Childhood leukaemia: a model of pre-obesity

Diet, physical activity, and body composition changes during the first year of treatment for childhood acute leukemia and lymphoma

BACKGROUND

Children who undergo treatment for childhood acute lymphoblastic leukemia (ALL) and lymphoma are at risk for several long-term health problems. Obesity, for which survivors of ALL and lymphoma are also at risk, may further exacerbate these problems. This pilot study evaluates changes in physical activity and body composition among children being treated for ALL and lymphoma and their parents.

PROCEDURES

Recently diagnosed adolescent ALL and lymphoma patients were recruited from 2 pediatric hematology and oncology clinics, and matched on age, race, and sex to healthy individuals in the community. Changes in diet, physical activity, and body composition were collected at baseline, 6, and 12 months.

RESULTS

All children (n=15) were, on average, 10.3 years of age at enrollment, and were fairly evenly distributed with regard to sex. Analyses revealed a significant difference between cases and controls with respect to the change in body mass index from baseline to 12 months (P=0.01). In addition, controls demonstrated a significantly greater increase in moderate-vigorous physical activity than the cases [229.8 metabolic equivalent of tasks (METs) vs. 23.5 METs]; indicating cases remained fairly inactive over the course of treatment.

CONCLUSIONS

Our data corroborate previous findings that following treatment for ALL and lymphoma, childhood cancer survivors tend to be less active and at greater risk for obesity than their healthy peers. The present study, which assessed cases prospectively over a 12-month period during the early phases of treatment, extends prior reports by demonstrating that these outcomes are evident at an early stage in treatment.

Nutritional status and dietary intake of children with acute leukaemia during induction or consolidation chemotherapy

BACKGROUND

The assessment of nutritional status among paediatric patients is important for the planning and execution of nutritional strategies that strive to optimise the quality of life and growth among sick children. The present study aimed to evaluate the nutritional status and dietary intake among children with acute leukaemia.

METHODS

This cross-sectional study included 53 paediatric patients aged 3-12 years old, who were diagnosed with either acute lymphoblastic leukaemia or acute myelogenous leukaemia and were undergoing chemotherapy treatments (induction or consolidation phase). Patients were matched for sex, age (±6 months) and ethnicity with healthy children as controls. Weight, height, body mass index, waist circumference, mid-upper arm circumference, triceps skinfold thickness, mid-upper arm muscle area and fat area were determined. Dietary intake was assessed using 3-day food records.

RESULTS

Anthropometric variables were generally higher among patients compared to controls, although the differences were not statistically significant (P > 0.05). The prevalence of overnutrition among patients according to body mass index-for-age, waist circumference-for-age, mid-upper arm circumference-for-age and triceps skinfold-for-age were 24.5%, 29.1%, 17.0% and 30.2%, respectively. Mean energy [5732 ± 1958 kJ (1370 ± 468 kcal) versus 6945 ± 1970 kJ (1660 ± 471 kcal), P < 0.01], protein (50.0 ± 19.7 g versus 62.3 ± 22.3 g, P < 0.01) and fat (43.6 ± 18.9 g versus 58.3 ± 16.7, P < 0.001) intakes of patients were significantly lower than controls.

CONCLUSIONS

The prevalence of being overweight and obesity in children with acute leukaemia was higher despite lower energy intake compared to controls. Studies assessing physical activity, the complex interaction and the effects of treatment drugs are warranted to better manage malnutrition among paediatric patients.

Physical activity of pediatric patients with acute leukemia undergoing induction or consolidation chemotherapy

This study aimed to assess the physical activity levels of pediatric patients with acute leukemia undergoing chemotherapy. Thirty-eight pediatric patients and matched controls, aged 3-12 years old, were measured for weight, height, and other anthropometric parameters. Physical activity was assessed using actical accelerometer and activity log book. Patients recorded significantly lower mean total activity counts (26.2±30.2 cpm vs. 192.2±68.8 cpm; p<0.01) and spent more time in sedentary activities (1301±121 min vs. 1020±101 min; p<0.001) compared to controls. They also achieved fewer 1-5-min bouts of moderate-vigorous physical activity (MVPA) compared to controls (1.50±5.95 vs. 37.38±40.36; p<0.001). In conclusion, patients had lower physical activity level and intensity; and simple exercise intervention programs may be needed to minimize the detrimental effects of prolonged sedentary behaviors.

