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

The Prevalence, Risk Factors and Cardiometabolic Complications of Obesity in Childhood Survivors of Acute Lymphoblastic Leukemia

Prevalence, risk factors and metabolic complications of overweight/obesity (OW/OB) are not well described in the childhood survivors of acute lymphoblastic leukemia (ALL). Longitudinal changes in body mass index-z score (BMIz) from diagnosis to the last follow-up visit after the end of treatment were evaluated in 73 children at first complete remission. Of them, 40 were tested for adipokine profiles at visit. The mean BMIz increased gradually from diagnosis (0.07 ± 1.68) to the end of dexamethasone containing reinduction therapy (0.70 ± 1.48, P:0.007), followed by a fall at the end of treatment (0.15 ± 1.24) and a rise again at visit (0.40 ± 1.23, P:0.007). OW/OB percentage of 15% at diagnosis, increased to 35% at visit (p < 0.05). Post-treatment OW/OB in survivors was related with being OW/OB at diagnosis (OR 5.4, 95% CI [0.94-31.7]; P = 0.02) and after dexamethasone containing reinduction therapy (OR 5.1, 95% CI [1.1-21.4]; P = 0.05), but not with age at diagnosis, gender, treatment intensity and cranial irradiation. Metabolic syndrome (MetS) was more prevalent in survivors (13%) than in Turkish children (2%). As compared with controls, survivors had higher leptin level (8.1 ± 8.6 vs 3.2 ± 2.2 ng/ml, P = 0.01) and leptin/adiponectin ratio (2.1 ± 3.5 vs 0.6 ± 0.5, P = 0.03). Leptin/adiponectin ratio was correlated with HOMA-IR (r: 0.57, P = 0.001). The prevalence of OW/OB and MetS are elevated in the childhood survivors of ALL. Post-treatment OW/OB in survivors is related with OW/OB at diagnosis and dexamethasone containing therapy. Elevated leptin level and leptin: adiponectin ratio may serve as an early sign of metabolic derangement increasing the risk for early cardiovascular disease.

Longitudinal changes in body mass index, height, and weight in children with acute myeloid leukemia

BACKGROUND

This study reported height prediction and longitudinal growth changes in Chinese pediatric patients with acute myeloid leukemia (AML) during and after treatment and their associations with outcomes.

METHODS

Changes in 88 children with AML in percentages according to the growth percentile curve for Chinese boys/girls aged 2-18/0-2 years for body mass index (BMI), height, and weight from the time of diagnosis to 2 years off therapy were evaluated. The outcomes of AML were compared among patients with different BMI levels.

RESULTS

The proportion of underweight children (weight < 5th percentile) increased significantly from the initial diagnosis to the end of consolidation treatment. The proportion of patients with low BMI (BMI < 5th percentile) was highest (23.08%) during the consolidation phase, and no children were underweight, but 20% were overweight (BMI > 75th percentile) after 2 years of drug withdrawal. Unhealthy BMI at the initial diagnosis and during intensive chemotherapy leads to poorer outcomes. For height, all patients were in the range of genetic height predicted based on their parents' height at final follow-up.

CONCLUSIONS

Physicians should pay more attention to the changes in height and weight of children with AML at these crucial treatment stages and intervene in time.

Socioeconomic status and adiposity in childhood cancer survivors: A cross-sectional retrospective study

This is a retrospective cross-sectional study examining the association between unemployment, cancer type, treatment and total body fat percentage of childhood cancer survivors recruited at St. Anne's University Hospital in Brno, Czech Republic. A total of 55 survivors aged 18-49 who were in remission of cancer and fulfilled the criteria for body composition measurements by the BIA and completed questionnaires investigating their socioeconomic status, employment status, and history. There was a significant relationship between the employment status and central nervous system-directed treatment (c2(1) = 7.53, p = 0.006, Cramér's V = 0.38) and between the type of cancer and employment status (c2(3) = 7.83, p = 0.049, Cramér's V = 0.38), the highest unemployment rate was recorded for brain and spine survivors (72.7%) compared to survivors with other diagnosis (35.7%) (uLR(1) = 4.91, p = 0.027; OR = 4.80, 95% CI:1.10-20.86, p = 0.036); these survivors did not have a significantly different body fat percentage compared to survivors with other diagnoses (t(53) = 1.29, p = 0.202, Cohen's d = 0.41) Interestingly, the survivors reporting having a partner also had a significantly higher percentage of body fat (t(53) = 2.90, p = 0.005, Cohen's d = 0.81). A linear regression model was used to model the percentage of body fat in relation to a set of selected variables and the we observed a significant effect of sex (female vs male: b = 6.37, 95% CI: 1.82-10.93, p = 0.007), partnership status (yes vs no: b = 5.65, 95% CI: 0.67-10.62, p = 0.027) and category of diagnosis (Brain and spinal column tumors vs Other solid tumors: b = 12.40, 95% CI: 0.59-24.21, p = 0.040; Brain and spinal column tumors vs Lymphoma: b = 14.02, 95% CI: 2.06-25.97, p = 0.023). Employment status and risk of adiposity in childhood cancer survivors depends on the type of treatment and diagnosis group, which may significantly impact their lifestyle and overall quality of life after treatment. Trial registration: This study was registered on July 29, 2022, at ClinicalTrials.gov (NCT05481229).

The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy in the world. Advances in treatment protocols have resulted in survival rates of >80% in most high-income countries (HIC); however, children and young people (CYP) with ALL continue to face significant nutrition-related challenges during treatment.

METHODS

This narrative review outlines the changing landscape of treatment and survivorship for CYP with ALL and the advances in nutrition knowledge that call for changes to clinical nutrition practice.

RESULTS

The incidence of ALL has remained stable in HIC; however, there have been significant advances in survival over the past 30 years. Overweight and obesity are increasingly prevalent in CYP with ALL at diagnosis, during treatment and in survivorship. Coupled with poor diet quality, high-energy and saturated fat intakes, altered eating behaviours and inactivity, this necessitates the need for a shift in nutrition intervention. Undernutrition remains a concern for CYP with high-risk treatment protocols where oral or enteral nutrition support remains a cornerstone of maintaining nutrition status.

CONCLUSIONS

With improved treatment protocols and high survival rates, a shift to focusing on diet quality, prevention of excessive weight gain and obesity during treatment and survivorship is necessary.

Navigating nutrition as a childhood cancer survivor: Understanding patient and family needs for nutrition interventions or education

AIM

Nutrition challenges are common during childhood cancer treatment and can persist into survivorship, increasing the risk of non-communicable diseases. Evidence-based practice and implementation of nutrition interventions/education for childhood cancer survivors has been poorly investigated and may influence their future health. This study aimed to explore the nutrition interventions/education needs of childhood cancer survivors and the barriers and facilitators to delivering follow-up services in New Zealand.

METHODS

Semi structured interviews were conducted with childhood cancer survivors and/or their families (n=22) and health professionals (n=9) from a specialist paediatric oncology centre in New Zealand. Interviews were audio-recorded and transcribed verbatim. Transcripts were analysed inductively using thematic analysis. A multi-level consensus coding methodology was used where each theme and associated subthemes were discussed with the study team for confirmation to ensure accurate coding and analysis.

