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

Caregiver perceptions of child heath behaviors and weight during treatment for acute lymphoblastic leukemia

BACKGROUND

Changes in health behaviors and weight are common during the early phases of pediatric acute lymphoblastic leukemia treatment, and may negatively impact treatment tolerability. Given that ALL is most prevalent in children, caregivers play an essential role in shaping health behaviors during treatment. This study presents a qualitative analysis of semi-structured interviews with caregivers of youth in the early phases of ALL treatment.

PROCEDURE

Caregivers (N = 17, 95% female) of a child (M age = 6.76 years) diagnosed with ALL and on treatment for less than 1 year (M = 8.7 months since diagnosis) completed a semi-structured interview about perceptions of their child's nutrition, physical activity, sedentary time, and weight during ALL treatment. Thematic analysis followed Braun and Clark's six-step framework (2006). Two coders established reliability (alpha = .88) and used a multi-pass coding system to extract themes.

RESULTS

Caregivers' concerns around their child's weight during ALL treatment primarily centered around avoiding malnutrition. Weight gain during treatment was less of a concern and often viewed as protective. Caregivers reported encouraging their child to eat palatable, calorie-dense foods to mitigate risk for weight loss. Caregivers also expressed concern that children were less active and more sedentary due to treatment-related pain. Caregivers discussed health behaviors during treatment as being child-directed, rather than parent- or provider-directed.

CONCLUSION

Future interventions may consider strategies to engage in joint parent-child decisions and caregiver education around risks of excessive weight gain during treatment. Interventions should include anticipatory guidance and aim to support parents in developing skills to support their child's health behaviors during treatment.

Nutritional assessment and dietary intervention among survivors of childhood cancer: current landscape and a look to the future

Over 85% of childhood cancer patients become long-term survivors. Still, cancer and its therapies are associated with a myriad of long-term complications such that childhood cancer survivors (CCS) endure excess disease burden, morbidity, and mortality throughout their lifetimes. Existing literature suggests that CCS maintain poor dietary intake and nutritional status. Thus, as childhood cancer cure rates continue to improve, the role of diet and nutrition in mitigating many of the most common adverse long-term health outcomes among CCS has gained significant interest. Herein we present an in-depth review of existing scientific literature evaluating dietary intake and nutrition status among CCS and its impact on treatment-related health complications; as well as contemporary intervention strategies aimed at overcoming distinctive barriers and improving deleterious lifestyle behaviors in this heterogeneous, at-risk population. Patient-specific, clinical, and systemic factors act as barriers to the timely conduct of comprehensive dietary/nutritional assessments and provision of tailored, risk-based recommendations. This Mini Review discusses the current state of the science, persisting research gaps, and opportunities for advancement of assessment and intervention strategies to address the unique needs of CCS. Search Strategy: We searched PubMed for peer-reviewed articles with the search terms "pediatric cancer," "pediatric malignancy," "pediatric oncology," "childhood cancer," "survivorship," "cancer late effects," "long-term follow-up," "body mass index," "nutritional status," "malnutrition," "body weight," "body weight changes," "body composition," "obesity," "overweight ", "Mediterranean diet," "DASH diet," "processed foods," "micronutrients," "antioxidants," "vitamin D," "calcium," "selenium," "zinc," "metabolic syndrome," "heart disease," "cardiovascular disease," "cardiometabolic disease," "hypertension," "hyperlipidemia," "HDL," "LDL," and "small dense LDL" from January 1, 1995, to July 21, 2023. We also selected relevant articles from our personal files and from reference lists of identified papers. We prioritized publications after 2013; however, commonly cited and highly regarded (defined by high citation count and journal impact factor) older publications were also included. Randomized controlled trials, observational studies, retrospective studies, meta-analysis, editorials, and review articles were included, whereas conference abstracts and case reports were excluded. We only searched for articles published in English, or those translated into English.

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.