Dietary intake after treatment in child cancer survivors

BACKGROUND

Childhood cancer survivors (CCS) are at increased risk of complications such as obesity, diabetes, and osteoporosis which have the potential to, in part, be controlled with dietary interventions. To allow the development of appropriate dietary interventions for younger cancer survivors data on their dietary intake as well as information on parental nutrition views and practices need to be assessed.

PROCEDURE

Dietary intake of 50 CCS was assessed with a 3-day food diary (parent report). Parent child feeding practices were assessed with the Child Feeding Questionnaire (CFQ). Historical and anthropometric data was extracted from medical records. Survivors were less than 13 years old and less than 5 years after treatment completion.

RESULTS

Twenty percent of participating CCS was overweight or obese and 54% were consuming above their estimated energy requirements. Fifty, 32% and 44% of children did not meet requirements for folate, calcium, and iron respectively. There was a significant trend for increasing BMI percentiles from diagnosis to time of assessment (56.29 vs. 67.17, P = 0.01). Results from the CFQ showed that parents were more likely to monitor (3.99) and use a restrictive form of parenting (3.43) to control their child's food intake rather than pressure their child to eat (2.77) (P = 0.001).

CONCLUSION

This group displayed excessive energy intake (kilojoules) and poor dietary habits. Parents' restrictive feeding style may be contributing to these habits. Early interventions targeting the dietary intake of young survivors and associated parent feeding practices may prevent some of the deleterious long-term effects associated with childhood cancer therapy.

Obesity in patients with acute lymphoblastic leukemia in childhood

Acute lymphoblastic leukemia is the most common malignancy in childhood. Continuous progress in risk-adapted treatment for childhood acute lymphoblastic leukemia has secured 5-year event-free survival rates of approximately 80% and 8-year survival rates approaching 90%. Almost 75% of survivors, however, have a chronic health condition negatively impacting on cardiovascular morbidity and mortality. Obesity can be considered one of the most important health chronic conditions in the general population, with an increasing incidence in patients treated for childhood cancers and especially in acute lymphoblastic leukemia survivors who are, at the same time, more at risk of experiencing precocious cardiovascular and metabolic co-morbidities. The hypothalamic-pituitary axis damage secondary to cancer therapies (cranial irradiation and chemotherapy) or to primary tumor together with lifestyle modifications and genetic factors could affect long-term outcomes. Nevertheless, the etiology of obesity in acute lymphoblastic leukemia is not yet fully understood. The present review has the aim of summarizing the published data and examining the most accepted mechanisms and main predisposing factors related to weight gain in this particular population.

Fitness of children with standard-risk acute lymphoblastic leukemia during maintenance therapy: response to a home-based exercise and nutrition program

BACKGROUND

Altered nutrient intake and decreased exercise in response to cancer therapies and their side effects, particularly corticosteroids, may be key factors in the increased body weight and differences in physical fitness reported in survivors of childhood acute lymphoblastic leukemia (ALL).

PURPOSE

To assess (1) the effect of a home-based nutrition and exercise intervention program on cardiovascular fitness, strength, and flexibility in children with ALL during maintenance therapy and (2) the feasibility of conducting and evaluating a home-based exercise and nutrition program in this patient population.

DESIGN

Children ages 4 to 10 years with standard-risk ALL were randomized when starting maintenance therapy to a 12-month home-based exercise and nutrition program (n=6, 3 males/3 females) or control (n=7, 4 males/3 females) group. Assessment of anthropometrics, dietary intake, physical activity, and fitness was performed at baseline and 6 and 12 months of study.

RESULTS

Although age, body size, and nutrient intakes were similar between both subject groups at 0, 6, and 12 months, exercise and nutrition program children had greater improvement in physical activity and cardiovascular fitness between 6 and 12 months than control children.

CONCLUSIONS

These results suggest that a home-based exercise intervention during maintenance therapy encouraged greater physical activity and improved cardiovascular fitness in children with standard-risk ALL. Further investigation involving larger populations of children with ALL is warranted.

Demographic correlates of body size changes in children undergoing treatment for acute lymphoblastic leukemia

INTRODUCTION

While it is known that leukemia therapy is associated with obesity in survivorship, limited information is available on its time-related pattern of development and its variation across patient subgroups. The goal of the present study was to examine demographic correlates of body mass index (BMI) changes over time from diagnosis through chemotherapy for children with B-precursor acute lymphoblastic leukemia (ALL).

METHODS

The study cohort consisted of 307 pediatric patients diagnosed with ALL who were treated at four South Texas pediatric oncology centers between 1990 and 2002. To minimize treatment-related variability, we excluded patients who received cranial irradiation as part of their treatment. Variation in age- and gender-standardized BMI z-scores according to age at diagnosis, gender, and ethnicity were assessed.