RESULTS

Three themes emerged from the analysis: (1) the current survivorship care pathway does not provide adequate interventions/education, (2) weight and dietary changes are common challenges and (3) requirements for interventions/education in survivorship are varied. Common nutrition-related concerns included fussy eating/limited dietary intake, poor diet quality, difficulties with tube weaning, and challenges with weight gain. Participants expressed a desire for education on healthy eating alongside information about cancer-related nutrition issues, such as learned food aversions. A preference for clear referral pathways and multifaceted interventions tailored to individual patient needs was identified.

CONCLUSION

The trifecta of treatment side effects, negative feeding practices and poor messaging from health professionals creates a challenging environment to optimise nutrition. A stepped care model matching the intervention intensity with the childhood cancer survivors is required. Education for healthcare professionals will improve the delivery of timely interventions/education and monitoring practices.

Weight status in survivors of childhood acute lymphocytic leukemia in South Korea: a retrospective descriptive study

PURPOSE

This study investigated weight status in survivors of childhood acute lymphocytic leukemia (ALL) and identified related factors.

METHODS

A retrospective review of the electronic medical records of survivors of childhood ALL (n=230) was conducted. We analyzed the survivors' characteristics, including sex, age, weight status at diagnosis, central nervous system involvement, risk classification, length of treatment, radiation therapy, and hematopoietic stem cell transplantation. Analysis of variance and the chi-squared test were applied to investigate influencing factors.

RESULTS

The weight status distribution was as follows: 23 individuals (10.0%) were classified as underweight, 151 individuals (65.7%) were healthy weight, and 56 individuals (24.3%) were overweight/obese. Age at diagnosis (F=10.03, p<.001), weight status at diagnosis (x2=43.41, p<.001), and risk classification (F=10.98, p=0.027) showed significant differences among the weight status groups. Survivors who were older at diagnosis and those in the very high-risk category had a higher likelihood of experiencing underweight status during their survivorship, while survivors who were overweight/obese at diagnosis were more likely to remain overweight/obese at the time of survival.

CONCLUSION

Considering the potential health implications related to an unhealthy weight status in survivors of ALL, it is imperative to undertake early identification and implement interventions for at-risk individuals.

Body mass trajectory from diagnosis to the end of treatment in a pediatric acute lymphoblastic leukemia cohort

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.

Proactive Glucose Screening Tool Effective for Time-sensitive Identification of Hyperglycemia in Childhood Cancer Patients

Approximately 4% to 35% of pediatric patients undergoing treatment for acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LLy) develop drug-induced hyperglycemia. Though hyperglycemia is associated with poor outcomes, no guidelines for identifying drug-induced hyperglycemia currently exist, and the time course for developing hyperglycemia remains relatively uncharacterized after induction therapy. The present study evaluated a hyperglycemia screening protocol that was implemented to identify hyperglycemia more promptly, examined predictors of hyperglycemia during ALL and LLy therapy, and described the timeline for developing hyperglycemia. A retrospective review of 154 patients diagnosed with ALL or LLy at Cook Children's Medical Center between March 2018 and April 2022 was performed. Predictors of hyperglycemia were examined with Cox regression. The hyperglycemia screening protocol was ordered for 88 (57%) patients. Fifty-four (35%) patients developed hyperglycemia. In multivariate analyses, age 10 years or older (hazard ratio = 2.50, P = 0.007) and weight loss (vs gain) during induction (hazard ratio = 3.39, P < 0.05) were associated with hyperglycemia. The present study identified a population of patients at risk of developing hyperglycemia and identifies strategies for hyperglycemia screening. In addition, the present study showed that some patients developed hyperglycemia after induction therapy, which highlights the importance of continued blood glucose monitoring in at-risk patients. Implications and suggestions for further research are discussed.

Epigenetic Age in Peripheral Blood Among Children, Adolescent, and Adult Survivors of Childhood Cancer

Importance

Certain cancer therapies are risk factors for epigenetic age acceleration (EAA) among survivors of childhood cancer, and EAA is associated with chronic health conditions (CHCs). However, small numbers of younger survivors (aged <20 years) previously evaluated have limited the ability to calculate EAA among this age group.

Objective

To evaluate the change rate of epigenetic age (EA) and EAA in younger compared with older survivors and the possible association of EAA with early-onset obesity (aged <20 years), severity/burden of CHCs, and late mortality (>5 years from cancer diagnosis).

Design, Setting, and Participants

Study participants were from the St Jude Lifetime Cohort, initiated in 2007 with ongoing follow-up. The present study was conducted from April 17, 2022, to March 23, 2023. Survivors in this cohort of European ancestry with DNA methylation data were included. Cross-sectional annual changes in EA and EAA were compared across 5 different chronologic age groups: age 0 to 9 (children), 10 to 19 (adolescents), 20 to 34 (younger adults), 35 to 49 (middle-aged adults), and greater than or equal to 50 (older adults) years. Logistic regression evaluated the association between EAA and early-onset obesity or severity/burden of CHCs. Cox proportional hazards regression assessed the association between EAA and late mortality.

Main Outcomes and Measures

Early-onset obesity, severity/burden of CHCs (graded using the Common Terminology Criteria for Adverse Events (grade 1, mild; 2, moderate; 3, severe/disabling; 4, life-threatening) and were combined into high vs low severity/burden based on frequency and grade), and late mortality were the outcomes based on follow-up until April 2020. Expanded DNA methylation profiling increased the number of survivors younger than 20 years (n = 690). Epigenetic age was calculated primarily using the Levine clock, and EAA was derived from least squares regression of EA against chronologic age and was standardized to a z score (Levine EEA).

Results

Among 2846 participants (median age, 30.3 [IQR, 9.3-41.5] years; 53% males), the cross-sectional annual change in EA_Levine was higher in children (1.63 years) and adolescents (1.14 years), and the adjusted least-squares mean of Levine EEA was lower in children (-0.22 years) and older adults (-1.70 years). Each 1-SD increase in Levine EEA was associated with increased risk of developing early-onset obesity (odds ratio [OR], 1.46; 95% CI, 1.19-1.78), high severity/burden of CHCs (OR, 1.13; 95% CI, 1.03-1.24), and late mortality (hazard ratio, 1.75; 95% CI, 1.35-2.26).

Conclusions and Relevance

The findings of this study suggest that EAA measured in children and adolescent survivors of childhood cancer is associated with early-onset obesity, severity/burden of all CHCs, and late mortality. Evaluating EAA may help identify survivors of childhood cancer at increased risk for early-onset obesity, morbidity in general, and mortality.

A cross-sectional study of nutritional status and dietary intake of paediatric oncology patients in Indonesia: Comparison between cancer aetiologies

Background: Adequate energy and protein intakes are required to maintain nutritional status and prevent clinical deterioration in paediatric oncology patients. There are limited investigations of malnutrition and dietary intake adequacy during treatment in developing countries. Aim: This study aimed to assess the nutritional status and macro- and micronutrient intake adequacy in paediatric oncology patients undergoing therapy. Methods: This cross-sectional study was conducted at Dr Sardjito Hospital, Indonesia. Sociodemographic, anthropometry, dietary intake, and anxiety status were collected. Patients were grouped based on cancer aetiology (haematological malignancy (HM) or solid tumour (ST). Variables between groups were compared. P-values of <0.05 were considered statistically significant. Results: 82 patients aged 5-17 years (65.9% HM) were analysed. The prevalence of underweight was 24.4% (ST vs HM: 26.9% vs 23.2%), overweight 9.8% (ST vs HM: 11.5% vs 8.5%), and obesity 6.1% (ST vs HM: 0.0% vs 8.5%) according to BMI-for-age z-score. Mid-upper-arm circumference identified undernutrition in 55.7% and overnutrition in 3.7% of the patients. Stunted growth was found in 20.8% of the patients. Percentages of children with inadequate energy and protein intake were 43.9% and 26.8%, respectively. The percentages of participants meeting the national micronutrient requirements were low, ranging from 3.8% to 56.1%, with the highest adherence rate observed for vitamin A and the lowest for vitamin E. Appetite loss was associated with lower overall intake. Conclusion: This study confirmed that malnutrition is prevalent in paediatric patients treated for cancer. Inadequate intakes of macro- and micro-nutrients were also common, highlighting the need for early nutritional assessment and intervention.