Physical Activity Level and Quality of Life of Children Treated for Malignancy, Depending on Their Place of Residence: Poland vs. the Czech Republic: An Observational Study

This study aimed to assess the level of physical activity (PA) and quality of life of cancer-treated children, depending on their place of residence (Poland vs. the Czech Republic, where incidence and mortality rates of childhood malignancies are similar). A total of 68 school-age children (7-18 years) undergoing oncological treatment were included in this study. This study used the quality of life questionnaire (KIDSCREEN-10) and the HBSC questionnaire. This study showed statistically significant differences in the level of PA between Polish and Czech children. In Poland, 93.75% of children exhibited no weekly physical effort at the level of moderate to vigorous PA. In the Czech Republic, 69.44% of children engaged in PA lasting at least 60 min per day, or at least 1 day weekly. Physically active children engaging in more frequent effort, at least 60 min daily, reported higher physical performance (rho = 0.41), higher energy levels (rho = 0.41), and less mood disturbance (rho = -0.31). Children with good relationships with parents were more likely to engage in submaximal PA and spend less time on stationary games. Our study showed that an appropriate level of PA improves well-being and quality of life. It is crucial to promote attractive PA programs tailored for cancer-treated children.

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.

Unique Features of a Web-Based Nutrition Website for Childhood Cancer Populations: Descriptive Study

Background

Children with cancer experience a myriad of nutritional challenges that impact their nutrition status during treatment and into survivorship. Growing evidence suggests that weight at diagnosis impacts cancer outcomes, but provider guidance on nutrition and diet during treatment varies. Nutrition literacy and culinary resources may help mitigate some common nutritional problems; however, many patients may face barriers to accessing in-person classes. Along with dietitian-led clinical interventions, web-based resources such as the newly updated electronic cookbook (e-cookbook) created by The University of Texas MD Anderson Cancer Center, @TheTable, may facilitate access to nutrition and culinary education during treatment and into survivorship.

Objective

We sought to define and describe the features and content of the @TheTable e-cookbook and compare it with analogous resources for a lay audience of patients with childhood cancer and childhood cancer survivors as well as their families.

Methods

We evaluated freely available web-based resources via a popular online search engine (ie, Google). These searches yielded three web-based resources analogous to @TheTable: the American Institute for Cancer Research’s Healthy Recipes, The Children’s Hospital of San Antonio’s Culinary Health Education for Families Recipe for Life, and Ann Ogden Gaffney and Fred Hutchinson Cancer Research Center’s Cook for Your Life. These sites were analyzed for the following: number of recipes, search functionality, child or family focus, cancer focus, specific dietary guidance, videos or other media, and miscellaneous unique features.

Results

Cook for Your Life and Culinary Health Education for Families Recipe for Life were the most comparable to @TheTable with respect to cancer focus and family focus, respectively. Healthy Recipes is the least user-friendly, with few search options and no didactic videos.

Conclusions

The @TheTable e-cookbook is unique in its offering of child- and family-focused content centered on the cancer and survivorship experience.

Poor Diet Quality in Children with Cancer During Treatment

Background: With improved long-term health outcomes and survivorship, the long-term nutritional management of childhood cancer survivors, from diagnosis to long-term follow-up, has become a priority. The aim of this study was to examine the diet quality of children receiving treatment for cancer. Methods: Participants were parents of children with cancer who were receiving active treatment and not receiving supplementary nutrition. A 24-h dietary recall assessed food and nutrient intake. Serves of food group intakes and classification of core and discretionary items were made according to the Australian Dietary Guidelines and compared with age and sex recommendations. Results: Sixty-four parents participated (75% female). Most children were not consuming adequate intake of vegetables (94% of patients), fruit (77%), and milk/alternatives (75%). Of the vegetables that were consumed, half were classified as discretionary foods (e.g., chips/fries). Nearly half (49%) of children exceeded recommendations for total sugar intake and 65% of patients had an excessive sodium intake. Discussion: Children receiving cancer treatment are consuming diets of reasonable quantity, but poor quality. Information provided during treatment should focus on educating parents on a healthy diet for their child, the importance of establishing healthy eating habits for life, and strategies to overcome barriers to intake during treatment.

