivors of cancer are not as prevalent as in their peers, the survivors' low engagement in health-promoting behaviors including PA, diet, and HPV vaccination is concerning.

IMPLICATIONS

More research is needed to develop and evaluate interventions to improve health-promoting behaviors in adolescent survivors of cancer by strengthening or facilitating psychosocial resources.

Microbiota and Hematological Diseases

The microbiota is directly involved in the host metabolic process, as well as in immune response modulation and recruitment of different cells typology in the inflammatory site. Human microbiota modification (dysbiosis) is a condition which could be correlated with various pathologies. The short-chain fatty acids produced by the metabolic process have an important role as immune mediators. In hematology field, dysbiosis can represent a predisposing condition for triggering and/or conditioning both non-neoplastic (iron deficiency anemia, thrombosis, thrombocytosis or thrombocytopenia) and neoplastic disorders (lymphomas, leukemias, myeloma). Dysbiosis may also interfere on therapy efficacy (iron supplementation, chemotherapy, immunotherapy, and hematopoietic stem cell transplantation), impacting on patient's outcome.

Prevalence of Obesity/Abdominal Obesity and Related Factors in Pediatric ALL Survivors

OBJECTIVE

Obesity has been increasingly recognized in pediatric acute lymphoblastic leukemia (ALL) survivors. The aim of the current study was to determine the prevelance and related factors of obesity/abdominal obesity and evaluate the association between nutrition and overweight/obesity after cancer treatment in pediatric ALL survivors.

METHOD

An observational retrospective cohort study was performed among 67 volunteers (aged 5-15). Participants completed 3 consecutive days (2 weekdays and 1 weekend day) recording food consumption and physical activity simultaneously. Weight, height, and waist circumference measurements were performed in remission period, and retrospective data were obtained from patient records. We examined data at three periods: diagnosis, end of treatment, and remission. Subjects were classified into four groups according to body mass index for age z score (BAZ): underweight, normal weight, overweight, and obese. Abdominal obesity was defined waist-to-height ratio ≥ 0.5.

RESULTS

Prevalence of overweight, obesity, and abdominal obesity were 25.3%, 23.9%, 38.8%, respectively in remission. BAZ at diagnosis and at treatment completion, dietary energy intake, and physical activity were associated with an increased risk of being overweight/obese in remission (p < .05). Gender, age at diagnosis, cranial radiotherapy, and treatment risk category were not significant (p > .05).

CONCLUSIONS

As in obesity, abdominal obesity was found an important problem in pediatric ALL survivors. Therefore, nutritional targets are needed to prevent obesity. Survivors should be closely monitored in terms of nutritional status during and after treatment and informed about and supported for healthy lifestyle (balanced and adequate nutrition, increase in physical activity).

Dietary Intake and Diet Quality of Adult Survivors of Childhood Cancer and the General Population: Results from the SCCSS-Nutrition Study

Childhood cancer survivors (CCSs) are at increased risk of developing chronic health conditions. This may potentially be reduced by a balanced diet. We aimed to compare dietary intake and diet quality using the Alternative Healthy Eating Index (AHEI) of adult CCSs and the general Swiss population. A food frequency questionnaire (FFQ) was completed by CCSs with a median age of 34 (IQR: 29-40) years. We compared dietary intake of 775 CCSs to two population-based cohorts who completed the same FFQ: 1276 CoLaus and 2529 Bus Santé study participants. CCSs consumed particular inadequate amounts of fiber and excessive amounts of sodium and saturated fat. Dietary intake was similar in CCSs and the general population. The mean AHEI was low with 49.8 in CCSs (men: 47.7, women: 51.9), 52.3 in CoLaus (men: 50.2, women: 54.0), and 53.7 in Bus Santé (men: 51.8, women: 54.4) out of a maximum score of 110. The AHEI scores for fish, fruit, vegetables, and alcohol were worse in CCSs than in the general population, whereas the score for sugar-sweetened beverages was better (all p < 0.001). Diet quality at follow-up did not differ between clinical characteristics of CCSs. Long-term CCSs and the general population have poor dietary intake and quality in Switzerland, which suggests similar population-based interventions for everyone.

Intestinal Dysbiosis and Development of Cardiometabolic Disorders in Childhood Cancer Survivors: A Critical Review

Significance: Survivors of pediatric cancers have a high risk of developing side effects after the end of their treatments. Many potential factors have been associated with the onset of cardiometabolic disorders (CMD), including cancer disease itself, chemotherapy, hormonal treatment, radiotherapy, and genetics. However, the precise etiology and underlying mechanisms of these long-term complications are poorly understood. Recent Advances: Greater awareness is currently paid to the role of microbiota in the emergence of cancers and modulation of cancer therapies in both children and adults. Alterations in the composition and diversity of intestinal microbiota can clearly influence tumor development and progression as well as immune responses and clinical output. As dysbiosis is closely linked to the development of host metabolic diseases, including obesity, metabolic syndrome, type 2 diabetes, and non-alcoholic fatty liver disease, it may increase the risk of CMD in cancer populations. Critical Issues: Only limited studies targeting the profile of intestinal dysbiosis before and after cancer treatment have been conducted. Further, the exact contribution of intestinal dysbiosis to the development of CMD in cancer survivors is poorly appreciated. This review intends to clarify the influence of gut microbiota on CMD in childhood cancer survivors, elucidate the potential mechanisms, and evaluate the latest research on the interplay between diet/food supplement, microbiota, and cancer-related CMD. Future Directions: The implication of intestinal dysbiosis in late metabolic complications of childhood cancer survivors should be clarified. Intervention strategies could be developed to reduce the risk of survivors to CMD. Antioxid. Redox Signal. 34, 223-251.