RESULTS

The overall study cohort exhibited an increase in age- and gender-adjusted BMI z-scores for the first 24 months of chemotherapy followed by a slight decrease in BMI at 30 months (end of therapy). A repeated measures analysis indicated a statistically significant difference in the time-related pattern of BMI changes for age at diagnosis (P = 0.001) but no significant effect for gender (P = 0.32) or Hispanic versus non-Hispanic ethnicity (P = 0.89).

DISCUSSION

In our cohort of ALL patients, BMI was elevated at diagnosis (mean standardized BMI z-score = 0.22, standard deviation = 1.4) then increased and remained elevated for the entire duration of chemotherapy. Children who were 2-9 years of age at diagnosis began therapy with a substantially lower BMI and remained lower over the course of chemotherapy than patients aged 10-18 years at diagnosis. It will be important for future investigations to explore the biological and behavioral factors that may underlie such differential patterns of BMI change over time.

Epidemiological and physiological approaches to understanding the etiology of pediatric obesity: finding the needle in the haystack

Recent increases in the prevalence of childhood obesity have created an urgent need for preventive strategies, but such strategies in turn depend on an improved understanding of the etiology of pediatric obesity. There is a dearth of evidence of the cause of pediatric obesity at present, with much of the literature of limited quality, inconclusive, and contradictory. The present review highlights the paradox of energy imbalance-its apparent simplicity but actual complexity-and the difficulties in etiologic research that arise from this complexity. The review identifies a number of emerging problems for etiologic studies. The review also makes a number of proposals that might improve future etiologic studies and provides a framework for integrating the diverse body of evidence of etiology that will become available in future. Gathering improved evidence of etiology, and then integrating and interpreting it, will take many years. In the meantime, an emphasis on developing more effective preventive interventions is necessary.

Physical activity during treatment in children with leukemia: a pilot study

The purpose of this pilot study was to measure physical activity (PA) levels in children undergoing treatment for acute lymphoblastic leukemia (ALL) and to compare the results with those from age-matched healthy children. We used the MTI Actigraph accelerometer to determine PA (during a 1 week period) in children (n = 7; age = 4–7 y) undergoing maintenance treatment for ALL and in age-matched controls (n = 7). The number of children accumulating at least 60 min of moderate-to-vigorous physical activity (MVPA) for 5 or more days of the week was 3 for the control group, whereas no children with ALL met this criterion. Significantly lower levels of total weekly time of MVPA were seen in children being treated for ALL (328 ± 107 min) than in controls (506 ± 175 min) (p < 0.05). When weekday data was analyzed, the ALL patients also had significantly lower mean daily times of MVPA (49 ± 23 min vs. 79 ± 25 min). It is thus important that young ALL sufferers are encouraged to participate in appropriate sports, games, and physical activities both in the family and school environments that will prime them with positive attitudes to PA during the critical early years of life.

Potential benefits of physical activity for children with acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) is the most common form of paediatric leukaemia. The survival rate in children with ALL has improved significantly over the past several years, which makes quality of life an important focus for researchers. Some of the side effects of treatment (i.e. osteoporosis and obesity) are not realized until years after conclusion of therapy. Few studies have addressed the impact of physical activity (PA) on the side effects that occur during treatment of children with ALL. This paper discusses the increased risk for both osteoporosis and obesity due to treatment for ALL and suggests ways that PA may attenuate bone loss and risk of obesity by discussing what is known about effects of PA in healthy children and children with other chronic diseases. Recommendations will be made for PA interventions and future research in children with ALL.

Therapy-related changes in body size in Hispanic children with acute lymphoblastic leukemia

BACKGROUND

The objective of this study was to examine changes over time in body mass index (BMI) from diagnosis through chemotherapy for pediatric patients with B-precursor acute lymphoblastic leukemia (ALL).

METHODS

The study cohort consisted of 141 white Hispanic pediatric patients who were diagnosed with ALL and were treated at 2 South Texas pediatric oncology centers between 1993 and 2002. Changes in age-standardized and gender-standardized BMI scores were assessed.

RESULTS

The study cohort exhibited a steady increase in age-adjusted and gender-adjusted BMI scores for the first 12 months of therapy, a modest increase in BMI scores during the 18-23 month and 24-29 month periods, followed by a slight decrease in BMI scores at 30 months (end of therapy). A repeated-measures analysis indicated significant effects for time (P = 0.019) and time by baseline BMI category interaction (P = 0.0001) but no significant interaction effect between time and gender (P = 0.65).

