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

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

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

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.

Survivors of standard risk acute lymphoblastic leukemia do not have increased risk for overweight and obesity compared to non-cancer peers: a report from the Children's Oncology Group

BACKGROUND

We sought to determine whether survivors of standard risk ALL (SR-ALL) treated without cranial radiation have increased risk for obesity by assessing changes in body mass index (BMI) during and after treatment; identifying contributing patient and treatment factors; comparing rates of overweight/obese to national health data.

PROCEDURE

Eligibility for this retrospective cohort study included: (i) previous enrollment on legacy therapy trials CCG1922 or CCG1952; (ii) continuous first remission; and (iii) age at follow-up evaluation of 6-16.99 years. Height and weight from diagnosis, consolidation, start of maintenance, last cycle of maintenance, and off-therapy were analyzed.

RESULTS

The 269 subjects were a median age of 3.5 years at diagnosis and 13.3 years at follow-up. BMI% significantly increased from induction to consolidation (+17.6 ± 1.6%), start of maintenance to end-of-treatment (+3.3 ± 1.6%) and decreased from end-of-treatment to follow-up (-3.5 ± 1.6%,). Higher BMI% at follow-up was associated with higher BMI% at diagnosis (P < 0.0001), but not age at diagnosis, gender, or race. Patients previously randomized to dexamethasone had a stronger association between BMI% at diagnosis and BMI% at follow-up than those who received prednisone (P = 0.0005). At follow-up, 39% of survivors were overweight or obese; the relative risk of overweight/obese was 1.028 (P = 0.738) compared to the general population.

CONCLUSIONS

Our study of patients with SR-ALL found a significant increase in BMI% largely during the first month of therapy that is greater with dexamethasone than prednisone. However, after therapy, there was no increased risk of overweight/obese BMI compared to non-cancer peers.

Effects of pediatric cancer and its treatment on nutritional status: a systematic review

CONTEXT

Malnutrition in pediatric cancer is common worldwide, yet its prevalence and effects on clinical outcomes remain unclear.

OBJECTIVE

The aim of this review was to evaluate primary research reporting the prevalence of malnutrition in pediatric cancer patients and to assess the effects of pediatric cancer and its treatment on nutritional status.

DATA SOURCES

Electronic databases of MEDLINE, CINHAL, and PubMed were searched (January 1990-February 2013).

STUDY SELECTION

Studies of patients aged <18 years who were diagnosed with and treated for cancer and for whom measurements of anthropometry were reported and included. The primary outcome was the prevalence of malnutrition (undernutrition and overnutrition), expressed as body mass index (BMI), in children diagnosed with and treated for cancer.

DATA EXTRACTION

Evidence was appraised critically by employing the Critical Appraisal Skills Program tool, and data was extracted from original articles.

DATA SYNTHESIS

A total of 46 studies were included, most of which were considered to be of low quality on the basis of heterogeneity in both the criteria and the measurements used to define malnutrition. Undernutrition was identified by measuring BMI, weight loss, mid-upper arm circumference, and triceps skinfold thickness, while overnutrition was assessed using BMI. Overall, the prevalence of undernutrition ranged from 0% to 65% and overnutrition from 8% to 78%. Finally, undernutrition in pediatric cancer at diagnosis was associated with poor clinical outcomes in 6 of 9 studies.

CONCLUSION

The possibility of a high prevalence of malnutrition in childhood cancer, indicated by the studies reviewed, highlights the need for high-quality, population-based, longitudinal studies using standard criteria to identify malnutrition.