Diet Quality Is Associated with Cardiometabolic Outcomes in Survivors of Childhood Leukemia

There is little information about how diet influences the health of childhood acute lymphoblastic leukemia (cALL) survivors. This study explores the associations between diet quality indices, cardiometabolic health indicators and inflammatory biomarkers among cALL survivors. Participants were part of the PETALE study (n = 241, median age: 21.7 years). Adherence to 6 dietary scores and caloric intake from ultra-processed foods were calculated. Multivariate logistirac regressions, Student t-tests and Mann-Whitney tests were performed. We found that 88% of adults and 46% of children adhered poorly to the Mediterranean diet, 36.9% had poor adherence to the World Health Organisation (WHO) recommendations and 76.3% had a diet to be improved according to the HEI-2015 score. On average, ultra-processed foods accounted for 51% of total energy intake. Low HDL-C was associated with a more inflammatory diet (E-DIITM score) and higher intake of ultra-processed foods. A greater E-DII score was associated with elevated insulin resistance (HOMA-IR), and consumption of ultra-processed foods was correlated with high triglycerides. Circulating levels of TNF-α, adiponectin and IL-6 were influenced by diet quality indices, while CRP and leptin were not. In conclusion, survivors of cALL have poor adherence to dietary recommendations, adversely affecting their cardiometabolic health.

Nutritional concerns of survivors of childhood cancer: A "First World" perspective

Childhood cancer survivor (CCS) numbers are increasing as a result of advances in both treatment and supportive care. This positive outcome is tempered by the recognition of a high burden of chronic health conditions. Here, we review the nutritional concerns of CCS, including dietary habits after treatment and the factors during treatment that may contribute to chronic health conditions. Dietary interventions that have been conducted in CCS will be summarized along with focused goals of these interventions. We will also address the need to leverage these interventions to reduce the risk of chronic disease in CCS.

Nutrition during childhood cancer treatment: current understanding and a path for future research

Proper nutritional status during cancer therapy has been recognised as being integral to a variety of health outcome measures, including overall survival, treatment tolerance, and quality of life. The prevalence of malnutrition, defined by WHO as either undernutrition or overnutrition, among children and adolescents with cancer is reported to be as high as 75%. Yet, over the past two decades there have been limited advances in elucidating the underlying pathophysiological drivers of malnutrition in this population. This effect has resulted in a paucity of research aimed at improving nutritional assessment and intervention among this group. This Review presents an in-depth discussion of the role of nutritional status in paediatric cancer care, as well as evolving avenues of investigation that might propel personalised nutrition into a viable reality. Thus, nutritional science might facilitate individualised intervention strategies, and thereby help to optimise clinical outcomes for patients and survivors of childhood cancer.

The health behaviour status of teenage and young adult cancer patients and survivors in the United Kingdom

PURPOSE

The primary aim of this study was to investigate the health behaviour status of teenage and young adult (TYA) cancer patients and survivors; the secondary aim was to determine if TYA cancer patients and survivors health behaviour differs to general population controls.

METHODS

Two hundred sixty-seven young people with cancer (n =83 cancer patients receiving active treatment: n =174 cancer survivors, 57.1% >1 year since treatment completion) and 321 controls completed a health and lifestyle questionnaire which included validated measures of physical activity (PA) (Godin Leisure Time Exercise Questionnaire), diet (Dietary Instrument for Nutrition Education, DINE), smoking status, and alcohol consumption (AUDIT-C).

RESULTS

General population controls and cancer survivors were more likely to meet current (PA) recommendations (p <0.001) than TYA cancer patients undergoing treatment (54.8% vs 52.3% vs 30.1%, respectively). Less than 40% of young people with cancer and controls met fat intake, sugar intake, fibre intake or current fruit and vegetable recommendations. TYA cancer survivors were more likely to report binge drinking than controls (OR=3.26, 95% CI 2.12-5.02, p <0.001). Very few young people with in the study were current smokers. The majority of TYA cancer patients and survivors reported a desire to make positive changes to their health behaviour.

CONCLUSION

Consideration should be given to whether existing health behaviour change interventions which have demonstrated positive effects among the general TYA population could be adapted for young people with cancer.

