Establishing the Use of Body Mass Index as an Indicator of Nutrition Risk in Children With Cancer

Nutritional Screening and Assessment, and Quality of Life in Children with Cancer: A Cross-Sectional Study in Mainland China

PURPOSE

To apply Screening Tool for Risk on Nutritional status and Growth (STRONGkids) and the subjective global nutritional assessment (SGNA) for evaluating nutritional status, to identify the disease-related and demographic-related factors of malnutrition, and to examine the relationship between nutritional status and quality of life (QOL) in children with cancer during chemotherapy in mainland China.

DESIGN AND METHODS

Children, ages 2-18, with a leukemia, lymphoma, or solid tumor diagnosis were recruited from a top cancer center in Guangzhou, China. Socio-demographic information, clinical information were collected, while nutritional status using SGNA, malnutrition risk using STRONGkids, and QOL of these children were measured. Descriptive analyses, Chi²-tests, ANOVA and logistic regression analysis were used to analyze data.

RESULTS

Among included participants, 55.8% of them were malnourished, and 74.2% of them had moderate to high risk of malnutrition. The overall QOL and subscales were associated with nutritional status. In the logistic-regression model, high malnutrition risk, patients' mother having primary school education or less, worse physical functioning quality of life, and lower BMI level were strongly associated with malnutrition.

CONCLUSIONS

The prevalence of malnutrition in children with cancer is high, which related to worse QOL. Patients' BMI, physical functioning QOL and mothers' educational level could help to predict their nutritional status.

PRACTICE IMPLICATIONS

STRONGkids and SGNA could be widely used in mainland China. Health professionals should pay attention to patients with lower BMI and physical functioning scores, and patients' mother having primary school education or less.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association Between Body Mass Index and Motor Competence in Santal Children of Purulia District, India

The purpose of this study was to evaluate the relationship between body mass index and motor competence in Santal children 5-12 years old. A total of 816 Santal children were studied. Children's adiposity status was assessed by body mass index (BMI) for age z-score based on World Health Organization reference data. Motor competence was measured using the Bruininks-Oseretsky Test of Motor Competence (BOT-2). There was no significant difference in mean BMI z-score between Santal boys (0.13 ± 0.07) and girls (-0.14 ± 0.07). Healthy weight (HW) children scored higher (p < .05) in some individual motor subtests (bilateral competence, balance, running speed and agility, upper limb competence, and strength) and in total BOT-2 score (p < .05) compared with scores for underweight (UW) and overweight (OW) children. Nonlinear regression analysis showed that BMI is a significant independent predictor of motor competence (p < .01). Motor competence showed a curvilinear relationship with BMI-z-score, with the lowest point motor scores in strength and upper limb competence (p < .05) for both UW and OW children compared to HW children who scored highest. The results also indicated that gross motor skills, but not fine motor skills, were poorer among children who were UW or OW compared with HW children.

Does body mass index at diagnosis or weight change during therapy predict toxicity or survival in intermediate risk rhabdomyosarcoma? A report from the Children's Oncology Group Soft Tissue Sarcoma Committee

BACKGROUND

Weight loss prevalence and its impact on toxicities and survival in intermediate risk rhabdomyosarcoma (IRMS) patients are unknown. We evaluated the association between weight change during therapy and number of toxicities, hospital days, infections, and overall survival and between baseline body mass index (BMI) and survival in patients treated on Children's Oncology Group trial D9803.

PROCEDURE

Four hundred sixty-eight IRMS patients age ≥2 and <21 years treated on D9803 had required data. Regression models evaluated association between weight loss from baseline and toxicities, hospital days, infections, and survival. Kaplan-Meier curves and regression models evaluated baseline BMI percentile's association with survival.

RESULTS

Thirty-five percent and 37% of patients had >5% weight loss at 12 and 24 weeks, respectively, with 16% and 19% losing >10% weight respectively. Greater than 10% weight loss at 24 weeks was associated with more toxicities and hospital days during subsequent therapy but not infection rate or survival. Baseline underweight patients (<5th percentile BMI) had borderline inferior survival compared with baseline average weight patients while there was no difference in survival seen between average weight and overweight or obese patients.

CONCLUSIONS

Nearly one in five IRMS patients experienced >10% weight loss on therapy. This was associated with increased toxicity but not decreased survival compared with patients who had less weight loss. Baseline BMI percentile trended toward a significant association with survival. Future studies might investigate nutritional impact on quality of life and if weight loss is preventable by early nutritional intervention.

Malnutrition in pediatric patients with cancer at diagnosis and throughout therapy: A multicenter cohort study

BACKGROUND

Malnutrition is a common problem in pediatric patients with cancer. Reported prevalence varies widely and has often been assessed only in a subset of childhood types of cancer. This study aimed to describe the prevalence of malnutrition among pediatric patients newly diagnosed with cancer, to describe the occurrence and course of malnutrition during therapy and to identify factors associated with malnutrition during therapy.