CONCLUSIONS

Although it is known that leukemia therapy is associated with prevalent obesity in survivorship, its pattern of development during therapy has not been elucidated. In the current cohort of Hispanic children with ALL, BMI scores were elevated at diagnosis (mean +/- standard deviation standardized BMI Z score, 0.33 +/- 1.4), then increased, and remained elevated for the entire duration of chemotherapy. Patients who were classified as normal weight exhibited an increase in BMI over time; patients who were classified as overweight at diagnosis exhibited BMI patterns that were relatively stable; and patients who were classified as obese exhibited a very slight decline over time. These findings suggest that the risk for chemotherapy-related weight gain applies predominantly to children who begin ALL therapy within a normal weight range.

Children, cancer, and nutrition--A dynamic triangle in review

The overall cure rate for cancer in childhood now exceeds 70% and is projected to reach 85% by the year 2010 in industrialized countries. Therefore, major attention is being placed on reducing the side effects of therapy. However, 85% of the world's children live in developing countries, where access to adequate care often is limited and health status frequently is influenced adversely by prevalent infectious diseases and malnutrition. Despite several confounding factors (different definitions of nutritional status, the wide variety of measures used for its assessment, the selection biases by disease and stage, treatment protocols of variable dose intensity and efficacy, small sample sizes of the studies conducted in the last 20 years), it is accepted that the prevalence of malnutrition at diagnosis averages 50% in children with cancer in developing countries; whereas, in industrialized countries, it is related to the type of tumor and the extent of the disease, ranging from < 10% in patients with standard-risk acute lymphoblastic leukemia to 50% in patients with advanced neuroblastoma. The importance of nutritional status in children with cancer is related to its possible influence on the course of the disease and survival. Some authors have described decreased tolerance of chemotherapy associated with altered metabolism of antineoplastic drugs, increased infection rates, and poor clinical outcome in malnourished children. In this article, the authors review methods of nutritional assessment and the pathogenesis of nutritional morbidity in children with cancer as well as correlations of nutritional status with diagnosis, treatment, and outcome.

Understanding chronic malnutrition in childhood and old age: role of energy balance research

Undernutrition is commonly associated with chronic disease in children and the elderly. Overnutrition is also, but less commonly, associated with chronic illness. In most diseases malnutrition arises because energy intake does not match energy output. Traditionally, the focus of research has been on abnormalities in energy expenditure, in the belief that these factors were the main determinants of energy imbalance. Recent studies using the doubly-labelled-water method to measure total energy expenditure, combined with more complex study design, have suggested an alternative conclusion. In many chronic diseases patient behaviour, and particularly energy intake, is responsible for energy imbalance and malnutrition. Energy balance studies have therefore provided a useful foundation for the design of strategies aimed at preventing or managing chronic malnutrition. However, modifying patient behaviour is an ambitious undertaking which may not be within the scope of existing clinical nutrition services. A number of non-traditional models of managing chronic malnutrition in children and the elderly are promising. Increasing recognition of the value of systematic review will also provide improved strategies for prevention and management of chronic malnutrition.

Effect of glucocorticoid therapy on energy intake in children treated for acute lymphoblastic leukemia

Despite a widespread belief that glucocorticoid therapy is associated with positive energy balance and excess weight gain there is a dearth of quantitative evidence about its effects and the underlying mechanisms of any effects. The primary aim of the present study was to quantify the effect of dexamethasone and prednisone treatment on energy intake in children treated for childhood acute lymphoblastic leukemia. A secondary aim was to test for differences in excess weight gain between patients treated using the 2 glucocorticoids. We measured energy intake in 26 patients (mean +/- SD age, 6.3 +/- 2.3 yr) during a 5-d period "on" steroids and again in the week before steroid treatment. Changes in body mass index from diagnosis to 1 and 2 yr postdiagnosis were expressed as SD scores. Steroid treatment was associated with a significant increase in energy intake of approximately 20% (mean paired difference, 1.7 MJ/d; SD, 2.8; 95% confidence interval, 0.7-2.8 MJ/d), with no significant difference between the 2 steroids. The mean change in body mass index SD score was +0.38 (SD, 1.10; P < 0.05) to 1 yr and +0.68 (SD, 1.38; P < 0.05) to 2 yr, with no significant difference between the 2 groups of patients. Glucocorticoid treatment in childhood acute lymphoblastic leukemia increases energy intake markedly, and this effect contributes to the excess weight gain and obesity characteristic of patients being treated for acute lymphoblastic leukemia.