Dietary Intakes Are Associated with HDL-Cholesterol in Survivors of Childhood Acute Lymphoblastic Leukaemia

Survivors of childhood acute lymphoblastic leukemia (cALL) are at high risk of developing dyslipidemia, including low HDL-cholesterol (HDL-C). This study aimed to examine the associations between food/nutrient intake and the levels of HDL-C in a cohort of children and young adult survivors of cALL. Eligible participants (n = 241) were survivors of cALL (49.4% boys; median age: 21.7 years old) recruited as part of the PETALE study. Nutritional data were collected using a validated food frequency questionnaire. Fasting blood was used to determine participants' lipid profile. Multivariable logistic regression models were fitted to evaluate the associations between intakes of macro- and micronutrients and food groups and plasma lipids. We found that 41.3% of cALL survivors had at least one abnormal lipid value. Specifically, 12.2% had high triglycerides, 17.4% high LDL-cholesterol, and 23.1% low HDL-C. Low HDL-C was inversely associated with high intake (third vs. first tertile) of several nutrients: proteins (OR: 0.27, 95% CI: 0.08-0.92), zinc (OR: 0.26, 95% CI: 0.08-0.84), copper (OR: 0.34, 95% CI: 0.12-0.99), selenium (OR: 0.17, 95% CI: 0.05-0.59), niacin (OR: 0.25, 95% CI: 0.08-0.84), riboflavin (OR: 0.31, 95% CI: 0.12-0.76) and vitamin B12 (OR: 0.35, 95% CI: 0.13-0.90). High meat consumption was also inversely associated (OR: 0.28, 95% CI: 0.09-0.83) with low HDL-C while fast food was positively associated (OR: 2.41, 95% CI: 1.03-5.63) with low HDL-C. The role of nutrition in the development of dyslipidemia after cancer treatment needs further investigation.

Interactions Between Gut Microbiota and Acute Childhood Leukemia

Childhood leukemia, the commonest childhood cancer, mainly consists of acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). Though great progresses have been made in the survival rates of childhood leukemia, the long-term health problems of long-term childhood leukemia survivors remain remarkable. In addition, the deep links between risk factors and childhood leukemia need to be elucidated. What can be done to improve the prevention and the prognosis of childhood leukemia is an essential issue. Gut microbiota, referred to as one of the largest symbiotic microorganisms that is accommodated in the gastrointestinal tract of human or animals, is found to be involved in the progression of various diseases. It is reported that microbiota may keep people in good health by participating in metabolism processes and regulating the immune system. Studies have also explored the potential relationships between gut microbiota and childhood leukemia. This review is meant to illustrate the roles of gut microbiota in the onset of acute childhood leukemia, as well as in the progress and prognosis of leukemia and how the treatments for leukemia affect gut microbiota. Besides, this review is focused on the possibility of building or rebuilding a healthy gut microbiota by adjusting the diet construction so as to help clinicians deal with childhood leukemia.

Early Nutrition Intervention Attenuates Weight Gain for Pediatric Acute Lymphoblastic Leukemia Patients in Maintenance Therapy

Obesity following treatment of pediatric acute lymphoblastic leukemia (ALL) has become a significant long-term concern. Excessive weight gain often occurs during treatment, particularly during induction and the first 6 months of maintenance therapy, and it may be potentially modifiable. This retrospective study aimed to evaluate the impact of an early, 3-visit nutrition intervention on weight gain during maintenance therapy in ALL patients. Medical records of the intervention group were compared with historical controls who were treated on the same ALL treatment protocols during an earlier time period. Anthropometrics were collected throughout intensive therapy and at every monthly visit during the first 12 months of maintenance therapy. In total, 67 patients were evaluated (33 in the intervention group and 34 in the control group). After controlling for significant predictors of body mass index (BMI) z-scores in maintenance therapy-including higher BMI at diagnosis and weight gain throughout intensive therapy-the intervention group demonstrated more controlled weight gain during maintenance therapy (P<0.0001). A 3-visit nutrition intervention was effective in attenuating weight gain trends during ALL maintenance therapy.

Association of dietary patterns with overweight risk and all-cause mortality in children with cancer

BACKGROUND/OBJECTIVES

This study aimed to investigate the association of dietary patterns with overweight risk and all-cause mortality in pediatric cancer patients.

SUBJECTS/METHODS

Prospective cohort study was undertaken; 83 cancer patients admitted to the pediatric cancer ward at a university hospital in Seoul were included and followed for obesity and death over 24 months. Food consumption data were collected from patients using validated meal order sheets for breakfast, lunch, and dinner at the pediatric cancer ward over 3 days. Using principal component analysis, three dietary patterns were derived from 29 food groups.

RESULTS

Eighteen deaths occurred among the patient cohort during the follow-up period. The “spicy & fried meat and fish” dietary pattern was positively associated with overweight risk at both baseline [odds ratio (OR) = 4.396, 95% confidence interval (CI) = 1.111-17.385, P for trend = 0.023] and after 6 months (OR = 4.088, 95% CI = 1.122-14.896, P for trend = 0.025) as well as all-cause mortality (hazard ratios = 5.124, 95% CI = 1.080-24.320, P for trend = 0.042), when comparing the highest and lowest tertiles after adjusting for covariates. The “fish, egg, meat, and fruits & vegetables” dietary pattern was associated with lower overweight risk after 24 months (OR = 0.157, 95% CI = 0.046-0.982, P for trend = 0.084).