Children and adolescents with ALL are taller than expected at diagnosis

We investigated whether the relative increased height of childhood acute lymphoblastic leukemia (ALL) survivors at diagnosis was due to referral bias, the height of California children, socio-economic status, or race/ethnicity. We reviewed the records of all Pediatric Oncology referrals to our institution from 1988 to 2007. Height at diagnosis, sex, age at and date of diagnosis, date of birth, diagnosis, race/ethnicity, and socio-economic status were evaluated. Heights were standardized by z score from age and sex norms for US children. Of the 883 cases, 180 were excluded (Down syndrome, noncancer diagnosis, data at relapse only, incorrect height measurement, or major growth disturbance). ALL patients were taller than those with other cancers and US children. Age at and date of diagnosis and date of birth had no effect. Whites, boys, and those with private insurance had higher height z scores. Multivariable analysis identified diagnosis and race/ethnicity as significant. ALL children and adolescents were taller and black and Asian children shorter than white children. The mean height increase for those with ALL was 1.3 cm. The reason for the increased height of these patients is unknown, but is not due to referral patterns, having childhood cancer, or the racial/ethnic makeup of California children.

Adapting a Videogame to the Needs of Pediatric Cancer Patients and Survivors

OBJECTIVE

This study assessed whether two serious videogames, "Escape from Diab" (Diab) and "Nanoswarm: Invasion from Inner Space" (Nano) (both from Archimage, Inc., Houston, TX) shown to effect change in healthy children's diet and possibly physical activity are acceptable for obesity prevention among pediatric cancer patients and survivors at high risk of obesity.

PATIENTS AND METHODS

Pediatric (9-12-year-old) cancer patients and survivors (n=28) were randomly assigned to one of three groups: Group A, watched film adaptations of both game stories and played the first two episodes of each game; Group B, played all of Diab; or Group C, played all of Nano. Qualitative interviews about what the children liked and didn't like and what should be changed were conducted midway and at the end of each group's participation. Data were analyzed using thematic analysis.

RESULTS

Pediatric cancer patients and survivors enjoyed playing both games. Two themes emerged to guide future modifications of the game: Three patients reported difficulty with the energy balance and meal selection portion of Nano, and four patients stated endings showing a character dying made them sad.

CONCLUSIONS

Two serious videogames designed to promote healthier diet and increased physical activity among healthy children were also found to be acceptable by pediatric cancer patients and survivors. Easier options needed to be programmed into energy balance games in Nano. To avoid possible emotional reactions, such as sadness, Nano's ending will be revised so that a character does not die from his affliction. Minor changes will be made in other gameplay mechanics and storylines to meet target audience needs and preferences.

Screening survivors of childhood acute lymphoblastic leukemia for obesity, metabolic syndrome, and insulin resistance

Acute lymphoblastic leukemia (ALL) survivors were screened for risk factors of cardiovascular disease. Forty-four ALL survivors in first remission were enrolled. Twenty-six also received 12-18 Gy cranial radiotherapy (RT). Patients' body mass indexes (BMIs) at dignosis and during the study were compared. Metabolic syndrome (MS) evaluation was performed in patients, parents, and siblings older than 6 years. Homeostasis Model Assessment (HOMA) index of the survivors was also calculated. In survivors with impaired fasting glucose levels, oral glucose tolerance test (OGTT) was performed. Thyroid functions and IGF-1 and/or IGFBP-3 levels of the survivors who received cranial RT were evaluated. Median age of the survivors was 11.5 years (6-23). At diagnosis, mean BMI percentile was 46.7 (3-95) and mean z-score was -0.09 ± 1.14; during the study, these values rose to 71.1 ± 25.6 (3-100) and 0.8 ± 0.94, respectively (P < .001). One patient (2.2%) and nine survivors (20%) were obese at diagnosis and during the study, respectively (P = .005). Survivors had significantly higher BMI percentile and BMI z-score compared to their siblings (P = .006 and P = .011, respectively). The study group was small and we could not show a correlation of the patients' obesity with RT, thyroid functions, IGF-1, and IGFBP-3 levels. In three survivors (6.8%), there was MS. Maternal and paternal MS was not found as a risk factor for MS of the survivors (P = .1, P = .5, respectively). The HOMA index revealed insulin resistance (IR) in 12 (27.2%) of the survivors, whereas OGTT revealed abnormal glucose regulation and/or IR in four. As a conclusion, ALL survivors have high risk for obesity and MS.