PROCEDURE

In a retrospective cohort study of 327 patients diagnosed from 2003 to 2006 in three Swiss tertiary care hospitals, weight and height measures together with patient-, disease-, and treatment-related characteristics were assessed. Malnutrition was defined as body mass index (BMI) below -2 standard deviation scores (SDS) or a weight loss >10% from diagnosis. Malnutrition was assessed at diagnosis and continuously during anticancer therapy.

RESULTS

At diagnosis, 5.8% of the patients (19) were malnourished based on BMI. During anticancer therapy, the cumulative incidence of malnutrition rose to 22% (70 patients) after 30 days, to 36% (116 patients) after 60 days, and finally to 47% (155 patients). In these 155 patients, the median duration of malnutrition was 60 days (interquartile range, 21-122). Age above 10 years at diagnosis, BMI ≤ -1.0 SDS at diagnosis, and a diagnosis of medulloblastoma were positively associated with a higher proportion of malnutrition time during therapy.

CONCLUSIONS

The rapid increase of malnutrition after the start of treatment underlines the need to develop evidence-based and efficient methods to provide nutritional support for children with cancer.

Nutritional Screening and Early Intervention in Children, Adolescents, and Young Adults With Cancer

Children and adolescents with cancer who receive chemotherapy and/or radiation treatments are at risk for malnutrition due to side effects such as nausea, vomiting, anorexia, and mouth sores. Malnutrition during treatment for childhood cancer increases the risk of infection, decreases tolerance to treatment, and even affects overall survival. A retrospective analysis of 79 children, adolescents, and young adults was conducted to evaluate nutritional screening at baseline and for the first 6 months of treatment. Interventions were also documented. Forty-nine participants had a positive screen for risk of malnutrition. In the patients with a positive screen, 78% had intervention within 24 hours of the identified risk for malnutrition. Thirty-five patients had a nutritional referral, which resulted in a full nutritional assessment and plan. Key independent variables were analyzed to determine if they were associated with an increased risk of malnutrition. In addition, individual risk factors were analyzed to determine their association with malnutrition. Future studies should find whether early intervention is effective in reversing the risk of malnutrition during treatment for childhood cancer.

The relationship between obesity, insulin and arsenic methylation capability in Taiwan adolescents

PURPOSE

This study evaluated the arsenic methylation profile of adolescents and explored the influence of body mass index (BMI) on the arsenic methylation profile of adolescents in an area of Taiwan with no-obvious arsenic exposure.

METHODS

This study evaluated 202 normal weight students and 101 obese students from eight elementary schools, recruited from September 2009 to December 2009. Concentrations of urinary arsenic species, including inorganic arsenic, monomethylarsonic acid (MMA(5+)) and dimethylarsinic acid (DMA(5+)) were determined by a high-performance liquid chromatography-linked hydride generator and atomic absorption spectrometry.

RESULTS

Urinary total arsenic was significantly decreased with increasing BMI, indicating that obese children may retain higher levels of arsenic in the body, as compared to normal weight children. Participants with obesity accompanied by high insulin levels had higher inorganic arsenic, significantly higher MMA percentage and significantly lower DMA percentage than those with obesity and low insulin levels. It seems children with obesity and high insulin levels had lower arsenic methylation capacity than those with obesity and low insulin.

CONCLUSIONS

This is the first study to demonstrate that total urinary arsenic is negatively associated with the BMI in adolescents in Taiwan, adjusted for age and sex. Obese adolescents with high insulin levels had significantly higher MMA% and significantly lower DMA% than obese adolescents with low insulin.

Hormonal, hypothalamic and striatal responses to reduced body weight gain are attenuated in anorectic rats bearing small tumors

Lack of compensatory or even reduced food intake is frequently observed in weight-losing cancer patients and contributes to increased morbidity and mortality. Our previous work has shown increased transcription factor expression in the hypothalamus and ventral striatum of anorectic rats bearing small tumors. mRNA expression of molecules known to be involved in pathways regulating appetite in these structures was therefore assessed in this study. Given that pain, pro-inflammatory cytokines and metabolic hormones can modify food intake, spinal cord cellular activation patterns and plasma concentrations of cytokines and hormones were also studied. Morris hepatoma 7777 cells injected subcutaneously in Buffalo rats provoked a 10% lower body weight and 15% reduction in food intake compared to free-feeding tumor-free animals 4 weeks later when the tumor represented 1-2% of body mass. No differences in spinal cord activation patterns or plasma concentration of pro-inflammatory cytokines were observed between groups. However, the changes in plasma ghrelin and leptin concentrations found in food-restricted weight-matched rats in comparison to ad libitum-fed animals did not occur in anorectic tumor-bearing animals. Real-time PCR showed that tumor-bearing rats did not display the increase in hypothalamic agouti-related peptide mRNA observed in food-restricted weight-matched animals. In addition, microarray analysis and real-time PCR revealed increased ventral striatal prostaglandin D synthase expression in food-restricted animals compared to anorectic tumor-bearing rats. These findings indicate that blunted hypothalamic AgRP mRNA expression, probably as a consequence of relatively high leptin and low ghrelin concentrations, and reduced ventral striatal prostaglandin D synthesis play a role in maintaining cancer-associated anorexia.