CONCLUSION

The results imply that dietary patterns might be associated with weight gain and premature death among pediatric cancer patients.

Risk factors and surveillance for reduced bone mineral density in pediatric cancer survivors

BACKGROUND

Pediatric cancer survivors are at increased risk of developing low bone mineral density (BMD) due to cancer treatment. This study assessed the yield of screening for low BMD in pediatric-aged cancer survivors as per the Children's Oncology Group Long-Term Follow-Up (COG-LTFU) Guidelines, which recommend screening survivors who received steroids, methotrexate, or hematopoietic cell transplant (HCT).

METHODS

This is a retrospective cohort study of 475 pediatric blood cancer and noncentral nervous system solid tumor survivors screened for low BMD with dual-energy X-ray absorptiometry (DXA) as per the COG-LTFU Guidelines from 2003 to 2010. Risk factors for low BMD (DXA Z-score ≤-2) were evaluated by univariate and multivariate analysis.

RESULTS

The mean DXA Z-score was -0.1 for both whole body and lumbar spine measurements. Among at-risk survivors, 8.2% (39/475) had low BMD. Multivariate analysis of survivors with low BMD showed significant association with male gender (odds ratio [OR] 3.4, 95% confidence interval [CI], 1.3-9.0), exposure to total body irradiation (TBI), cranial, or craniospinal radiation (OR 5.2, 95% CI, 1.8-14.9), and gonadal dysfunction (OR 4.3, 95% CI, 1.4-13.0). Methotrexate exposure was not significantly associated with low BMD. Survivors receiving HCT had a reduced risk of low BMD (OR 0.2, 95% CI, 0.1-0.9).

CONCLUSION

The highest risk factors for low BMD were male gender, exposure to TBI, cranial, or craniospinal radiation, and gonadal dysfunction. Survivors receiving methotrexate or HCT therapy have the lowest risk for low BMD among those screened. Future studies should investigate risk of low BMD for survivors receiving HCT without radiation exposure.

Lifestyle advice provision to teenage and young adult cancer patients: the perspective of health professionals in the UK

PURPOSE

Health professionals are an important source of information for teenage and young adult (TYA) cancer patients. However, little is known about health professionals' provision of lifestyle advice to young people with cancer who are in their care.

METHODS

An online survey was distributed to health professionals within the UK who identified themselves as working with TYA cancer patients. Health professional awareness of lifestyle guidance, provision of lifestyle advice to young people and views on lifestyle information format and delivery were explored.

RESULTS

Ninety-five health professionals (44% nurses; 28% allied health professionals; 17% physicians) completed the survey. The majority (72%) of respondents were aware of some lifestyle guidance for cancer patients. However, less than half of TYA health professionals (46%) were able to successfully recall the source of the guidelines and less than a third reported proving specific advice to the majority of their patients on weight management, smoking, alcohol consumption and sun safety. Many health professionals (38%) felt that they were not the right person to provide advice and cited lack of resources as a key barrier to advice provision. The majority (95%) reported being interested in a resource containing relevant lifestyle information that could be given to young people with cancer.

CONCLUSIONS

TYA health professionals' awareness of lifestyle guidance and provision of advice regarding health behaviour is sub-optimal. Clear and comprehensive guidance written specifically for TYA health professionals could overcome the reported barriers and improve professionals' confidence in addressing and providing advice on lifestyle to young people with cancer.

Prevalence and Predictors of Overweight and Obesity Among a Multiethnic Population of Pediatric Acute Lymphoblastic Leukemia Survivors: A Cross-Sectional Assessment

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.

Dietary intake and childhood leukemia: The Diet and Acute Lymphoblastic Leukemia Treatment (DALLT) cohort study

OBJECTIVE

Children with acute lymphoblastic leukemia (ALL) are at elevated risk for nutrition-related morbidity both during and after therapy. We present the demographic characteristics and nutrient intake at study entry of a prospective cohort in which evaluating dietary intake in children diagnosed with ALL was investigated.

METHODS

Dietary intake data were collected for participants enrolled on the Dana-Farber Cancer Institute ALL Consortium Protocol. Dietary intake was assessed with a food frequency questionnaire and was compared with the dietary reference intake by ALL risk group (standard and high risk).

RESULTS

Dietary intake data were collected from 81% of participants (n = 640). We found that 27% of participants were overweight/obese. Intake of total calories and other nutrients exceeded the dietary reference intake in up to 79% of children. This was evident in both risk groups and was pronounced among younger children. For micronutrients, dietary intake of calcium, vitamin D (females only), and zinc differed significantly between patients with standard-risk and those with high-risk ALL.

CONCLUSIONS

This study was successful in collecting dietary intake data at the time of cancer diagnosis in a multicenter setting in a pediatric population at high-risk for nutrition-related morbidity. We identified "at-risk" dietary intakes, which vary by sex and ALL risk group; such patients may benefit from future dietary interventions.