Role of Nutrition in Pediatric Patients with Cancer

Children with cancer are at high risk for developing short-term and long-term nutritional problems related to their underlying disease and side effects of multimodal treatments. Nutritional status (NS) can influence several clinical outcomes, such as overall survival (OS) and event-free survival (EFS), treatment tolerance, risk of developing infections and quality of life (QoL). However, the importance of nutrition in children with cancer is still underestimated. This review focuses on alterations of NS that occurs in children during cancer treatment. In particular, we reviewed the pathogenesis of undernutrition in oncological children, as well as how NS affects treatment tolerance and response, the immune system and the risk of infections of children with cancer. Thanks to recent advances in all types of supportive therapy and to the progress of knowledge on this topic, it has been realized that NS is a modifiable prognostic factor that can be intervened upon to improve the outcome of these patients. Currently, there is a lack of a systematic approach and standard recommendations for nutritional care in the pediatric cancer population. Literature analysis showed that it is essential to define the NS and treat any alterations in a timely manner ensuring proper growth and development. Nutritional follow-up should become an integral part of the care pathway. Regular nutritional monitoring should be performed at diagnosis, during treatment and during follow-up. A close collaboration and sharing of expertise between pediatric oncologists and nutrition specialists, combined with careful and participatory sharing of the feeding experience with the family and the child (after age 6 years), is strongly required.

Changes in body mass index during treatment of childhood acute lymphoblastic leukemia with the Nordic ALL2008 protocol

OBJECTIVES

Children with acute lymphoblastic leukemia (ALL) have a tendency to gain weight during treatment. As overweight and obesity associate with health problems, prophylactic interventions are warranted. Therefore, it is important to identify the children most prone to gain weight.

METHODS

Patients aged 2.0-17.9 years at ALL diagnosis were identified from the NOPHO ALL2008 registry. Registry data was complemented with height and weight at the end of therapy from questionnaires. Body mass index (BMI) was classified according to international age- and sex-adjusted International Obesity Task Force BMI cut-offs. BMI values were transformed into standard deviation scores (SDS) to calculate the difference in BMISDS during treatment.

RESULTS

Data on BMI change were available for 765 children. Overweight and obesity doubled during treatment: 9.7% were overweight and 2.1% obese at diagnosis and 21.8% and 5.4% at the end of therapy, respectively. The mean BMISDS change was +0.64. Younger (2.0-5.9 years) and healthy weight children were most prone to become overweight (mean change in BMI SDS +0.85 and + 0.65, respectively).

CONCLUSIONS

Younger children (2.0-5.9 years) with healthy weight at diagnosis were most prone to becoming overweight and therefore are an important group to target while considering interventions.

Multidisciplinary Network ActiveOncoKids guidelines for providing movement and exercise in pediatric oncology: Consensus-based recommendations

BACKGROUND

Pediatric cancer leads to reduced participation in exercise and only few patients comply with national physical activity recommendations. Physically inactive behavior hinders motor development and increases physical and psychological adverse effects of therapy and incidence of sequelae. Currently, there is neither nationwide coverage nor uniform level of knowledge regarding exercise promotion. The objective of the guideline is to facilitate qualified exercise interventions through standardized procedures in addition to regular physiotherapy and overall avoid physical inactivity in pediatric cancer patients.

METHODS

This guideline addresses the multidisciplinary treatment team and informs physiotherapists and decision-makers in tertiary care hospitals and health insurance companies. The requirements of the Association of the Scientific Medical Societies in Germany were followed. Contents were based on best practice experience of experts, patient advocates, as well as on scientific evidence.

RESULTS

The guideline includes 11 recommendations. Recommendations 1-4 declare the relevance of implementing exercise interventions and address general framework conditions. Recommendations 5-11 focus on the design of exercise programs, prevention and safety issues, relative contraindications for specific training loads, and options to overcome barriers to exercise.

CONCLUSION

This guideline summarizes existing and established structures and evidence in the context of movement and exercise in pediatric oncology. It takes into consideration the rights, varying needs, and characteristics of children and adolescents as well as national and international experience in this field. In the future, relevant research gaps need to be addressed by high-quality intervention studies to provide the scientific background for a stronger evidence-based guideline.

Changes in body mass index, weight, and height in children with acute myeloid leukemia and the associations with outcome

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.

Early Nutritional Intervention to Promote Healthy Eating Habits in Pediatric Oncology: A Feasibility Study

This study aims to describe the feasibility of a nutritional intervention that promotes healthy eating habits early after cancer pediatric diagnosis in patients and their parents. Participants were recruited 4 to 12 weeks after cancer diagnosis as part of the VIE study. The one-year nutritional intervention included an initial evaluation and 6 follow-up visits every 2 months with a registered dietician. The feasibility assessment included rates of retention, participation, attendance, completion of study measures, and participants' engagement. A preliminary evaluation of the intervention's impact on the participants' dietary intakes was conducted. A total of 62 participants were included in the study (51.6% male, mean age = 8.5 years, mean time since diagnosis = 13.2 weeks). The retention and attendance rates were 72.6% and 71.3%, respectively. Attendance to follow-up visits declined over time, from 83.9% to 48.9%. A majority of participants had high participation (50.8%) and high engagement (56.4%). Measures of body-mass-index or weight-for-length ratio and dietary 24-h recalls were the procedures with the highest completion rates. Participants with refractory disease or relapse were less likely to complete the intervention. Post-intervention, participants (n = 21) had a lower sodium intake compared to the initial evaluation. These results suggest that a nutritional intervention that involves patients and parents early after a pediatric cancer diagnosis is feasible.

Frequency of obesity and metabolic syndrome in childhood leukemia and lymphoma survivors

OBJECTIVES

In this study, it was aimed to determine the prevalence and clinical features of obesity and metabolic syndrome, which are long-term effects of survivors after treatment in children with leukemia and lymphoma.

PATIENTS AND METHODS

Patients with leukemia and lymphoma, who were diagnosed between 2000 and 2012 (at least 2 two years after remission) were included. Data obtained through reviewing the family history, demographic characteristics, anthropometric measurements, and laboratory parameters (blood glucose, lipid, and insulin levels) were analyzed and compared at the time of diagnosis, after the treatment and at time of the study.

RESULTS

Eighty nine patients (45 boys, 44 girls) were included (mean age: 14.7 ± 4.3 years): 77.5% had acute lymphoblastic leukemia, 11.2% had acute myeloid leukemia, and 11.2% had lymphoma. Overall, 46% patients had received radiotherapy, 7% had undergone surgery, and 2.2% had received stem cell transplantation in addition to chemotherapy. The mean duration of treatment was 2.4 years, and the time elapsed after treatment was 4.9 years. While only one had obesity at the diagnosis, a significant increase in obesity (20%), hypertension (15.7%), hyperglycemia (15%), insulin resistance (35%) were observed at the time of study, and family history of hypertension, dyslipidemia, and cardiovascular diseases were significantly higher in this subgroup.

