Risk factors for excess weight gain in children treated for acute lymphoblastic leukaemia

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.

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.

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.

Comparison of malnutrition and malnutrition screening tools in pediatric oncology patients: A cross-sectional study

OBJECTIVES

The aim of this study was to determine the prevalence of malnutrition, to compare nutritional evaluation tools, and to highlight the importance of nutritional status in pediatric oncology patients.

METHODS

This study evaluated the nutritional status, based on height, weight, and midupper arm circumference, of 170 patients ages 5 months to 18 years who were hospitalized at the Ege University Hospital Pediatric Oncology Clinic. The prevalence of malnutrition was determined using the malnutrition screening tools, STRONGkids (SK) and Pediatric Yorkhill Malnutrition Score (PYMS). Correlations, sensitivity, specificity, and the positive and negative predictive values between the screening tools were calculated.

RESULTS

In all, 68.2% of the patients were diagnosed with a solid tumor. According to SK, 59.4% had a moderate risk of malnutrition, and 40.6% had a high risk. According to PYMS, 30.6% of patients had a low to moderate risk of malnutrition, and 69.4% had a high risk of malnutrition. Minimal agreement was noted between SK and PYMS (Kappa value: 0.40 and 0.18, respectively). The sensitivity of PYMS was higher than that of SK (92.68 and 78.05, respectively). In total, 22.9% of the patients had a body mass index of <5%, and 21.2% had a midupper arm circumference of <5.

CONCLUSIONS

The present findings show that, in general, pediatric oncology patients have a high risk of malnutrition. Although SK and PYMS do not differ significantly, PYMS has higher sensitivity for detecting malnutrition. The nutritional status of pediatric oncology patients should be monitored using appropriate screening techniques throughout their treatment.

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.

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.

Growth patterns of survivors of retinoblastoma treated with ophthalmic artery chemosurgery

Although studies from pediatric cancers (largely acute lymphoblastic leukemia) have shown that patients undergoing systemic chemotherapy may experience decreased growth velocity during the treatment phase, no such data exist for retinoblastoma patients treated with systemic chemotherapy or ophthalmic artery chemosurgery (OAC). The purpose of this study is to report growth patterns of our retinoblastoma (Rb) population who were treated with OAC in a retrospective, single center (Memorial Sloan Kettering Cancer Center) review of 341 patients treated between 2006 and 2016. Children who only received OAC were classified as naive; those who were treated initially with systemic chemotherapy and subsequently presented to our center for OAC were termed secondary; and a small group of patients who received single-agent systemic chemotherapy prior to OAC were labeled bridge. For all patients, height and weight were recorded at monthly intervals during OAC (short-term) and then annually during a follow-up period (long-term) up to 3 years after treatment. Excluded from this study were children who received external radiation therapy and those with genetic syndromes, which are independently associated with growth derangements. During OAC, there was no significant difference in growth velocity between the naïve and secondary groups. In either group, number of treatments also did not affect growth rate. Three years after the end of OAC, naïve patients were in the 68th percentile by height (95% CI 61.30, 74.63) compared to secondary patients in the 61st percentile (95% CI 51.1, 71.47). Both groups were in the same weight percentiles during the first two years of follow-up but at the three-year follow-up period, naïve patients were in the 63rd percentile (95% CI 57.4, 69.4) and secondary patients were in the 60th percentile (95% CI 50.4, 69.7). OAC for retinoblastoma does not appear to impact short-term growth velocity, weight gain during the treatment period or after three years.

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

As previous studies of obesity in survivors of pediatric acute lymphoblastic leukemia (ALL) have primarily been conducted among non-Hispanic white survivors or children treated on older protocols, our objective was to describe the prevalence and correlates of overweight status among an ethnically diverse population of pediatric ALL survivors, largely treated with more contemporary therapies. We evaluated the overweight/obesity status of pediatric ALL survivors (n=406) followed in the Texas Children's Cancer Center between 2004 and 2014. Survivors were classified as underweight, normal weight, overweight, or obese on the basis of their body mass index at their most current follow-up visit. Our results showed that Hispanic ethnicity (39% of the subjects) was associated with being overweight (adjusted odds ratio=1.88; 95% confidence interval, 1.13-3.14) or obese (adjusted odds ratio=2.84; 95% confidence interval, 1.59-5.06) at follow-up, even after adjusting for cranial radiotherapy (CRT) exposure. Body mass index z-score at diagnosis was also associated with overweight/obesity at follow-up. In addition, there was a statistically significant interaction between younger age at diagnosis and CRT, indicating that younger age at diagnosis was associated with obesity among patients who received CRT. These findings may help identify pediatric ALL patients that are at increased risk of being overweight or obese after treatment.