Barriers and Facilitators of Healthy Diet and Exercise Among Adolescent and Young Adult Cancer Survivors: Implications for Behavioral Interventions

PURPOSE

This study uses qualitative methods to identify barriers to and facilitators of exercise and healthy eating among adolescent and young adult (AYA) cancer survivors (survivors currently aged 18-39 years and diagnosed with cancer anytime in their lives), as reported by survivors and their primary supporters.

METHODS

Survivors (M(age) = 27.6 years, SD = 6.6 years) had completed active cancer therapy. Survivors and supporters (i.e., nominated by survivors as someone who was a main source of support) attended separate focus group sessions (five survivor focus groups, five supporter focus groups) and were asked to complete a self-reported questionnaire assessing demographic and cancer history and engagement in exercise and healthy eating.

RESULTS

In total, 25 survivors and 19 supporters participated. The three overarching themes identified were barriers to exercise and healthy eating (e.g., lack of resources, negative thoughts and feelings, negative social and environmental influences), facilitators of exercise and healthy eating (e.g., cognitive motivators, tools for health behavior implementation, social relationships), and intervention implications (e.g., informational needs, desire for social support).

CONCLUSION

AYA cancer survivors and their supporters identified barriers to and facilitators of healthy lifestyle behaviors, which should be considered when designing interventions to improve the long-term health of survivors.

Obesity in Childhood Cancer Survivors: Call for Early Weight Management

A high prevalence of obesity and cardiometabolic conditions has been increasingly recognized in childhood cancer survivors. In particular, survivors of pediatric acute lymphoblastic leukemia have been found to be at risk of becoming overweight or obese early in treatment, with increases in weight maintained throughout treatment and beyond. Nutrition plays an important role in the etiology of obesity and cardiometabolic conditions and is among the few modifiable factors that can prevent or delay the early onset of these chronic conditions. However, nutritional intake in childhood cancer survivors has not been adequately examined and the evidence is built on data from small cohorts of survivors. In addition, the long-term impact of cancer diagnosis and treatment on survivors' nutritional intake as well as how survivors' nutritional intake is associated with chronic health conditions have not been well quantified in large-scale studies. Promoting family-based healthy lifestyles, preferably at a sensitive window of unhealthy weight gain, is a priority for preventing the early onset of obesity and cardiometabolic conditions in childhood cancer survivors.

Comparison of childhood cancer survivors' nutritional intake with US dietary guidelines

BACKGROUND

Despite improved survival, childhood cancer survivors experience significantly elevated risk of premature mortality and serious morbidity due to chronic health conditions. Poor diet quality can exacerbate chronic health conditions in the survivors but their nutritional intake has not been adequately studied.

PROCEDURE

We assessed the Healthy Eating Index 2010 (HEI-2010) in 22 survivors of pediatric acute lymphoblastic leukemia and lymphoma (median age = 11.7 years) and compared survivors' dietary intake to the 2010 Dietary Guidelines for Americans. Dietary data were collected using repeated 24 hr dietary recalls over a 1-year period, which were averaged to estimate habitual intake.

RESULTS

The mean HEI-2010 in childhood cancer survivors was 52.7, about 50 percent of the maximum score. Long-term survivors (time from diagnosis ≥10 years) had a significantly lower HEI-2010 than recent survivors (time from diagnosis <5 years) (β = -11.5, 95% CI: -22.1, -0.9, P = 0.047). For individual food groups and nutrients, survivors had a particularly poor adherence to green vegetables and beans, total vegetables, and whole fruits. None of the survivors met the guidelines for dietary fiber and potassium intake. Only 4%, 19%, 24%, and 29% met the guidelines for vitamin D, sodium, calcium, and saturated fat intake. The average intake in relative to the recommended intake was 32% for vitamin D, 50% for potassium, 63% for fiber, and 85% for calcium, but was 115% for saturated fat and 143% for sodium.

CONCLUSIONS

Childhood cancer survivors, in particular long-term survivors, have a poor adherence to the US dietary guidelines.

A meta-analysis of body mass index of adolescent and adult survivors of pediatric acute lymphoblastic leukemia

PURPOSE

We conducted a meta-analysis of existing studies to examine body mass index (BMI) of adolescent and adult survivors of pediatric acute lymphoblastic leukemia (ALL) compared to individuals without cancer.

METHODS

Studies were identified and reviewed using specific inclusion criteria. The effect size was odds ratio (OR) of the prevalence of overweight/obese BMI (≥ 25 kg/m(2)) in ALL survivors versus comparison groups. Study data were coded and validated. Fixed-effects (FE) and random-effects (RE) estimates of the effect size were estimated.

RESULTS

A total of 9 studies met our inclusion criteria. Survivors were more likely to be overweight/obese compared to comparison groups (FE OR = 1.12, 95% CI 1.06-1.18 and RE OR = 1.28, 95% CI 1.07-1.53). When limited to studies from North American samples, female survivors were overweight/obese more often than the comparison groups (FE OR = 1.30, 95% CI 1.19-1.43).