Feasibility and Acceptability Findings of an Energy Balance Data Repository of Children, Adolescents, and Young Adults with Cancer

Cancer patients suffer changes in energy balance (EB), the combination of energy intake (nutrition) and energy expenditure (physical activity (PA)), which may influence cancer-related morbidity, mortality, and quality of life. Significant gaps remain in our understanding of the frequency and magnitude of these EB changes. Herein, we report on the feasibility and acceptability of a longitudinal repository of EB outcomes in children, adolescents and young adults (AYA) with cancer along the cancer continuum to fill these gaps. This EB repository includes PA, nutrition, and physical function (PF) parameters. PA data were gathered through activity trackers. Nutritional data were gathered through food diaries and micronutrient labs. PF was assessed with validated objective and patient-reported measures. Feasibility was achieved with >50% enrollment of eligible patients (n = 80, Mage = 18.1 ± 7.5); 26 were children with cancer and 54 were AYAs with cancer. An 88.75% retention rate indicated acceptability. Despite COVID-19 disruptions, >50% of participants provided completed data for PA and micronutrient labs as of April 2020. Food diaries and PF data collection experienced disruptions. Methodological adaptations are in progress to minimize future disruptions. Overall, our findings demonstrate that prospective EB assessments are feasible and acceptable among children and AYAs with cancer.

Children's physical activity behavior following a supervised physical activity program in pediatric oncology

BACKGROUND

The theory of planned behavior (TPB) model and its components have been applied to comprehend the adoption of physical activity along with informational and motivational parameters. Thus, the first aim of this exploratory study was to explore the evolution of children's physical activity levels over a supervised physical activity program. The second aim was to describe the evolution of TPB measures, self-reported fitness and self-esteem in the physical domain to better understand children's physical activity behavior over the course of the physical activity program.

METHODS

A total of 16 children (8 boys and 8 girls) with cancer answered psychosocial questionnaires before and after a supervised physical activity program to explore the TPB measures, self-reported fitness, self-esteem in the physical domain and their daily physical activities.

RESULTS

A significant increase of 13.8 min/day [95% CI (16.7; 10.8); p < 0.0001; d = 1.4] of daily MVLPA was observed between the time before (9.3 ± 9.1 min/day) and after (23.1 ± 10.8 min/day) the physical activity program. We found that the physical activity program positively impacted children's TPB measures (mean in attitude, identity, facilitating factors, self-confidence and intention) and MVLPA levels. The TPB model explained 36.2% of the variance in MVLPA by injunctive norms after the physical activity program.

CONCLUSION

This study highlighted the need to provide children with physical activity support as soon as the cancer is diagnosed and showed that children's physical activity behaviors were facilitated by familial support measured by injunctive norms.

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.

Adherence to Multiple Treatment Recommendations in Adolescents and Young Adults with Cancer: A Mixed Methods, Multi-Informant Investigation

Purpose: This mixed methods study sought to assess adolescent and young adult (AYA) adherence to three cancer treatment recommendations (medications, diet, physical activity), and determine the individual, family, and health system factors associated with suboptimal adherence. Methods: In Stage 1, 72 AYA-caregiver dyads completed a validated adherence interview and surveys about individual and family functioning. Matched providers (n = 34 who reported on 61 AYAs) completed global adherence ratings through survey. In Stage 2, a subset (n = 31) completed qualitative interviews. Results: Medication adherence was higher (M = 94.8%) than diet (M = 73.9%) and physical activity (M = 55.4%), although ≥50% demonstrated "Imperfect Adherence" for each subtask. Univariately, AYAs who missed a medication had more depressive symptoms, worse health-related quality of life (HRQOL), and more medication barriers; their families had more financial stress, worse family functioning, and lower self-efficacy. The odds of adhering to medications were lower with worse HRQOL (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.02-1.15) and family functioning (OR = 0.18; 95% CI, 0.04-0.91). The odds of adhering to physical activity and diet were lower with worse family functioning (OR = 0.09; 95% CI, 0.01-0.91) and more barriers (OR = 0.24, CI: 0.10-0.61), respectively. Qualitative themes further supported multilevel influences on AYA adherence. Conclusions: Adherence challenges were identified across medications, diet, and physical activity. Multilevel contextual factors were associated with suboptimal adherence, including poorer HRQOL and family functioning. Findings support the need to improve clinical adherence assessment and develop contextually tailored interventions.

Poor Dietary Polyphenol Intake in Childhood Cancer Patients

Emerging research demonstrates polyphenol-rich diets like the Mediterranean diet may play a role in improving the outcomes of adult cancer therapy. To date, there are no trials assessing the intake or efficacy of polyphenol-rich diets in childhood cancer patients. In this study we collected dietary data on 59 childhood cancer patients on treatment using a three-pass 24-h dietary recall (24-HDR), which is based on a validated and structured three-part methodology. Polyphenol consumption was calculated by matching the food consumption data with polyphenol content extracted from the most updated Phenol-Explorer database. The mean total polyphenol intake was 173.31 ± 141.02 mg/day. The major food sources of polyphenols were fruits, beverages, and cereals. There were no significant associations with time since diagnosis, body mass index (BMI) z-score, types of cancer, treatment intensity, food-related symptoms, relapse, and total daily polyphenol intake. Further investigation with larger studies will facilitate the steps in assessing the value of polyphenol-rich dietary patterns in future nutritional interventions for childhood cancer patients.