Trajectories of Obesity and Overweight Rates Among Survivors of Childhood Acute Lymphoblastic Leukemia

PURPOSE/OBJECTIVES

To describe the trajectories of obesity/overweight rates by age group among survivors of childhood acute lymphoblastic leukemia (ALL) from diagnosis through several years post-therapy.

DESIGN

Longitudinal, descriptive.

SETTING

Hematology/oncology clinic in the southwestern United States.

SAMPLE

62 child and adolescent ALL survivors receiving treatment and follow-up care from 1999-2013.

METHODS

Retrospective chart review of height, weight, and body mass index.

MAIN RESEARCH VARIABLES

Annual obesity/overweight rates and developmental age groups.

FINDINGS

Different trajectories of obesity/overweight rates existed among age groups. Forty-seven percent of adolescents met the Centers for Disease Control and Prevention criteria for obesity/overweight status at some point following diagnosis, compared to 68% of school-age and 73% of preschool children. Preschool children demonstrated the most rapid rate increase following diagnosis, with a particularly susceptible period in the years immediately following therapy. Obesity/overweight persistence was most characteristic of school-age children.

CONCLUSIONS

Important variations in rate and pattern of weight status trajectories exist by age group, demonstrating that children diagnosed with ALL during the preschool and school-age developmental years have the greatest vulnerability of developing obesity/overweight status.

IMPLICATIONS FOR NURSING

Obesity/overweight prevention efforts are greatly needed in children with ALL, and efforts should occur before ALL treatment completion in preschool and school-age children.

Premature Atherosclerotic Cardiovascular Disease in Childhood Cancer Survivors

Survival rates of childhood cancer have increased over the last 30 years, revealing a population with unique characteristics and risks. The effects of radiation and cardiotoxic chemotherapy predispose these children to both early and late cardiovascular disease. Cranial radiation also increases the likelihood of growth hormone deficiency, which leads to metabolic disturbances. Childhood cancer survivors are less likely to be active than their healthy siblings, and have a lower aptitude for physical activity. These issues are additive to the usual risks experienced by the general population, thereby significantly increasing the likelihood of premature cardiovascular disease. Early and regular screening and risk factor management in this population is recommended.

Growth patterns during and after treatment in patients with pediatric ALL: A meta-analysis

BACKGROUND

Survivors of pediatric acute lymphoblastic leukemia (ALL) have a significantly higher body mass index (BMI) than their peers. Understanding the critical time periods in which patients with pediatric ALL are vulnerable to unhealthy weight gain will lay the groundwork for developing effectively timed interventions.

PROCEDURE

We determined the growth patterns of patients with pediatric ALL during and after treatment through the conduct of a systematic review and meta-analysis. A search of MEDLINE, Scopus, and Web of Science was performed from its inception through May 2014. Studies met the inclusion criteria if they included at least 10 patients of pediatric ALL, and longitudinally assessed BMI at diagnosis and at least one time point after diagnosis

RESULTS

Twenty-one studies met the inclusion criteria for the systematic review and 16 were included in meta-analysis. The mean increase in BMI z-score during treatment in 1,514 patients with pediatric ALL was 0.81 (95% CI: 0.25-1.38). Specifically, patients experienced substantial weight gain in early treatment (Δ = 0.41, 95% CI: -0.34, 1.17) and again during maintenance (Δ = 0.34, 95% CI:-0.22, 0.90). The mean increase in BMI z-score ranged between 0.52 and 0.89 beyond treatment completion. Subgroup analyses found unhealthy weight gain occurred regardless of patients' receipt of cranial radiation therapy, sex, and, weight status at diagnosis.

CONCLUSIONS

Patients with pediatric ALL experience unhealthy weight gain early in treatment, and increases in weight are maintained beyond treatment completion. Preventing early onset of obesity is a priority for improving the care and outcomes for patients with pediatric ALL.

Screening and management of adverse endocrine outcomes in adult survivors of childhood and adolescent cancer

5 year survival for childhood and adolescent cancer in developed countries is now in excess of 80% and the number of survivors of cancer continues to increase worldwide. After completion of therapy, many of these survivors will face a lifelong risk of endocrine late effects. We summarise the available evidence related to the prevalence and risk factors for endocrine late effects among adult survivors of childhood and adolescent cancer. Present screening, surveillance, and treatment recommendations differ by country and region, so we also highlight the continued effort to harmonise the international guidelines for this population.