CONCLUSIONS

Adolescent and adult survivors of pediatric ALL, especially female survivors, may be at a higher risk of being overweight/obese compared to individuals without cancer. However, few studies provided detailed information on patient and treatment factors (e.g., cranial radiation) that can impact BMI. Standardized reporting of study content is vital for providing robust information on the risk of developing late effects among cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Adolescent and adult survivors of pediatric ALL require additional weight management resources such as targeted counseling for physical activity and dietician support both early in treatment and after the end of their therapy. Female survivors may need additional guidance to develop healthy eating practices and to participate in exercise programs.

Age-dependent changes in health status in the Childhood Cancer Survivor cohort

PURPOSE

To compare age-dependent changes in health status among childhood cancer survivors and a sibling cohort.

METHODS

Adult survivors of childhood cancer and siblings, all participants of the Childhood Cancer Survivor Study, completed three surveys assessing health status. At each of three time points, participants were classified as having poor outcomes in general health, mental health, function, or daily activities if they indicated moderate to extreme impairment. Generalized linear mixed models were used to compare survivors with siblings for each outcome as a function of age and to identify host- and treatment-related factors associated with age-dependent worsening health status.

RESULTS

Adverse health status outcomes were more frequent among survivors than siblings, with evidence of a steeper trajectory of age-dependent change among female survivors with impairment in at least one health status domain (P = .01). In adjusted models, survivors were more likely than siblings to report poor general health (prevalence ratio [PR], 2.37; 95% CI, 2.09 to 2.68), adverse mental health (PR, 1.66; 95% CI, 1.52 to 1.80), functional impairment (PR, 4.53; 95% CI, 3.91 to 5.24), activity limitations (PR, 2.38; 95% CI, 2.12 to 2.67), and an adverse health status outcome in any domain (PR, 2.10; 95% CI, 1.97 to 2.23). Cancer treatment and health behaviors influence the magnitude of differences by age groups. Chronic conditions were associated with adverse health status outcomes across organ systems.

CONCLUSION

The prevalence of poor health status is higher among survivors than siblings, increases rapidly with age, particularly among female participants, and is related to an increasing burden of chronic health conditions.

Nutritional Counseling in Survivors of Childhood Cancer: An Essential Component of Survivorship Care

There is a growing body of evidence suggesting that nutritional status during treatment for cancer has a significant impact on treatment-related toxicities and outcomes among children and adolescents with cancer. The effects of nutritional status appear to extend into survivorship with a large proportion of survivors at risk for a variety of nutrition-related morbidities. The influence of dietary intake on overall treatment outcomes and long-term morbidities is largely unknown. In adults, evidence suggests that greater adherence to cancer prevention dietary guidelines improves long-term health outcomes among survivors of cancer. Surveys describing dietary intake among survivors of childhood cancer have found that most survivors are not meeting the recommended guidelines for many dietary nutrients and this may have an unfavorable effect on nutrition-related outcomes. However, more research is needed in this area so that well-designed clinical trials may be developed and tested. This review presents an overview of the existing literature describing dietary intake among survivors of childhood cancer, the clinical implications of reported dietary behaviors among survivors, and identifies areas for future research.

Predictors of being overweight or obese in survivors of pediatric acute lymphoblastic leukemia (ALL)

BACKGROUND

A high prevalence of obesity has been increasingly recognized in survivors of pediatric ALL. However, longitudinal patterns of weight change during and after treatment, and associated factors, are less well elucidated.

PROCEDURE

In a retrospective cohort of 83 pediatric patients with ALL diagnosed between 1985 and 2010, we examined body mass index (BMI) status at several key time points: diagnosis; end of induction; end of consolidation; every 6 months during maintenance; and yearly for up to 5 years post-treatment.

RESULTS

At diagnosis, 21% were overweight (BMI = 85-94.9th percentile) or obese (BMI ≥ 95th percentile). At the end of treatment and 5 years post-treatment, approximately 40% were overweight or obese. The mean BMI z-score was 0.2 (58th percentile) at diagnosis and increased significantly during induction (Δ = 0.5, P < 0.0001). It increased again during the first 6 months of maintenance (Δ = 0.2, P < 0.01) and did not significantly change over the remainder of maintenance (BMI z-score at the end of treatment = 0.8, 79th percentile) and 5 years post-treatment (BMI z-score = 0.7, 76th percentile). High BMI z-score at diagnosis was associated with an increased risk of being overweight/obese at treatment completion (OR = 2.9, 95% CI: 1.6-5.1). Weight gain during treatment was associated with being overweight/obese 5 years post-treatment (OR = 3.8, 95% CI: 1.1-12.5).

CONCLUSION

Children with ALL are at risk of becoming overweight/obese early in treatment. Increases in weight are maintained throughout treatment and beyond. Lifestyle interventions are needed targeting weight control early during treatment, particularly for patients overweight/obese at diagnosis and those who experience substantial weight gain during treatment.

Late effects of multiagent chemotherapy on salivary secretion in children cancer survivors

OBJECTIVE

The aim of this study was to investigate the later oral consequences of chemotherapy on the oral health of children with emphasis on the cariological status and the major and minor salivary gland function.