CONCLUSION

The prevalence of metabolic syndorme is higher in children with leukemia and lymphoma after treatment, and begins to increase with the initiation of treatment and continues to increase over time. These children should be followed-up for late-effects including metabolic syndrome through life-long period.

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).

Screening for asymptomatic diabetes and metabolic comorbidities in pediatric patients during therapy for acute lymphoblastic leukemia

OBJECTIVES

Chronic metabolic disturbances related to cancer treatment are well reported among survivors of pediatric acute lymphoblastic leukemia (ALL). However, few studies have investigated the incidence of these complications during the phase of chemotherapy. We evaluated the incidence of acute metabolic complications occurring during therapy in our cohort of patients diagnosed with ALL.

METHODS

A prospective study involving 50 ALL pediatric patients diagnosed and treated between 2012 and 2016 in our oncology unit. We collected weight, blood pressure, fasting plasma glucose and hemoglobin A1C (HBA1c) levels during the two years of therapy.

RESULTS

Obesity and overweight occurred in 43 and 25%, respectively among patients and have been reached at 12 months of chemotherapy. About 26% of the patients developed high blood pressure and 14% experienced hyperglycemias without meeting diabetes criteria. There was a significant decrease of HBA1c levels between the beginning and the end of therapy (p<0.0001).

CONCLUSIONS

Increase of body mass index in our ALL pediatric patients occurred during the first months of therapy and plateaued after a year of treatment. We should target this population for early obesity prevention. HbA1c levels measured during therapy did not reveal diabetes criteria. Hence, fasting blood glucose levels are sufficient to monitor ALL pediatric patients' glycemia.

A bilingual dietary intervention early in treatment is feasible and prevents weight gain in childhood acute lymphoblastic leukemia

BACKGROUND

Childhood acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. The onset of obesity during childhood ALL has been well established and is associated with inferior survival rates and increased treatment-related toxicities. This pilot study sought to determine if a dietary intervention is feasible and minimizes weight gain during the initial phases of treatment for ALL.

METHODS

Participants were recruited from four institutions, fluent in English or Spanish, between 5 and 21 years old, and enrolled within 3 days of starting induction therapy. Participants were counseled for 6 months to follow a low glycemic diet. Dietary and anthropometric data were collected at diagnosis, end of induction, and end of month 6 (NCT03157323).

RESULTS

Twenty-three of 28 participants (82.1%) were evaluable and included in the analysis. Dietary changes targeted by the nutrition intervention were successful; sugar intake declined (P = .003), whereas vegetable intake increased (P = .033). The majority of participants were able to adhere to the dietary principles prescribed: ≥70.0% reduced glycemic load and ≥60.0% increased fiber intake and decreased sugar intake. Importantly, we did not observe an increase in body mass index z-score during induction or over the 6-month intervention period. Most families found the nutrition intervention easy to follow (60%) and affordable (95%) despite simultaneous initiation of treatment for ALL.

CONCLUSIONS

A 6-month nutrition intervention initiated during the initial phase of treatment for childhood ALL is feasible and may prevent weight gain. Our preliminary findings need to be confirmed in a larger clinical trial.

Fatigue, Physical and Functional Mobility, and Obesity in Pediatric Cancer Survivors

BACKGROUND

Survivors of childhood cancer are prone to an increased risk of chronic issues such as cardiovascular disease, fatigue, weight-related problems, and emotional disturbances.

OBJECTIVE

This study utilized the biopsychosocial model to examine the hypothesis that greater depression and lower mobility would be significantly associated with greater fatigue and higher body mass index in survivors of childhood cancer.

METHODS

Data were analyzed for 144 children treated and followed up for an oncology condition at a southeastern academic medical center. Voluntarily, children completed the Patient-Reported Outcomes Measurement Information System 1.0, and parents completed the Family Symptom Inventory as part of a brief annual psychosocial screening battery. Height and weight were collected by a clinic nurse prior to questionnaire completion.

RESULTS

Hierarchical linear regression showed that shorter time since diagnosis (β = -.154, P < .05), greater child-reported depression (β = .396, P < .01), and lower mobility (β = .427, P < .01) significantly predicted greater fatigue (adjusted R = 0.54). Older age (β = .262, P < .01) and not receiving chemotherapy (β = -.209, P < .05) significantly predicted higher body mass index (adjusted R = 0.051).

CONCLUSIONS

Findings showed that fatigue tends to improve over time after treatment but may be predicted by greater depression symptoms and lower mobility in recent survivors of childhood cancer.

IMPLICATIONS FOR PRACTICE

For survivors of childhood cancer with higher levels of fatigue, treating symptoms of depression and maximizing physical and mobility may be of clinical value. With the impact of psychological and social factors not yet understood in pediatric cancer survivors, weight status in recent survivors of childhood cancer is likely a complex interaction between biological and treatment factors.

Increased Levels of Adipocyte and Epidermal Fatty Acid-Binding Proteins in Acute Lymphoblastic Leukemia Survivors

Childhood cancer survivors are highly exposed to the development of side effects after many years of cessation of anticancer treatment, including altered lipid metabolism that may result in an increased risk of overweight and metabolic syndrome. Adipocyte (A-FABP) and epidermal (E-FABP) fatty acid-binding proteins are expressed in adipocytes and are assumed to play an important role in the development of lipid disturbances leading to the onset of metabolic syndrome. The aim of this study was to investigate the association between serum A-FABP and E-FABP levels, overweight, and components of the metabolic syndrome in acute lymphoblastic leukemia survivors. Sixty-two acute lymphoblastic leukemia (ALL) survivors (34 females) were included in the study. The mean age at the time of the study was 12.41 ± 4.98 years (range 4.71–23.43). Serum levels of A-FABP and E-FABP were analyzed using a commercially available ELISA kit. The ALL survivors presented statistically higher A-FABP levels in comparison with the healthy controls (25.57 ± 14.46 vs. 15.13 ± 7.61 ng/mL, p < 0.001). The subjects with body mass index (BMI) above the normal range (18 overweight, 10 obese) had a greater level of A-FABP compared to the ALL group with normal BMI (32.02 ± 17.10 vs. 20.33 ± 9.24 ng/mL, p = 0.006). Of all participants, 53.23% had at least one risk factor of metabolic syndrome; in this group, only the A-FABP level showed a statistically significant difference compared to the healthy control group (30.63 ± 15.91 vs. 15.13 ± 7.61 ng/mL, p < 0.001). The subjects with two or more metabolic risk factors (16.13%) presented higher levels of both A-FABP (33.62 ± 17.16 vs. 15.13 ± 7.61 ng/mL, p = 0.001) and E-FABP (13.37 ± 3.62 vs. 10.12 ± 3.21 ng/mL, p = 0.021) compared to the controls. Univariable regression models showed significant associations between BMI and systolic blood pressure with the A-FABP level (coeff. 1.02 and 13.74, respectively; p < 0.05). In contrast, the E-FABP level was only affected by BMI (coeff. 0.48; p < 0.01). The findings reported herein suggest that the increased levels of A-FABP and E-FABP may be involved in the pathogenesis of overweight and the onset of metabolic syndrome in acute lymphoblastic leukemia. However, further longitudinal, prospective studies of fatty acid-binding proteins and their potential role in the pathogenesis of obesity and metabolic syndrome in ALL survivors remain to be performed.