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

BACKGROUND

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

PROCEDURE

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

RESULTS

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

CONCLUSION

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

Active video games to promote physical activity in children with cancer: a randomized clinical trial with follow-up

Background

Low levels of physical activity, musculoskeletal morbidity and weight gain are commonly reported problems in children with cancer. Intensive medical treatment and a decline in physical activity may also result in reduced motor performance. Therefore, simple and inexpensive ways to promote physical activity and exercise are becoming an increasingly important part of children’s cancer treatment.

Methods

The aim of this study is to evaluate the effect of active video games in promotion of physical activity in children with cancer. The research is conducted as a parallel randomized clinical trial with follow-up. Patients between 3 and 16 years old, diagnosed with cancer and treated with vincristine in two specialized medical centers are asked to participate. Based on statistical estimates, the target enrollment is 40 patients. The intervention includes playing elective active video games and, in addition, education and consultations for the family. The control group will receive a general recommendation for physical activity for 30 minutes per day. The main outcomes are the amount of physical activity and sedentary behavior. Other outcomes include motor performance, fatigue and metabolic risk factors. The outcomes are examined with questionnaires, diaries, physical examinations and blood tests at baseline and at 2, 6, 12 and 30 months after the baseline. Additionally, the children’s perceptions of the most enjoyable activation methods are explored through an interview at 2 months.

Discussion

This trial will help to answer the question of whether playing active video games is beneficial for children with cancer. It will also provide further reasoning for physical activity promotion and training of motor skills during treatment.

Trial registration

ClinicalTrials.gov identifier: NCT01748058 (October 15, 2012).

Obesity in pediatric ALL survivors: a meta-analysis

BACKGROUND AND OBJECTIVE

Previous studies of survivors of pediatric acute lymphoblastic leukemia (ALL) have drawn heterogeneous conclusions regarding the prevalence of obesity and risk factors for developing obesity in pediatric ALL survivors. We sought to determine the prevalence of obesity in pediatric ALL survivors and examine risk factors for obesity through a systematic review and meta-analysis.

METHODS

A MEDLINE search was performed from its inception through 2013. Studies met the inclusion criteria if they (1) included at least 10 survivors of pediatric ALL; (2) assessed the prevalence or indicators of obesity; and (3) compared obesity among ALL survivors to a reference population or external control group. Extracted data included patient and treatment characteristics, study design, population used for comparison, and prevalence of obesity.

RESULTS

Forty-seven studies met the inclusion criteria. Despite significant heterogeneity among the studies (I(2) = 96%), the mean BMI z score in 1742 pediatric ALL survivors was 0.83 (95% confidence interval: 0.60-1.06), which corresponds to the 80th BMI percentile, indicating a significantly higher BMI in pediatric ALL survivors than the reference population. Subgroup analyses found a high prevalence of obesity in ALL survivors regardless of survivors' receipt of cranial irradiation, gender, or age at diagnosis.

CONCLUSIONS

Obesity is prevalent in pediatric ALL survivors and is independent of patient- and treatment-related characteristics. Clinicians need to screen for obesity and its associated health conditions early in survivorship.

Radiation-induced hypopituitarism in children with acute lymphoblastic leukemia

Background:

Acute Lymphoblastic Leukemia (ALL) is the most common malignancy among children for whom radiotherapy and chemotherapy are used for treatment. When hypothalamus-pituitary axis is exposed to radiotherapy, children's hormone level and quality of life are influenced. The aim of this study is to determine late effects of radiotherapy on hormonal level in these patients.

Materials and Methods:

In this study 27 children with ALL, who have been referred to Shahid Ramezanzadeh Radiation Oncology Center in Yazd-Iran and received 18-24 Gy whole brain radiation with Cobalt 60 or 9 MV linear accelerator, were assessed. These patient's basic weight, height and hormonal levels were measured before radiotherapy and also after different periods of time.

Results:

GHD (growth hormone deficiency) after clonidine stimulation test was observed in 44% (n=12) and that in 50% of them (n=6), less than 1 year, had been passed from their radiation therapy. None of these patients demonstrated hormone deficiency in other axes.

Conclusions:

This study showed that even application of a 18-24 Gy radiation dose might influence growth hormone levels; therefore, we recommend reduction of radiotherapy dose in such patients whenever possible.

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.