METHOD

Thirty-eight 12-year-old children (mean age 12.3 ± 0.58 years) who underwent chemotherapy were evaluated after 5 years of treatment. Forty age- and sex-matched healthy children with similar socioeconomic backgrounds served as controls. Subjects' cariological status was explained by the number of decayed, filled, missing permanent teeth (DMF-T), and unstimulated and stimulated whole saliva flow rates were measured by the spitting method. Palatal saliva flow rate using a Periotron meter (Oraflow Inc., Plainview, NY) and salivary buffer capacity using CRT buffer (Ivoclar Vivadent AG, Schaan, Lichtenstein) were also investigated.

RESULTS

Children who underwent chemotherapy had significantly more decayed teeth than healthy controls (3.97 ± 3.58 vs 0.84 ± 1.75, respectively, p < 0.001). Recipients of chemotherapy had significantly lower stimulated whole saliva flow rate (0.84 ± 0.35 vs 1.13 ± 0.46 ml/min, p < 0.05) compared to the controls. Palatal saliva flow rate was at the same time significantly higher in the test group compared to the controls (1.64 ± 0.87 vs 0.46 ± 0.32 ml/min/cm(2), respectively, p < 0.001). High levels of buffer capacity of the saliva could be detected in a significantly higher prevalence in the patient group compared to the controls (high: 81.6% vs 40%).

CONCLUSIONS

According to these results, chemotherapy in children might result in a decreased stimulated whole saliva flow rate, hyposalivation, and, consequently, increased caries risk. Although these processes might be compensated to a limited extend by the increased minor saliva flow rate, resulting in a higher buffer capacity, nutrition and oral hygiene control of children obtaining cancer therapy is essential in the preservation of the oral tissues.

Obesity in pediatric ALL survivors: a meta-analysis

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.

Dietary quality, caloric intake, and adiposity of childhood cancer survivors and their siblings: an analysis from the cardiac risk factors in childhood cancer survivors study

Childhood cancer survivors are at increased risk of cardiovascular disease, in part because of adiposity. Whether survivors have healthy diets and whether dietary quality is associated with adiposity among survivors are not known. Survivors and siblings from the Cardiac Risk Factors in Childhood Cancer Survivors Study completed 3-day food records that were used to estimate daily caloric intake relative to recommended and dietary quality using the Healthy Eating Index-2005 (HEI). Medical records were reviewed for cancer therapies. Body composition was measured by dual-energy x-ray absorptiometry. Of 91 childhood cancer survivors and 30 sibling controls, there were no marked differences in mean daily caloric intakes (98% vs. 100% of recommended) or HEI total scores (55.5 vs. 53.3), respectively, with both groups scoring worst for the consumption of dark green vegetables and whole grains. Survivors exposed to cranial irradiation had lower total HEI scores (-6.4, P = 0.01). Among survivors, better dietary quality, as reflected by the total HEI score, was associated with decreasing percent body fat (β = -0.19, P = 0.04). Survivors consume diets similar to their siblings although these diets are only moderately adherent to current guidelines. Decreased dietary quality is associated with higher body fat and receipt of cranial irradiation in survivors.

The need for evidence based nutritional guidelines for pediatric acute lymphoblastic leukemia patients: acute and long-term following treatment

High survival rates for pediatric leukemia are very promising. With regard to treatment, children tend to be able to withstand a more aggressive treatment protocol than adults. The differences in both treatment modalities and outcomes between children and adults make extrapolation of adult studies to children inappropriate. The higher success is associated with a significant number of children experiencing nutrition-related adverse effects both in the short and long term after treatment. Specific treatment protocols have been shown to deplete nutrient levels, in particular antioxidants. The optimal nutrition prescription during, after and long-term following cancer treatment is unknown. This review article will provide an overview of the known physiologic processes of pediatric leukemia and how they contribute to the complexity of performing nutritional assessment in this population. It will also discuss known nutrition-related consequences, both short and long term in pediatric leukemia patients. Since specific antioxidants have been shown to be depleted as a consequence of therapy, the role of oxidative stress in the pediatric leukemia population will also be explored. More pediatric studies are needed to develop evidence based therapeutic interventions for nutritional complications of leukemia and its treatment.

Health promotion for adolescent childhood leukemia survivors: building on prevention science and ehealth

Teenage survivors of childhood acute lymphoblastic leukemia (ALL) have increased morbidity likely due to their prior multicomponent treatment. Habits established in adolescence can impact individuals' subsequent adult behaviors. Accordingly, healthy lifestyles, avoiding harmful actions, and appropriate disease surveillance are of heightened importance among teenage survivors. We review the findings from prevention science and their relevance to heath promotion. The capabilities and current uses of eHealth components including e-learning, serious video games, exergaming, behavior tracking, individual messaging, and social networking are briefly presented. The health promotion needs of adolescent survivors are aligned with those eHealth aspects to propose a new paradigm to enhance the wellbeing of adolescent ALL survivors.