Lipodystrophy as a Late Effect after Stem Cell Transplantation

Survivors of childhood cancer are at high risk of developing metabolic diseases in adulthood. Recently, several patients developing partial lipodystrophy following hematopoietic stem cell transplantation (HSCT) have been described. In this review, we summarize the cases described so far and discuss potential underlying mechanisms of the disease. The findings suggest that HSCT-associated lipodystrophies may be seen as a novel form of acquired lipodystrophy.

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.

Nutritional Status of Pediatric Cancer Patients at Diagnosis and Correlations with Treatment, Clinical Outcome and the Long-Term Growth and Health of Survivors

Malnutrition is caused either by cancer itself or by its treatment, and affects the clinical outcome, the quality of life (QOL), and the overall survival (OS) of the patient. However, malnutrition in children with cancer should not be accepted or tolerated as an inevitable procedure at any stage of the disease. A review of the international literature from 2014 to 2019 was performed. Despite the difficulty of accurately assessing the prevalence of malnutrition, poor nutritional status has adverse effects from diagnosis to subsequent survival. Nutritional status (NS) at diagnosis relates to undernutrition, while correlations with clinical outcome are still unclear. Malnutrition adversely affects health-related quality of life (HRQOL) in children with cancer and collective evidence constantly shows poor nutritional quality in childhood cancer survivors (CCSs). Nutritional assessment and early intervention in pediatric cancer patients could minimize the side effects of treatment, improve their survival, and reduce the risk of nutritional morbidity with a positive impact on QOL, in view of the potentially manageable nature of this risk factor.

Prevalence and predictors of weight loss during induction therapy for childhood acute lymphoblastic leukemia

OBJECTIVE

Children with acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma often experience significant weight gain during induction therapy. However, a subgroup of patients may experience weight loss, which can impact outcomes; thus, identifying and understanding this underrecognized concern is important. Our aim was to identify the prevalence and predictors for weight loss during ALL induction therapy.

METHODS

This was a single-institution retrospective study of 187 patients, ages 2 to 20 y, diagnosed with ALL or lymphoblastic lymphoma. We analyzed weight trends during induction therapy and predictors of weight loss.

RESULTS

Significant weight loss (≥5%) occurred in 17% of patients. Having high-risk disease, trisomy 21, overweight/obese status at the time of diagnosis, and/or hyperglycemia were positively associated with weight loss and negatively associated with weight gain during induction therapy.

CONCLUSION

Future studies should aim to better understand the etiology and importance of weight loss during induction therapy.

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.

[Body composition evaluation by anthropometry and bioelectrical impedance analysis in childhood acute leukemia survivors]

Introduction

Background: survivors of childhood acute leukemia are at risk for obesity. The purpose was to evaluate the different clinical measurements of body composition and to compare with body mass index (BMI). Methods: cross-sectional study of 39 survivors with more than ten years of survivorship since diagnosis. Anthropometry and body composition accuracy measurements were determined and also obesity risk factors. Results: obesity prevalence by body fat percentage were: 38.5% for BMI; 46.1% for waist circumference; 51.3% for skinfolds and 56.4% for bioelectrical impedance analysis (BIA). There was a good correlation among the measurements, but BMI underestimated the percent body fat among childhood leukemia survivors in comparison with: waist circumference (-1.03 ± 2.01), skinfolds (-2.95 ± 5.78) and BIA (-3.78 ± 7.4), and this bias appears to be more variable with increasing percent of body fat > 30%. Three patients showed sarcopenia and only one sarcopenic obesity. Waist circumference fat mass was the better predictor of cardiovascular risk factors (LDL-cholesterol: r = 0.703; HDL-cholesterol: r = -0.612; p < 0.05 and hypertension: OR 4.17; IC 95%: 1.012-19.3). Obesity risk factors were: female sex, high-risk tumor, radiotherapy and stem cell transplantation. Conclusions: BMI underestimates obese childhood leukemia survivors in comparison with waist circumference, skinfolds and bioelectrial impedance analysis. BMI use could misclassify obese survivors as non-obese. Female sex, high tumoral risk and coadyuvant treatments (radiotherapy and stem cell transplant) are risk factors for adiposity.

The role of nutrition in pediatric oncology

Introduction: Obesity compromises survival in children with cancer in high-income countries (HICs) and is accompanied often by sarcopenia. In low and middle-income countries (LMICs), where the great majority of children live, the prevalence of under-nutrition is as high as 95% in those with cancer. Nutritional support improves clinical outcomes, including survival.Areas covered: This narrative review describes the evolution of attention to nutrition in children with cancer and the increasing understanding of this relationship. An initial focus on obesity in children with acute leukemias in HICs has been matched more recently by a recognition of the negative effect of under-nutrition on survival in children with cancer in LMICs. These observations have stimulated explorations of underlying mechanisms, including dysbiosis of the gut microbiome, and structured nutritional interventions to redress adverse outcomes.Expert opinion: Studies of the gut microbiome and metabolome have yielded important information on the pathogenesis of malnutrition in children, providing new avenues for interventions. Combinations of plant products that are inexpensive and readily available in LMICs have been shown to 'mature' the microbiome and the corresponding plasma proteome in children with acute malnutrition, offering the prospect of cost-effective remedies that are tested in children with cancer.

Bariatric interventions in obesity treatment and prevention in pediatric acute lymphoblastic leukemia: a systematic review and meta-analysis

Most children are surviving acute lymphoblastic leukemia (ALL) today. Yet, the emergence of cardiometabolic comorbidities in this population may impact long-term outcomes including the quality of life and lifespan. Obesity is a major driver of cardiometabolic disorders in the general population, and in ALL patients it is associated with increased risk of hypertension, dysglycemia, and febrile neutropenia when compared with lean ALL patients undergoing therapy. This systematic review aims to assess the current evidence for bariatric interventions to manage obesity in children with ALL. The primary outcome for this systematic review was the change in BMI z-score with implementation of the interventions studied. Literature searches were conducted in several databases. Ten publications addressing the study question were included in this review, and five studies were used in the meta-analysis to assess the impact of the bariatric interventions on obesity. The BMI z-score did not change significantly with the interventions. However, the quality of evidence was low, which precluded the recommendation of their use. In conclusion, prospective, rigorous, adequately powered, and high-quality longitudinal studies are urgently needed to deliver effective lifestyle interventions to children with ALL to treat and prevent obesity. These interventions, if successful, may improves cardiometabolic health outcomes and enhance the quality of life and life expectancy in children with ALL.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients: A Scientific Statement From the American Heart Association

This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.