Malnutrition and obesity in pediatric oncology patients: causes, consequences, and interventions

In children with cancer, suboptimal nutrition states are common consequences of the disease and its treatment. These nutrition states have been attributed to a number of etiologies dependent on the patient's tumor type and treatment, and are associated with increased morbidity and mortality. Interventions vary from psychosocial to pharmacological and surgical management. Further research is necessary to understand the epidemiology and etiology of these nutrition states. Of great importance is the development and implementation of effective interventions to optimize nutritional status among children with cancer during and after therapy.

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.

ICRP publication 118: ICRP statement on tissue reactions and early and late effects of radiation in normal tissues and organs--threshold doses for tissue reactions in a radiation protection context

This report provides a review of early and late effects of radiation in normal tissues and organs with respect to radiation protection. It was instigated following a recommendation in Publication 103 (ICRP, 2007), and it provides updated estimates of 'practical' threshold doses for tissue injury defined at the level of 1% incidence. Estimates are given for morbidity and mortality endpoints in all organ systems following acute, fractionated, or chronic exposure. The organ systems comprise the haematopoietic, immune, reproductive, circulatory, respiratory, musculoskeletal, endocrine, and nervous systems; the digestive and urinary tracts; the skin; and the eye. Particular attention is paid to circulatory disease and cataracts because of recent evidence of higher incidences of injury than expected after lower doses; hence, threshold doses appear to be lower than previously considered. This is largely because of the increasing incidences with increasing times after exposure. In the context of protection, it is the threshold doses for very long follow-up times that are the most relevant for workers and the public; for example, the atomic bomb survivors with 40-50years of follow-up. Radiotherapy data generally apply for shorter follow-up times because of competing causes of death in cancer patients, and hence the risks of radiation-induced circulatory disease at those earlier times are lower. A variety of biological response modifiers have been used to help reduce late reactions in many tissues. These include antioxidants, radical scavengers, inhibitors of apoptosis, anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, growth factors, and cytokines. In many cases, these give dose modification factors of 1.1-1.2, and in a few cases 1.5-2, indicating the potential for increasing threshold doses in known exposure cases. In contrast, there are agents that enhance radiation responses, notably other cytotoxic agents such as antimetabolites, alkylating agents, anti-angiogenic drugs, and antibiotics, as well as genetic and comorbidity factors. Most tissues show a sparing effect of dose fractionation, so that total doses for a given endpoint are higher if the dose is fractionated rather than when given as a single dose. However, for reactions manifesting very late after low total doses, particularly for cataracts and circulatory disease, it appears that the rate of dose delivery does not modify the low incidence. This implies that the injury in these cases and at these low dose levels is caused by single-hit irreparable-type events. For these two tissues, a threshold dose of 0.5Gy is proposed herein for practical purposes, irrespective of the rate of dose delivery, and future studies may elucidate this judgement further.

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.

A cross-sectional study of overweight in pediatric survivors of acute lymphoblastic leukemia (ALL)

BACKGROUND

Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for overweight, predisposing them to long-term morbidity. We examined the relationship between body mass index (BMI) and demographic and lifestyle factors in a cohort of ALL survivors.

PROCEDURE

We enrolled consecutive ALL survivors who attended the institutional AfterCare Clinic over a 1-year period. BMI (kg/m(2) ) at diagnosis, end-therapy, and current time were calculated. Survivors were classified as overweight/obese (overweight group; BMI for age ≥ 85th percentile) or normal/underweight (normal weight group; BMI for age <85th percentile). We assessed the relationship between current BMI and self-reported current caloric intake, physical activity, and sedentary behavior.

RESULTS

102/157 (65%) eligible survivors consented to enrollment. Median age was 14.3 years (range 8.4-18.6) and time from end of treatment 7 years (2.5-15.6). The proportion of overweight survivors was 21%, 45%, and 35% at diagnosis, end-therapy, and current time, respectively. The overweight group reported less calories (Δ324 kcal, P = 0.018), fat (Δ14.5 g, P = 0.02), and carbohydrates (Δ39 g, P = 0.02) than the normal weight group. These differences disappeared after excluding patients classified as under-reporting their calorie intake according to the Goldberg cut-off method. There were no differences in sedentary behavior or activity between groups.

CONCLUSIONS

Many children with ALL gain weight during therapy and fail to return to normal weight after treatment concludes. Subsequent diet, physical activity, and sedentary behavior do not appear to differ between overweight and normal weight survivors. Clinicians should focus on ways to minimize weight gain during therapy rather than waiting for treatment to conclude.