Avaliação e monitoramento do estado nutricional de pacientes hospitalizados: uma proposta apoiada na opinião da comunidade científica

OBJETIVO: A desnutrição pode afetar adversamente a evolução clínica de pacientes hospitalizados e aumentar o tempo de permanência hospitalar. O objetivo deste estudo foi certificar critérios para avaliação e acompanhamento do estado nutricional de pacientes hospitalizados aceitos pela comunidade de pesquisadores, docentes e profissionais da área de nutrição clínica. MÉTODOS: Com este propósito aplicou-se um questionário via Internet, à comunidade científica, cadastrada na Plataforma Lattes - sistema nacional de cadastro curricular unificado on-line -, para apoiar atividades de fomento de agencias federais e estaduais. O questionário é composto de recomendações acompanhadas por uma escala Likert e espaços para justificativas dos participantes em relação à opção de aceitação parcial ou discordância do procedimento proposto. Foi considerado aprovado o procedimento que teve concordância total ou parcial maior ou igual a 70,0%. RESULTADOS: Responderam ao questionário 35,2% dos profissionais contatados. A maioria (84,0%) era professor universitário, sendo 62,0% de universidade pública; 67,0% eram doutores; 63,0% tinha mais de 20 anos de formado; 74,0% eram nutricionistas e 25,0% médicos. Os procedimentos propostos versam sobre as seguintes necessidades: triagem para definição de complexidade da atenção nutricional, indicadores de avaliação e monitoramento nutricional durante a internação e equipamentos e protocolos para o atendimento nutricional. Todos os procedimentos foram aceitos pelos entrevistados. Foi proposto pelos autores um modelo de triagem para definição da complexidade do atendimento nutricional, considerando os procedimentos aceitos. CONCLUSÃO: A aceitação dos procedimentos propostos fortalece o reconhecimento da necessidade de implantação de padrões para a avaliação e monitoramento nutricional nas instituições hospitalares.

Classification of malnutrition in cystic fibrosis: implications for evaluating and benchmarking clinical practice performance

BACKGROUND

In 2005, the Cystic Fibrosis Foundation (CFF) revised the nutrition classification guidelines to eliminate the use of percentage of ideal body weight (%IBW) to define "nutritional failure"; the CFF also recommended that children with cystic fibrosis maintain a body mass index percentile (BMIp) > or = 50th.

OBJECTIVE

We assessed the effect of the 2005 CFF nutrition classification guidelines on evaluating the performance of nutritional care practices.

DESIGN

Data from 14,702 children reported to the 2002 CFF Patient Registry were analyzed to compare malnutrition rates in 113 cystic fibrosis centers in the United States. Nutritional failure was defined according to the 2002 CFF criteria--ie, height < 5th percentile, %IBW < 90%, or BMIp < 10th. "Below BMI goal" was defined according to the 2005 CFF criterion, ie BMIp < 50th.

RESULTS

Eliminating %IBW resulted in a 6% reduction (from 33% to 27%) in the nutritional failure rate in the United States. The use of BMIp < 50th led to the classification of 57% of children as below the BMI goal. Misclassification of nutritional failure according to %IBW ranged from 1% to 16% among 113 centers and was greater in the centers with a larger proportion of tall patients. After the elimination of %IBW, one-third of centers changed to a different tertile ranking for nutritional failure rates (kappa = 0.50, moderate-to-poor agreement). More than half the centers changed to a different tertile ranking, from nutritional failure to below BMI goal (kappa = 0.22, poor agreement).

CONCLUSION

Eliminating misclassification by %IBW and implementing the new BMI goal led to profound and unequal changes in malnutrition rates across cystic fibrosis centers.

Validation of percent body fat indicators in pediatric oncology nutrition assessment

BACKGROUND

Given the high prevalence of malnutrition and potential impact nutritional status can have on a child undergoing treatment for cancer, it is vital that oncology centers regularly assess nutritional status. It is important that simple noninvasive anthropometric nutrition assessment measures correlate to more accurate body composition measures.

OBJECTIVES

The aim of this study was to determine the relationship between anthropometric measures and percent body fat determined via air displacement plethysmography in the children being treated in a pediatric oncology and hematology department.

DESIGN

This cross-sectional study measured height, weight, percent ideal body weight (%IBW), mid arm circumference, triceps skinfolds, and mid upper arm fat area in 23 children. These anthropometric variables were compared against the reference measure of percent body fat via air displacement plethysmography.

RESULTS

Correlational analysis and general linear models showed that there was a significant statistical relationship between percent body fat and body mass index Z score, %IBW, mid arm circumference, triceps skinfolds, and arm fat area.

CONCLUSIONS

Simple anthropometric measurements of %IBW and triceps skinfolds are good indicators of percent body fat and should be incorporated into regular nutrition assessment of the pediatric oncology patient.