Increased Adiposity Enhances the Accumulation of MDSCs in the Tumor Microenvironment and Adipose Tissue of Pancreatic Tumor-Bearing Mice and in Immune Organs of Tumor-Free Hosts

Obesity is associated with increased risk and reduced survival for many types of cancer. Increasing adiposity may affect the balance between immunosuppressive and antitumor mechanisms critical for dictating cancer progression or remission. The goal of the current study was to determine if increased adiposity altered tumor growth, survival, and myeloid-derived suppressor cell (MDSC) accumulation in a subcutaneous murine model of pancreatic cancer. C57BL/6 mice were placed on a 30% kcal calorie-restricted diet, 10% kcal from fat diet fed ad libitum, or 60% kcal from fat diet fed ad libitum for 16 weeks to generate lean, overweight, and obese mice, respectively; followed by subcutaneous injection with 1 × 10⁶ Panc.02 cells. We observed a significant linear relationship between increased adiposity and increased tumor growth and mortality; increased accumulation of Gr-1⁺CD11b⁺ MDSCs; and reduced CD8 T cell:MDSC ratio in multiple tissues, including tumor. Increased adiposity also increased the accumulation of MDSCs in the spleen and lymph node of tumor-free mice. These data suggest adiposity induces MDSC accumulation, which may contribute to an immunosuppressive environment promoting tumor growth. Overall, our findings provide a rationale to prevent or reverse increased body weight as a strategy to reduce the accumulation of immunosuppressive cell types.

Early Lifestyle Intervention for Obesity Prevention in Pediatric Survivors of Acute Lymphoblastic Leukemia

Patients with pediatric acute lymphoblastic leukemia (ALL) experience rapid weight gain during treatment and increases in weight are maintained throughout treatment and beyond. Without prompt interventions, altered dietary and physical activity behaviors may become difficult to reverse, contributing to obesity risk long-term. Fifteen children, aged 3–9 years, diagnosed with pediatric ALL who were on maintenance therapy or within two years of treatment completion (mean BMI percentile: 70.4^th) and one parent from each family, were enrolled into a 12-week lifestyle intervention delivered remotely through web-based sessions and phone calls with a lifestyle coach. Outcomes were assessed at baseline and end of the intervention. Thirteen of the 15 enrolled families (86.7%) completed the intervention. Parents reduced the “pressure to eat” feeding practice (change in mean score: −0.60, 95% CI: −1.12 to −0.07; p-value = 0.03) post intervention. Children increased the consumption of milk (0.54 serving/d, 0.02 to 1.07; p-value = 0.04) and percent of calories from protein (2.54%, 0.22 to 4.87%; p-value = 0.04) and reduced the consumption of potatoes (−0.16 serving/d, -0.30 to −0.03; p-value = 0.02). No significant changes were observed for children’s levels of physical activity, BMI, or waist circumference. Results from this pilot support the feasibility and preliminary efficacy of early lifestyle intervention among pediatric ALL survivors.

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.

Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review

The number of patients surviving ≥5 years after initial cancer diagnosis has significantly increased during the last decades due to considerable improvements in the treatment of many cancer entities. A negative consequence of this is that the emergence of long-term sequelae and endocrine disorders account for a high proportion of these. These late effects can occur decades after cancer treatment and affect up to 50% of childhood cancer survivors. Multiple predisposing factors for endocrine late effects have been identified, including radiation, sex, and age at the time of diagnosis. A systematic literature search has been conducted using the PubMed database to offer a detailed overview of the spectrum of late endocrine disorders following oncological treatment. Most data are based on late effects of treatment in former childhood cancer patients for whom specific guidelines and recommendations already exist, whereas current knowledge concerning late effects in adult-onset cancer survivors is much less clear. Endocrine sequelae of cancer therapy include functional alterations in hypothalamic-pituitary, thyroid, parathyroid, adrenal, and gonadal regulation as well as bone and metabolic complications. Surgery, radiotherapy, chemotherapy, and immunotherapy all contribute to these sequelae. Following irradiation, endocrine organs such as the thyroid are also at risk for subsequent malignancies. Although diagnosis and management of functional and neoplastic long-term consequences of cancer therapy are comparable to other causes of endocrine disorders, cancer survivors need individually structured follow-up care in specialized surveillance centers to improve care for this rapidly growing group of patients.

Weight trends in a multiethnic cohort of pediatric acute lymphoblastic leukemia survivors: A longitudinal analysis

BACKGROUND

As survival rates for childhood acute lymphoblastic leukemia (ALL) continue to improve, there is growing concern over the chronic health conditions that survivors face. Given that survivors of childhood ALL are at increased risk of cardiovascular complications and obesity, we sought to characterize BMI trends from diagnosis through early survivorship in a multi-ethnic, contemporary cohort of childhood ALL patients and determine if early weight change was predictive of long-term weight status.

METHODS

The study population consisted of ALL patients aged 2-15 years at diagnosis who were treated with chemotherapy alone at Texas Children's Hospital. Each patient had BMI z-scores collected at diagnosis, 30-days post-diagnosis, and annually for five years. Linear regression models were estimated to evaluate the association between: 1) BMI z-score change in the first 30 days and BMI z-scores at five-years post-diagnosis; and 2) BMI z-score change in the first year post-diagnosis and BMI z-scores at five-years post-diagnosis.

RESULTS

This retrospective cohort study included longitudinal data from 121 eligible patients. The mean BMI z-scores for the population increased significantly (p-value<0.001) from baseline (mean = 0.25) to 30 days post-diagnosis (mean = 1.17) before plateauing after one year post-diagnosis (mean = 0.99). Baseline BMI z-scores were statistically significant predictors to five year BMI z-scores (p <0.001). Independent of baseline BMI z-score and other clinical factors, the BMI z-score at one year post-diagnosis was significantly associated with BMI z-score at five-years post-diagnosis (β = 0.63, p <0.001), while BMI z-score at 30 days post-diagnosis was not (β = 0.10, p = 0.23).

CONCLUSION

Our results suggest that weight gain within the first year after diagnosis is more strongly associated with long-term BMI than early weight gain (within 30 days). If confirmed, this information may help identify a window of time during therapy when ALL patients would benefit most from weight management directed interventions.

Long-term effects on growth, development, and metabolism of ALL treatment in childhood

INTRODUCTION

One aim of the long-term care in survivors from acute lymphoblastic leukemia (ALL) during childhood is to avoid or limit complications caused by aggressive therapeutic strategies.

AREAS COVERED

ALL survivors are a heterogeneous group according to therapeutic protocols. In the last decades, cranial radiotherapy (cRT) has been largely replaced by intrathecal chemotherapy (CT) with a reduction of endocrine sequelae. Published studies are generally difficult to be interpreted because patients were treated according to different risk-adapted protocols and results are conflicting. We perform this review on endocrine long-term effects in childhood ALL survivors focusing on studies published in the last decades. Articles were selected using the following terms (Mesh terms): 'acute lymphoblastic leukemia' AND 'survivors' AND 'childhood' AND 'growth/puberty/fertility/obesity/metabolic syndrome/bone'.

EXPERT COMMENTARY

Most childhood ALL survivors treated with CT alone attain normal height and have adequate pubertal development. Despite recent protocols improvements, ALL survivors still develop long-term metabolic complications (overweight, obesity, and cardiovascular disease) especially the female gender and patients with an increased body mass index (BMI) at diagnosis. The aim of this review is to describe the state of the art on these topics. We should be able to anticipate, prevent, and treat endocrine long-term morbidities through a well-established follow-up strategy.

Overweight in childhood cancer patients at diagnosis and throughout therapy: A multicentre cohort study

BACKGROUND

Childhood cancer patients (CCP) have been reported to be at increased risk of becoming overweight during treatment. We assessed prevalence of overweight in CCP at diagnosis and at the end of treatment, determined risk factors, and identified weight change during treatment by type of cancer.