Endocrine health problems detected in 519 patients evaluated in a pediatric cancer survivor program

CONTEXT

Many pediatric cancer survivors have endocrine conditions. Surveillance for late effects is recommended by national guidelines. Endocrine surveillance is recommended after alkylating agents, steroids, methotrexate, and radiation.

OBJECTIVE

The objective of the study was to describe the endocrine outcomes in patients followed up in a program that uses national screening guidelines.

DESIGN

The design of the study was a medical records review.

SETTING

The study was conducted in the Comprehensive Cancer Survivor Program, an academic pediatric oncology program.

PARTICIPANTS

The study included 519 pediatric and young adult survivors of noncentral nervous system childhood malignancies between January 1, 2001, and December 15, 2005.

INTERVENTION

Patients were evaluated with history, physical examinations, and evaluations recommended in the Children's Oncology Group's Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent and Young Adult Cancers.

OUTCOME MEASURES

The frequency and types of endocrine conditions were measured.

RESULTS

Four hundred eighty endocrine conditions were observed in 299 survivors (57.6% of survivors). The most common types of endocrine conditions were problems with weight and gonadal function. In a Cox regression model, stem cell transplant, radiation, and older age at cancer diagnosis were associated with higher hazard of an endocrine condition. Radiation, stem cell transplant, and sarcoma diagnosis were associated with growth problems.

CONCLUSIONS

Endocrine disorders were common after pediatric cancers. Endocrinologists should be aware of national guidelines, anticipate referral of pediatric cancer survivors, and participate in further research to optimize screening for and treatment of endocrine effects of cancer therapy.

Energy balance: an overview with emphasis on children

Childhood obesity is a significant public health problem, affecting one in five children in the United States. At the crux of this issue is a dysregulation of energy intake and energy expenditure. This review will provide an overview on energy and nutrient balance. We discuss energy balance studies in children using indirect and direct measures, and focus particularly on obesity as a deleterious consequence in childhood survivors of cancer. Obesity affects 11-57% of children with acute lymphoblastic leukemia, probably due to increased energy intake and reduced energy expenditure secondary to reduced habitual activity caused by fatigue. However, most of the studies in children with leukemia are retrospective, use BMI as a measure of obesity, and are inconclusive about the impact of the type of treatment on the development of obesity later in life. To better understand the etiology of obesity in both healthy and sick children, we need to undertake nutrient balance studies with appropriate measures of fat mass and fat distribution while keeping in mind the influence of normal tissue growth and puberty on energy balance.

Body mass index and blood pressure changes over the course of treatment of pediatric acute lymphoblastic leukemia

BACKGROUND

Obesity and hypertension are reported among survivors of pediatric acute lymphoblastic leukemia (ALL). However, little is known about the trajectory of body mass index (BMI) and blood pressure over the course of ALL therapy.

PROCEDURE

In a retrospective cohort of 183 pediatric ALL patients diagnosed from 2000 to 2008, prevalence, severity, and risk factors for obesity and hypertension were assessed during treatment.

RESULTS

At diagnosis, 36% of patients were overweight and 19% were obese. Median BMI increased during induction therapy with a return to baseline soon after, but increased again over the first 22 months of maintenance therapy. At the end of therapy, 49% were overweight and 21% were obese. Increased BMI z-score at diagnosis was associated with increased z-score during maintenance (P < 0.001). Elevated parental BMI was associated with elevated BMI at diagnosis. Median BMI z-score increased over the first 22 months of maintenance (P < 0.001). Patients with high risk disease had lower BMI z-scores regardless of cranial radiotherapy exposure (P < 0.001). Pre-hypertension was prevalent over the course of therapy (31.1% with systolic pre-hypertension and 18.6% with diastolic pre-hypertension). Hypertension was also highly prevalent with 41.5% meeting systolic criteria and 24.0% meeting diastolic criteria.

CONCLUSIONS

During ALL therapy, patients are at risk for early development of elevated BMI and blood pressure, which places them at potentially increased risk for future adverse health conditions. Future studies are needed to develop strategies to mitigate these risks, such as potential reduction of corticosteroid pulses or a family-based diet and exercise intervention during maintenance therapy.