Perceptions of changes in clinical, informational, and supportive relationships after end of treatment among parents of young childhood cancer survivors

BACKGROUND

Parents of childhood cancer patients experience changes in relationships with their health-care team as the child transitions from treatment to long-term survivorship (LTS). These changes may affect parent receptivity of survivorship-health-related programs, yet little is known about the experience of changing clinical relationships for parents as treatment ends and children transition into LTS.

METHODS

In-depth, semistructured interviews were conducted with 20 English-speaking parents of childhood cancer survivors less than 13 years old who were greater than 1-year posttreatment. Audiotaped, transcribed interview content was analyzed using emergent themes grouped and refined in a process of multistaged constant comparison.

RESULTS

There was a consensus among parents regarding the emotional stressors of the period immediately after the end of treatment. Regardless of positive or negative recollection of treatment, parents commonly viewed their health-care team with affection and this period as one of stability and security. Transitioning off treatment was viewed as a severe disruption of the security of weekly, treatment-related contact with nurses, nurse practitioners, physician's assistants, and physicians. LTS was generally viewed as presenting lower levels, but new types of stress as new, psychosocial late effects were seen to emerge. Clinical needs shifted to prevention and late-effect management.

CONCLUSION

Parents of young childhood cancer survivors experience a similar emotional trajectory from treatment to transitioning off treatment and into LTS. This period is seen by parents as uniquely distressing because it represents a disruption of the hard-won safety represented by regular clinical relationships.

Personalized Nutrition in Disrupting Cancer - Proceedings From the 2017 American College of Nutrition Annual Meeting

Cancer is a major public health problem and is the second leading cause of death in the United States and worldwide; nearly one in six deaths are attributable to cancer. Approximately 20% of all cancers diagnosed in the United States are attributable to unhealthy diet, excessive alcohol consumption, physical inactivity, and body fatness. Individual cancers are distinct disease states that are multifactorial in their causation, making them exceedingly cumbersome to study from a nutrition standpoint. Genetic influences are a major piece of the puzzle and personalized nutrition is likely to be most effective in disrupting cancer during all stages. Increasing evidence shows that after a cancer diagnosis, continuing standard dietary recommendations may not be appropriate. This is because powerful dietary interventions such as short-term fasting and carbohydrate restriction can disrupt tumor metabolism, synergizing with standard therapies such as radiation and drug therapy to improve efficacy and ultimately, cancer survival. The importance of identifying dietary interventions cannot be overstated, and the American College of Nutrition's commitment to advancing knowledge and research is evidenced by dedication of the 2017 ACN Annual Meeting to "Disrupting Cancer: The Role of Personalized Nutrition" and this resulting proceedings manuscript, which summarizes the meeting's findings.

Physical training interventions for children and teenagers affected by acute lymphoblastic leukemia and related treatment impairments

A decreased physical fitness has been reported in patients and survivors of acute lymphoblastic leukemia (ALL). This is influenced by the negative effects of the disease and by the treatments of childhood cancer.

In the past, children were advised to recover in bed, and to take as much relax as possible. Nowadays, it is considered that too much immobility may result in a further decrease of physical fitness and functioning. Exercise training for ALL children has frequently been reported to improve physical fitness and the well-being of the children, since it prevents the negative effects of a sedentary life-style, such as obesity and a poor skeletal health. In recent years, different studies and protocols on this subject has become available for children and young adults with cancer, both during and after treatment.

The efficacy of recent physical exercise training interventions, that act on several ALL impairments in children such as skeletal, musculoskeletal, neuromuscular, cardiopulmonary and cardiovascular systems, fatigue, body balance disorders and metabolism alterations have been examined.

These side effects might be prevented or significantly reduced by introducing a physical exercise program during or shortly after cancer treatment. Several interventions are discussed and presented for each impairment, reducing their level caused by the disease and thus suggesting the importance of physical training activity in ameliorating the children quality of life.