Adverse effects of treatment in childhood acute lymphoblastic leukemia: general overview and implications for long-term cardiac health

Survival of childhood acute lymphoblastic leukemia (ALL) is one of the greatest medical success stories of the last four decades. Unfortunately, childhood ALL survivors experience medical late effects that increase their risk of morbidity and premature death, often due to heart and vascular disease. Research has helped elucidate the mechanisms and trajectory of direct damage to the heart from treatment exposure, particularly to anthracyclines, and has also contributed knowledge on the influences of related chronic conditions, such as obesity and insulin resistance on heart health in these survivors. This article summarizes the key issues associated with early morbidity and mortality from cardiac-related disease in childhood ALL survivors and suggests directions for interventions to improve long-term outcomes.

Important aspects of nutrition in children with cancer

Adequate nutrition during cancer plays a decisive role in several clinical outcome measures, such as treatment response, quality of life, and cost of care. However, the importance of nutrition in children and young adults with malignancies is still an underestimated topic within pediatric oncology. The importance of our work is to reinforce and indicate that malnutrition in children with cancer should not be accepted at any stage of the disease or tolerated as an inevitable process. Unique to our manuscript is the close collaboration, the exchange of knowledge and expertise between pediatric oncologists and a nutritional specialist, as well as the comprehension of the mechanisms during cancer cachexia and malnutrition. We provide a critical review of the current state of research and new knowledge related to nutritional management in childhood cancer.

Characteristics and determinants of adiposity in pediatric cancer survivors

BACKGROUND

Adiposity and the diseases associated with it, including cardiovascular disease, are emerging long-term complications of pediatric cancer survivors. Direct evaluations of adiposity and comparisons to contemporary controls that can differentiate recent trends in obesity from cancer-related treatments and sequelae are limited.

METHODS

We evaluated demographic, treatment, lifestyle, and endocrine factors at the time of dual-energy X-ray absorptiometry testing in 170 non-Hispanic white survivors and 71 sibling controls, and compared three measures of adiposity [body mass index (BMI), total body fat, and trunk fat]. For the survivors alone, we determined factors independently associated with BMI and body fat.

RESULTS

Survivors were at 12 years since diagnosis; 58% had leukemia or lymphoma. BMI did not differ between groups. Among males, body fat was greater in survivors than in controls (25.8% versus 20.7%; P = 0.007), as was trunk fat (26.7% versus 21.3%; P = 0.008). Total or trunk fat did not differ among females. Cholesterol, triglycerides, low-density lipoprotein cholesterol, and television viewing hours were higher among male survivors than in controls. Independent factors associated with higher BMI and total and trunk fat included any cranial radiation and television viewing hours, whereas prior treatment with cyclophosphamide was associated with lower BMI and body fat measures.

CONCLUSIONS

Compared with siblings, male survivors have greater body fat and metabolic risks. Cranial irradiation and television hours are important risk factors for adiposity in pediatric cancer survivors.

IMPACT

Pediatric cancer survivors should be carefully monitored for cardiovascular risk factors and sedentary lifestyles.

Risk factors for the development of obesity in children surviving ALL and NHL

We investigated obesity [body mass index (BMI) >95th percentile] and being heavy (BMI >85th percentile) in 95 children in first remission more than 2 years after treatment for acute lymphoblastic leukemia or non-Hodgkin lymphoma seen at our institution. Height, weight and BMI at diagnosis, end of treatment and follow-up, and blood pressure at diagnosis were adjusted by z-score for age and sex. At follow-up, obesity and overweight were not more prevalent than in the general population. Median BMI z-scores rose significantly between diagnosis (0.38) and treatment end (0.62) but not during follow-up (0.70). Median weight z-scores rose significantly during both periods (diagnosis 0.23, treatment end 0.49, and follow-up 0.68). Median height z-scores were 0.51, 0.14, and 0.16 for the same 3 time points, respectively. Repeated measures, multivariate logistic regression identified Hispanic ethnicity, younger age at diagnosis, and a positive age:weight interaction as being associated with obesity and being heavy at follow-up. There was no association with diagnosis, sex, age alone, radiation dose or field, metabolic diagnosis in patient/family, height z-score at diagnosis, duration of treatment, and systolic or diastolic blood pressure. Obesity and overweight were a combination of weight gain and height loss during treatment although weight continued to increase after treatment. We did not identify disease-related parameters associated with these effects.

Longitudinal changes in obesity and body mass index among adult survivors of childhood acute lymphoblastic leukemia: a report from the Childhood Cancer Survivor Study

PURPOSE

We examined the rate of increase in the body mass index (BMI; kg/m(2)) after final height attainment in survivors of acute lymphoblastic leukemia (ALL) and a noncancer comparison group.