METHODS

In a multicentre cohort study, we collected height and weight measurements of CCP at diagnosis and repeatedly during treatment. We calculated age- and sex-adjusted BMI Z-scores using references of the International Obesity Taskforce for children. Risk factors were described by multivariable linear regression, and weight change during treatment by multilevel segmented linear regression.

RESULTS

The study included 327 CCP with a median age of 7 years (IQR 3-12) at diagnosis (55% boys), who had been diagnosed with acute lymphoblastic leukaemia (ALL, 29%), lymphoma (16%), central nervous system (CNS) tumours (13%), sarcoma (18%), and other types of cancer (24%). At diagnosis, 27 CCP (8%) were overweight. This increased to 43 (13%) at end of treatment, on average 0.7 years after diagnosis. Being a boy (p = 0.005) and having been diagnosed with ALL or lymphoma (p < 0.001) were risk factors for weight gain during treatment. During the first half of treatment, BMI Z-scores increased in ALL (regression slope β = 0.4, 95% CI 0.1-0.7) and lymphoma (β = 1.5, 95% CI 0.2-2.9) patients, whereas for patients with CNS tumours (β = -1.4, 95% CI -2.7 to -0.2), sarcoma (β = -1.4, 95% CI -2.0 to -0.7), or other types of cancer (β = -0.3, 95% CI -1.5-0.9) BMI Z-scores tended to drop initially. During the second half of treatment BMI Z-scores of all patients tended to increase. Exploratory analyses showed that BMI Z-scores of younger ALL patients (<7 years at diagnosis) increased during induction (β = 3.8, 95% CI 0.5-7.0). The inverse was seen for older ALL patients (≥7 years at diagnosis), in whom BMI Z-scores tended to decrease during induction (β = -1.5, -5.1-2.2), both groups tended to increase afterwards.

CONCLUSION

CCP diagnosed with ALL or lymphoma are at increased risk of weight gain during treatment, and might particularly benefit from early lifestyle interventions.

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.

Comparison of Resting Energy Expenditure Assessment in Pediatric Oncology Patients

BACKGROUND

Evaluation of energy requirements is an important part of the nutrition assessment of pediatric oncology patients. Adequate provision of energy in this population is of extreme importance because of the prevalence of malnutrition and its effect on growth, development, quality of life, morbidity, and mortality. Numerous methods are used in clinical practice for estimating the resting energy expenditures (REE), specifically indirect calorimetry and predictive equations. A relatively new instrument used to assess REE is the hand-held indirect calorimeter. The purpose of this quality improvement project was to compare the accuracy of REE measurements taken by a hand-held indirect calorimeter and predictive equations to that of a standard indirect calorimeter metabolic cart.

METHODS

Patients receiving therapy for pediatric cancer, aged 7-18 years, and having a weight ≥15 kg and scheduled for a REE nutrition assessment were eligible. Sequentially, the patient's REE was assessed with the cart and the hand-held indirect calorimeter along with the predictive equation calculation.

RESULTS

Post hoc pairwise comparisons revealed that all 3 methods were significantly different from one another (P < .0001). When compared with the cart, the portable hand-held calorimeter was found to underestimate REE by 11.9%, whereas predictive equations overestimated REE by 12.4%.

CONCLUSION

Our quality improvement project suggests that the hand-held indirect calorimeter underestimated REE, and predictive equations overestimated REE in pediatric oncology nutrition assessment. Therefore, we recommend that these limitations in assessment be considered when assessing REE using a hand-held indirect calorimeter or predictive equations.

Diet and exercise interventions for pediatric cancer patients during therapy: tipping the scales for better outcomes

Obesity at diagnosis is a negative prognostic indicator for several pediatric cancers including acute leukemia and bone tumors. Incidence of obesity in children has increased three-fold over the past 2 decades, and causes for this include poor diet, excessive caloric intake, and lack of physical activity, which are collectively referred to as energy balance-related behaviors. Few energy balance interventions have been implemented in pediatric cancer patients during treatment, and here we will probe the rationale for pursuing such studies. The need to modify composition of calories consumed and to identify specific beneficial exercise regimens will be discussed, relative to weight reduction or management.

Overweight in childhood cancer survivors: the Swiss Childhood Cancer Survivor Study

Background

An increased risk of becoming overweight has been reported for childhood cancer survivors (CCSs), in particular leukemia survivors, although the evidence is inconclusive.

Objective

We assessed the prevalence of overweight in CCSs, with a focus on leukemia survivors, compared it with their peers, and determined potential risk factors.

Design

As part of the Swiss Childhood Cancer Survivor Study, we sent a questionnaire between 2007 and 2013 to all Swiss resident CCSs aged <21 y at diagnosis who had survived ≥5 y. We calculated body mass index (BMI) from medical records at diagnosis and self-reported heights and weights at survey. We calculated BMI z scores by using Swiss references for children and compared overweight prevalence in CCSs, their siblings, and the general population with the use of the Swiss Health Survey (SHS) and assessed risk factors for being overweight by using multivariable logistic regression.

Results

The study included 2365 CCSs, 819 siblings, and 9591 SHS participants. At survey, at an average of 15 y after diagnosis, the prevalence of overweight in CCSs overall (26%) and in leukemia survivors (26%) was similar to that in siblings (22%) and the general population (25%). Risk factors for being overweight in CCSs were male sex (OR: 1.8; 95% CI: 1.5, 2.1), both young (OR for ages 5-14 y: 1.6; 95% CI: 1.2, 2.3) and older (range-OR for ages 25-29 y: 1.7; 95% CI: 1.2, 2.4; OR for ages 40-45 y: 4.0; 95% CI: 2.5, 6.5) age at study, lower education (OR: 1.4; 95% CI: 1.1, 1.8), migration background (OR: 1.3; 95% CI: 1.1, 1.7), and no sports participation (OR: 1.4; 95% CI: 1.1, 1.7). Risk factors for overweight were similar in peers. CCSs treated with cranial radiotherapy (≥20 Gy) were more likely to be overweight than their peers (OR: 1.6; 95% CI: 1.2, 2.2).

Conclusions

The prevalence of and risk factors for being overweight are similar in long-term CCSs and their peers. This suggests that prevention methods can be the same as in the general population. An important exception is CCSs treated with cranial radiotherapy ≥20 Gy who may need extra attention during follow-up care. This study was registered at clinicaltrials.gov as NCT03297034.

Cardiovascular Risk Factors after Childhood Cancer Treatment Are Independent of the FTO Gene Polymorphism?

The study objective was to assess the prevalence of cardiovascular disease risk factors in patients treated for childhood cancer (N = 101) and to determine the involvement of clinical (cancer type and therapy) and/or genetic (FTO gene rs9939609 polymorphism) factors. Anthropometric features, laboratory findings, and standardized osteodensitometric indices (fat and lean mass) were considered. Overweight/obesity was found in 17.82% of the patients; however, central adiposity was found in as many as 42.5%. At least one abnormality in lipid metabolism was observed in 35.6%. Densitometry revealed elevated levels of fat mass in 44.55% of the patients. None of the parameters studied were associated with the FTO gene polymorphism. Standardized waist circumference was significantly higher in patients treated for leukemia than those treated for solid tumors (p = 0.04). Our findings indicate a high rate of central adiposity among childhood cancer survivors, especially leukemia patients. The prevalence of risk factors of cardiovascular disease after anticancer therapy is not FTO gene polymorphism-dependent.