Long-term skeletal consequences of childhood acute lymphoblastic leukemia in adult males: a cohort study

OBJECTIVE

Long-term health sequelae of childhood-onset acute lymphoblastic leukemia (ALL) remain largely unknown. Low bone mineral content (BMC) and bone mineral density (BMD) are recognized complications, but it is unknown whether these persist until adulthood. We evaluated skeletal characteristics and their association with ALL therapy in long-term male ALL survivors.

DESIGN

This cross-sectional cohort study included 49 long-term male ALL survivors and 55 age-matched healthy males.

METHODS

BMD and compression fractures were assessed by dual-energy X-ray absorptiometry; blood biochemistry was obtained for parameters of calcium homeostasis.

RESULTS

The ALL survivors (median age 29 years, range 25-38 years), assessed 10-38 years after ALL diagnosis, had lower lumbar spine (P<0.001), femoral neck (P<0.001), and whole-body (P=0.017) BMD than expected based on normative values. When compared with the controls (median age 30 years, range 24-36 years), the ALL survivors had lower lumbar spine BMC (P=0.014), lower whole-body BMC (P<0.001), and lower whole-body BMD (P<0.001), but the differences were partly explained by differences in height. Altogether, 20% of the ALL survivors had spinal compression fractures, but these were equally prevalent in the controls. Males diagnosed with ALL before age 5 years had significantly lower BMD values. Other recognized risk factors included untreated hypogonadism, vitamin D deficiency, hypophosphatemia, low IGF-binding protein-3, and low physical activity.

CONCLUSIONS

At young adulthood, long-term male ALL survivors have significantly reduced BMC and BMD and a high prevalence of spinal compression fractures. Careful follow-up and active treatment of the recognized risk factors are warranted.

Vitamin D status in pediatric patients with a history of malignancy

BACKGROUND

Multiple studies associate low vitamin D levels with cancer morbidity and mortality. However, few studies have measured vitamin D in pediatric patients with malignancy. Our aim was to assess vitamin D status in a large cohort of pediatric patients with cancer and to define risk factors for deficiency.

METHODS

Circulating 25-hydroxyvitamin D (25OHD) levels were measured in 211 patients. Calcium intake and sun exposure habits were assessed in 142 patients (age 12.1 ± 5.8 y; number of male patients, 69; mean time from diagnosis, 4.4 ± 3.8 y).

RESULTS

Daily calcium intake was 66.2 ± 39.3% of the recommended daily allowance. Mean 25OHD levels were 20.6 ± 7.9 ng/ml. Vitamin D deficiency (<15 ng/ml) was found in 24.6% of the patients and insufficiency (15-20 ng/ml) in 23.2%. Younger age and amount of sun exposure were associated with higher serum 25OHD. No association was found with calcium intake, disease type, gender, BMI SD score, years since diagnosis, or stem cell transplantation. The 25OHD levels during winter were significantly lower than the summer levels.

CONCLUSION

The prevalence of vitamin D deficiency and insufficiency in pediatric patients with a history of malignancy was high, whereas calcium intake was low. These findings are concerning, given the risk for osteoporosis in this population and the possible role of vitamin D in the context of malignancy.

Do Childhood Cancer Survivors Meet the Diet and Physical Activity Guidelines? A Review of Guidelines and Literature

Despite advances in cancer treatment, childhood cancer survivors are at higher risk of developing chronic health conditions than peers who have not had cancer. Being overweight or obese adds to the already elevated risk of cardiovascular diseases and metabolic abnormalities. Diet and physical activity are modifiable behaviors that reduce obesity risk and have been shown to improve cancer survival in adult cancer survivors. Specific guidelines have been developed for cancer survivors that provide advice on nutrition, physical activity and weight management following cancer diagnosis and treatment. In this review, we report on existing nutrition and physical activity guidelines for cancer survivors, supplemented by available literature on diet and physical activity status of childhood cancer survivors and their associations with health-related outcomes. The 2012 American Cancer Society (ACS) and the 2008 Children’s Oncology Group (COG) guidelines provide similar advice on diet but the ACS guidelines also offer specific advice on physical activity and weight management. Thirty-one observational studies and 18 intervention trials published prior to June 2012 that met the inclusion criteria were reviewed. Results suggest that a high proportion of childhood cancer survivors had poor adherence to dietary and physical activity guidelines. Although findings from existing intervention trials are preliminary due to small sample size, available evidence suggests that exercise intervention is safe and feasible for patients and survivors of childhood cancer. Childhood cancer survivors should be encouraged to engage in physical activity, adopt a healthy diet, and maintain a healthy weight throughout cancer survivorship.

Late effects in adult survivors of pediatric cancer: a guide for the primary care physician

Because of significant medical advances in the past 50 years, the number of adult survivors of childhood/adolescent cancer has increased dramatically. Unfortunately, more than 60% of these survivors will have at least 1 long-term side effect from treatment. This growing population requires dedicated care by their primary physicians because they have specific risk factors depending on their initial cancer diagnosis and the treatment modalities they received. Internists and family physicians play an integral role in providing appropriate screening, treatment, and counseling to prevent morbidity and mortality in these patients.