METHODS

Childhood Cancer Survivor Study (CCSS) is a retrospectively ascertained cohort study that prospectively tracks the health status of adults who were diagnosed with childhood cancer between 1970 and 1986 and a comparison group of siblings. Changes in BMI from baseline enrollment to time of completion of follow-up (mean interval, 7.8 years) were calculated for 1,451 ALL survivors (mean age, 32.3 years at follow-up) and 2,167 siblings of childhood cancer survivors (mean age, 35.9 years).

RESULTS

The mean BMI of the CCSS sibling comparison group increased with age (women, 0.25 units/yr, 95% CI, 0.22 to 0.28 units; men, 0.23 units/yr, 95% CI, 0.20 to 0.25 units). Compared with CCSS siblings, ALL survivors who were treated with cranial radiation therapy (CRT) had a significantly greater increase in BMI (women, 0.41 units/yr, 95% CI, 0.37 to 0.45 units; men, 0.29 units/yr; 95% CI, 0.26 to 0.32 units). The rate of BMI increase was not significantly increased for ALL survivors who were treated with chemotherapy alone. Younger age at CRT exposure significantly modified risk.

CONCLUSION

CRT used in the treatment of childhood ALL is associated with a greater rate of increasing BMI, particularly among women treated with CRT during the first decade of life. Health care professionals should be aware of this risk and interventions to reduce or manage weight gain are essential in this high-risk population.

Pediatric obesity in acute and critical care

Pediatric obesity has reached epidemic proportions in the United States. Significant obesity-related comorbidities are being noted at earlier ages and often have implications for the acute and critically ill child. This article will review the latest in epidemiologic trends of pediatric obesity and examine how it affects multisystem body organs. The latest data evaluating the specific effects of obesity on acute and critically ill children will be reviewed. Available nonpharmacologic, pharmacologic, and surgical strategies to combat pediatric obesity will be discussed.

Energy balance and its measurement in childhood disease

Under and overweight, usually secondary to energy imbalance, are common complications of childhood chronic disease. A simple energy balance paradigm has been helpful in understanding the etiology of underweight and overweight in chronic disease, including malignant disease, particularly when measurements of total energy expenditure have been made using the doubly labeled water method. Measurements of energy intake are usually insufficiently accurate and precise to be informative, and measurements of energy expended at rest alone provide an incomplete and potentially misleading assessment of energy expenditure and the causes of energy imbalance. In some diseases, such as acute lymphoblastic leukemia, the natural history and etiology of energy imbalance are now particularly well understood. Recent improvements in our understanding of etiology should lead to improved strategies for the prevention and treatment of underweight and overweight in chronic disease. In some diseases, cachectic processes drive the development of underweight: these are partly independent of energy balance, and strategies for prevention and treatment may require approaches aimed at modifying the cachectic process rather than attempting to modify energy balance directly.

Leptin assessment in acute lymphocytic leukemia survivors: role of cranial radiotherapy?

Leptin has been hypothesized to play a role in the development of obesity in leukemia survivors, particularly those who have received cranial radiotherapy. This cross-sectional study evaluated the relationship between leptin levels and body mass index (BMI) in a sample of 26 acute lymphocytic leukemia survivors of both sexes, treated with and without cranial irradiation, aged 7.6 to 17 years, at a mean 3.4+/-2.0 years off treatment. There were significantly more males among the irradiated group (P<0.001), even though no differences were encountered in pubertal stage (P=1.000), BMI standard deviation score (mean+/-SD) (0.68+/-1.00 vs. 1.19+/-0.78; P=0.164), or leptin concentrations (17.01+/-17.04 vs. 23.3+/-13.4; P=0.309). Nonetheless, there was a positive correlation between the natural logarithm of leptin and BMI standard deviation score [t(22)=2.348, P=0.028], however, no differences were recorded among irradiated and nonirradiated patients [F(2,22)=0.384, P=0.685]. When this relationship was compared between sexes, a significant difference was encountered [F(2,22)=4.907, P=0.017], with males having the strongest association (R(2)males=65.5%, R(2)females=34.7%). Leptin is a reliable adiposity index as it strongly correlates with BMI. Overall, the current data suggest that cranial irradiation did not play a role upon this relationship; however, sex differences influenced positively this correlation.

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.

Long-Term Health Status Among Survivors of Childhood Cancer: Does Sex Matter?