Genomic determinants of long-term cardiometabolic complications in childhood acute lymphoblastic leukemia survivors

BACKGROUND

While cure rates for childhood acute lymphoblastic leukemia (cALL) now exceed 80%, over 60% of survivors will face treatment-related long-term sequelae, including cardiometabolic complications such as obesity, insulin resistance, dyslipidemia and hypertension. Although genetic susceptibility contributes to the development of these problems, there are very few studies that have so far addressed this issue in a cALL survivorship context.

METHODS

In this study, we aimed at evaluating the associations between common and rare genetic variants and long-term cardiometabolic complications in survivors of cALL. We examined the cardiometabolic profile and performed whole-exome sequencing in 209 cALL survivors from the PETALE cohort. Variants associated with cardiometabolic outcomes were identified using PLINK (common) or SKAT (common and rare) and a logistic regression was used to evaluate their impact in multivariate models.

RESULTS

Our results showed that rare and common variants in the BAD and FCRL3 genes were associated (p<0.05) with an extreme cardiometabolic phenotype (3 or more cardiometabolic risk factors). Common variants in OGFOD3 and APOB as well as rare and common BAD variants were significantly (p<0.05) associated with dyslipidemia. Common BAD and SERPINA6 variants were associated (p<0.05) with obesity and insulin resistance, respectively.

CONCLUSIONS

In summary, we identified genetic susceptibility loci as contributing factors to the development of late treatment-related cardiometabolic complications in cALL survivors. These biomarkers could be used as early detection strategies to identify susceptible individuals and implement appropriate measures and follow-up to prevent the development of risk factors in this high-risk population.

Nutritional Characteristics of the Diets of Child and Adolescent Cancer Survivors

PURPOSE

Diseases associated with prior treatment, such as obesity, have been described in cancer survivors. Recent studies have shown that current estimates of overweight do not differ from that in the general population, suggesting the influence of environmental factors, such as dietary intake. In this context, there is increasing interest in the examination of health behaviors that may modify and reduce the risk of overweight and obesity. This study aimed to evaluate the characteristics of dietary intake among child cancer survivors living in a developing country.

METHODS

This retrospective cross-sectional study included children and adolescents up to 18 years of age. Dietary intake of the patients was assessed using 24-hour dietary recall.

RESULTS

All age groups showed sufficient carbohydrate and protein consumption levels. The mean percentages of carbohydrate and protein consumption were 54% and 20.8%, respectively. Regarding lipid quality, survivors showed low consumption levels of polyunsaturated and monounsaturated fats. The consumption level of saturated fats was close to the upper limit. Fiber intake was below the recommended level in all patient categories, and its mean was 11.5 g/day. The average daily intake of some vitamins and minerals was below the recommended intake levels for all sexes and age groups, with values below 50% of suitability.

CONCLUSION

The imbalance of lipids quality and low consumption of micronutrients demonstrated that the diet quality is poor in child cancer survivors. This favors the development of not only obesity but also other chronic diseases, and potentially predisposes such patients to secondary cancers.

IMPLICATIONS FOR CANCER SURVIVORS

this is a relevant issue due to the increased number of childhood cancer survivors who develop obesity and chronic and metabolic complications due to inadequate food consumption. Our study may help understand, prevent, or minimize public health problems.

Growth and pubertal patterns in young survivors of childhood acute lymphoblastic leukemia

BACKGROUND

Survivors of acute lymphoblastic leukemia (ALL) may experience endocrine dysfunction. This study evaluated growth and pubertal patterns in survivors of childhood ALL.

METHODS

Longitudinal assessment of anthropometric measurements and pubertal status was performed in a retrospective cohort of survivors (n=183). Median age at last endocrine visit was 16.1 years (range 8.2-27.6); median follow-up time was 8.7 years (range 3-21.4).

RESULTS

Treatment with chemotherapy+prophylactic cranial radiation (pCRT, n=29) was associated with lower mean height standard deviation score (SDS) than chemotherapy alone (n=154) (p=0.001) and higher prevalence of adult short stature (13% vs. 2.2%). Mean age at pubertal onset was normal (girls: 10.3±1.3 years; boys: 12.0±1.3 years). Precocious puberty, diagnosed in 8.7% of patients, was more prevalent in pCRT-treated girls. Rates of overweight and obesity were 22.9% and 9.3%, respectively. Predictors of endocrine disorders were pCRT (p=0.031) and female gender (p=0.041); of obesity, higher body mass index (BMI)-SDS at diagnosis (p=0.001); and of short stature, lower height-SDS at diagnosis (p=0.038).

CONCLUSIONS

Most childhood ALL survivors given chemotherapy alone attain normal adult height and puberty. Childhood ALL survivors are at increased risk of overweight, especially those with increased BMI at diagnosis. Clinicians should screen for overweight early in survivorship and introduce early interventions.

Early Nutrition and Physical Activity Interventions in Childhood Cancer Survivors

PURPOSE OF REVIEW

Childhood cancer survivors experience excessive weight gain early in treatment. Lifestyle interventions need to be initiated early in cancer care to prevent the early onset of obesity and cardiovascular disease (CVD). We reviewed the existing literature on early lifestyle interventions in childhood cancer survivors and consider implications for clinical care.

RECENT FINDINGS

Few lifestyle interventions focus on improving nutrition in childhood cancer survivors. A consistent effect on reducing obesity and CVD risk factors is not evident from the limited number of studies with heterogeneous intervention characteristics, although interventions with a longer duration and follow-up show more promising trends. Future lifestyle interventions should be of a longer duration and include a nutrition component. Interventions with a longer duration and follow-up are needed to assess the timing and sustainability of the intervention effect. Lifestyle interventions introduced early in cancer care are both safe and feasible.

Assessment of Obesity and Hepatic Late Adverse Effects in the Egyptian Survivors of Pediatric Acute Lymphoblastic Leukemia: a Single Center Study

Background

Childhood acute lymphoblastic leukemia (ALL) with current cure rates reaching 80% emphasizes the necessity to determine treatment-related long-term effects. The aim of this study is to estimate the prevalence of overweight, obesity, and hepatic late adverse effects in a cohort of ALL survivors treated at the Hematology and Oncology Unit, Pediatrics Department, Menoufia University, Egypt.

Methods

In this case-control study, height, weight, and body mass index (BMI) were assessed for 35 pediatric ALL survivors and 35 healthy children. These parameters were plotted on the growth and WHO standard deviation charts for both males and females. Overweight and obesity were defined by BMI > 85^th and 95^th percentile respectively. Laboratory investigations were done in the form of iron profile, liver enzymes, total and direct bilirubin levels, serum urea &creatinine and detection of hepatitis C virus antibodies by ELISA.

Results

The weight and BMI were significantly greater in the survivors than controls (P value =0.002 and 0.039 respectively). ALT, total & direct bilirubin, serum ferritin and transferrin saturation were considerably higher in the survivors than the controls (P value = 0.03, 0.036, 0.044, 0.006 and 0.03 respectively). Ten (28.6%) of survivors had hepatitis C antibodies with none (0%) of controls (P value =0.02)

Conclusions

Pediatric ALL survivors are at increased risk of overweight/obesity, hepatic dysfunction in the form of elevated liver enzymes, bilirubin levels, and C viral hepatitis. Screening of those survivors for such complications should be considered.