Increasing numbers of children diagnosed with cancer will survive their primary malignancy. Within this growing population of long-term survivors, considerable effort has been put forth to identify treatment-related risks for adverse health-related outcomes, such as exposure to alkylating agents, anthracyclines, radiotherapy, and surgery. Patient sex has been identified as a risk factor for numerous long-term adverse outcomes, with female sex more commonly associated with higher risks. In this article, we review the literature, which generally supports associations between female sex and cognitive dysfunction after cranial irradiation, cardiovascular outcomes, obesity, radiation-associated differences in pubertal timing, development of primary hypothyroidism, breast cancer as a second malignant neoplasm and suggests an increased prevalence for the development of osteonecrosis among females. Results of this review support future investigations to further define sex as a risk factor for other common treatment-specific exposures and outcomes. Additionally, research should focus on understanding the underlying biologic and physiological basis of these sex-specific risks. Historically, evidence from both basic science and clinical research has been used to develop risk-stratified therapy, allowing reduction of toxic therapies to low-risk patients without compromising overall survival. With greater knowledge of sex-specific risks, the potential application of sex-specific therapy designed to avoid poor long-term adverse outcomes may become a viable strategy.

Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

Incidence of obesity does not appear to be increased after treatment of acute lymphoblastic leukemia in Brazilian children: role of leptin, insulin, and IGF-1

BACKGROUND/AIMS

It has been reported that children treated for acute lymphoblastic leukemia (ALL) in developed countries show an increased risk of overweight and obesity in adolescence and adulthood. However, the majority of patients who came to our observation in Brazil have low or normal body weight and only one of them was obese. Therefore, we have decided to assess some biochemical parameters possibly related to the intermediate metabolism and body composition in these patients.

METHODS

Two groups of subjects were studied: 27 survivors of childhood ALL (14.0 +/- 4.2 years old; post-treatment interval 8.6 +/- 3.9 years) (ALL group) and 17 healthy subjects (12.8 +/- 4 years old) (control group) selected on the basis of their kinship with the patients.

RESULTS

14/27 patients of the ALL group and 4/17 of the control group had leptin levels higher than the normal range for age and sex (p < 0.05). The leptin level was significantly higher in the ALL group (15.5 +/- 1.8 ng/ml) than in the control group (10.7 +/- 2 ng/ml) (p < 0.05). When adjusted by sex, BMI z-score, and age, the level of leptin in patients of the ALL group was 8.5 higher than in subjects of the control group (p = 0.006). Leptin/insulin correlation in the ALL group was 0.08 and in the control group it was +0.585 (p < 0.05).

CONCLUSION

The data indicate the presence of alterations in the homeostatic regulatory mechanisms controlling body weight in Brazilian patients treated for ALL in childhood, still, it did not lead to obesity in the absence of favorable environmental conditions.

The late effects of childhood cancer therapy

In this article the difficulties that face survivors of childhood cancer therapy are presented, and the late effects of such therapy, separated into nonmalignant and malignant late effects, are discussed according to organ system. Recommendations for monitoring the late effects are set forth. A table listing radiation-therapy site and chemotherapeutic agents and selected late effects that result from their use is provided. Finally, a brief recommendation regarding the establishment of a late-effects clinic is also presented.

Cardiovascular Risk Reduction in High-Risk Pediatric Patients

Although for most children the process of atherosclerosis is subclinical, dramatically accelerated atherosclerosis occurs in some pediatric disease states, with clinical coronary events occurring in childhood and very early adult life. As with most scientific statements about children and the future risk for cardiovascular disease, there are no randomized trials documenting the effects of risk reduction on hard clinical outcomes. A growing body of literature, however, identifies the importance of premature cardiovascular disease in the course of certain pediatric diagnoses and addresses the response to risk factor reduction. For this scientific statement, a panel of experts reviewed what is known about very premature cardiovascular disease in 8 high-risk pediatric diagnoses and, from the science base, developed practical recommendations for management of cardiovascular risk.

The prevalence of overweight and obesity in pediatric survivors of cancer

OBJECTIVE

To compare the prevalence of overweight in a cohort of pediatric survivors of cancer with that in the general population.

STUDY DESIGN

We reviewed the charts of 441 cancer survivors followed at a Canadian tertiary care pediatric hospital and calculated their most recent body mass index. We compared this cohort with population data generated from the Canadian Community Health Survey.

RESULTS

At a median age of 14.7 years (range, 3.4 to 19.5 years) and a median time from diagnosis of 9.7 years (range, 3.4 to 19.2 years), 140 of 441 patients (31.7%) were overweight or obese. Only 12 of the 441 patients (2.7%) were underweight. Males age 6 to 11 years (odds ratio [OR] = 2.29; 95% confidence interval [CI] = 1.36 to 3.86; P < .001) and male survivors of acute lymphoblastic leukemia (OR = 1.55; 95% CI = 1.03 to 2.52; P = .04) were more likely to be overweight than the general population. No other age or diagnostic group had an increased risk of overweight.

CONCLUSIONS

The prevalence of overweight was not increased in this cohort compared with the general population. However, almost 1/3 of these patients are overweight, necessitating a clinical and research focus on preventing and combating overweight in childhood cancer survivors.

Body composition in children in remission from acute lymphoblastic leukemia

BACKGROUND

Changes in body composition are commonly reported in pediatric survivors of acute lymphoblastic leukemia (ALL). However, the effect of ALL and of its treatment on body composition in children in remission from ALL has not been fully examined with the use of a reference method.

OBJECTIVES

We aimed to determine the body composition and composition of fat-free mass (FFM) in children in remission from ALL. We also aimed to compare the effects that prednisolone and dexamethasone had on the body composition of an ALL survivor population.

DESIGN

This cross-sectional study measured height, weight, body volume, total body water, and bone mineral content in 24 children in remission from ALL and 24 age-matched, healthy control subjects. Body composition and FFM composition were evaluated by using the 4-component model.

RESULTS

The mean body mass index and fat mass index were significantly (P = 0.05 for both) higher in the ALL survivors than in age-matched control subjects. The composition of the FFM in the 2 treatment groups was not observed to differ significantly. Examination of the composition of FFM made it evident that children in remission from ALL had both significantly greater hydration (P = 0.001) and lower density (P = 0.0001) of FFM than did the control children.

CONCLUSIONS

Children in remission from ALL may develop excess body fat. To measure body composition accurately in an ALL population, the high hydration and low density of FFM in this population should be taken into consideration.

Obesity in pediatric oncology

Today's obesity pandemic began in the United States, spread to Western Europe and other developed regions, and is emerging in developing countries. Its influences on outcomes of childhood cancer are unknown. A recent Children's Oncology Group symposium considered epidemiology of obesity, pharmacology of chemotherapy and outcomes in obese adults with cancer, excess mortality in obese pediatric patients with acute myeloid leukemia (AML), and complications in obese survivors. The salient points are summarized herein. Body mass index (BMI) is the accepted index of weight for height and age. In the US, obesity prevalence (BMI > 95th centile) is increasing in all pediatric age groups and accelerating fastest among black and Hispanic adolescents. Pharmacologic investigations are few and limited: half-life, volume of distribution, and clearance in obese patients vary between drugs. Obese adults with solid tumors generally experience less toxicity, suggesting underdosing. For patients undergoing bone marrow transplantation, obese adults generally experience greater toxicity. In pediatric acute myeloblastic leukemia, obese patients have greater treatment-related mortality (TRM), similar toxicity and relapse rates, and inferior survival compared with patients who are not obese. An excess of female survivors of childhood leukemia who received cranial irradiation are obese. Ongoing treatment effects of childhood cancer may predispose to a sedentary lifestyle. These findings call for measures to prevent obesity, retrospective and prospective studies of chemotherapy pharmacology of analyzed according to BMI and outcomes, additional studies of the obesity impact on outcomes in pediatric cancer, and promotion of a healthy lifestyle among survivors.

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.

Steatohepatitis in children

Steatohepatitis in children occurs in the childhood version of non-alcoholic fatty liver disease (NAFLD), as a result of hepatotoxicity and with certain genetic/metabolic diseases. Until recently, NAFLD was considered to be rare in children. It is now recognized as an important childhood liver disease, especially because childhood obesity is much more common. Children with NAFLD may present as young as 4 years old; males tend to predominate; fibrosis is often found on liver biopsy and cirrhosis has been reported. Treatment for childhood NAFLD currently consists of weight reduction plus regular aerobic exercise; vitamin E may be an effective adjunctive therapy. Drug hepatotoxicity and genetic/metabolic diseases that can cause fatty liver, such as Wilson's disease and cystic fibrosis, must be excluded since treatment is radically different. Other causes of chronic hepatitis, such as chronic viral hepatitis, must also be excluded. Multisystemic inherited diseases with hyperinsulinaemia plus insulin resistance may have NAFLD as hepatic involvement and should be identified.

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.