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

Nutritional status, body composition and diet quality in children with cancer

During cancer treatment, nutritional status disorders such as malnutrition or obesity affect the tolerance of cancer treatment, quality of life, but also the pharmacokinetics of drugs. It is hypothesized that changes in fat and lean body mass can modify chemotherapy volume distribution, metabolism and clearance. In children with cancer, lean body mass decreases or remains low during treatment and fat mass increases. Body composition is influenced by the cancer itself, aggressive multimodal-therapies, changes in metabolism, unbalanced diet and reduced physical activity. Due to the side effects of treatment, including changes in the sense of taste and smell, nausea, vomiting, diarrhea, and stress, eating according to recommendation for macronutrients and micronutrients is difficult. Research indicates that throughout cancer treatment, the consumption of fruits, vegetables, and dairy products tends to be insufficient, whereas there is an elevated intake of sugar and unhealthy snacks. Children exhibit a preference for high-carbohydrate, salty, and strongly flavored products. This review revealed the importance of body composition and its changes during cancer treatment in children, as well as eating habits and diet quality.

Nutritional status and appetite-regulating hormones in early treatment of acute lymphoblastic leukemia among children and adolescents: a cohort study

BACKGROUND

Children with acute lymphoblastic leukemia are at risk of malnutrition, but few studies have described the changes in nutritional status during the different phases of chemotherapy.

OBJECTIVE

To evaluate changes in nutritional status, food intake and appetite-regulating hormones among children and adolescents with acute lymphoblastic leukemia in the first phase of chemotherapy.

DESIGN AND SETTING

Cohort study developed in the pediatric oncology departments of two hospitals in the city of Natal, Rio Grande do Norte, Brazil.

METHODS

Fourteen children/adolescents (mean age of 7 years; 50% female) with acute lymphoblastic leukemia were monitored over the 28 days of an induction chemotherapy cycle. Anthropometric measurements, 24-hours food weight records and appetite-regulating hormone levels (ghrelin, leptin, insulin and cortisol) were obtained at three different times (before, in the middle and at the end of the induction phase).

RESULTS

Most of the patients (85.7%) had normal weight at the beginning of the treatment, and this did not change significantly during the 28 days. Energy and nutrient intakes improved from the start of the treatment to the midpoint, according to the ghrelin levels (from 511.1 ± 8.3 to 519.3 ± 6.6 pg/ml; P = 0.027). Other appetite-regulating hormones did not present changes.

CONCLUSION

Food consumption improves during the first phase of treatment, without alterations in anthropometric nutritional status.

The effects of chemotherapy on energy metabolic aspects in cancer patients: A systematic review

BACKGROUND & AIMS

Cancer survival rates have increased significantly creating more awareness for comorbidities affecting the Quality of Life. Chemotherapy may induce serious metabolic alterations. These complications can create an energy imbalance, worsening prognosis. The effect of chemotherapy on energy metabolism remains largely unknown. The purpose of this systematic review is to determine the impact of chemotherapy on energy metabolism, creating more insight in a patients' energy requirements.

METHODS

We identified relevant studies up to May 2nd, 2019 using PubMed and Web of Science. Studies including all types of cancer and stages were selected. Only patients that underwent chemotherapy whether or not followed by surgery or radiotherapy were selected. Maximum follow-up was set at 6 months. Resting energy expenditure (REE), measured by indirect calorimetry (IC) or predicted by the Harris-Benedict equation (HB_Eq), was our primary outcome. Results regarding body composition were considered as secondary outcome parameter.

RESULTS

16 studies were selected, including 267 patients. Overall, a significant decrease in REE [-1.5% to -24.91%] 1-month post-chemotherapy was reported. Two studies on breast cancer conducted a 3 and 6-month follow-up and found an increase in REE of 4.01% and 5.72% (p < .05), revealing a U-shaped curve in the expression of REE. Changes are accompanied by (non)significant variations in body composition (Fatmass (FM) and Fatfree Mass (FFM)). HB_Eq tends to underestimate REE by 4.03%-27.1%.

CONCLUSION

Alterations in REE, accompanied by changes in body composition, are found during and after chemotherapy in all cancer types and stages, revealing a U-shaped curve. Changes in FFM are suggested to induce variations in REE concomitant to catabolic effects of the disease and administered drug. HB_Eq tends to underestimate REE, stressing the need for adequate assessment to meet patients' energy requirements and support dietary needs.

Overweight and obesity as predictors of early mortality in Mexican children with acute lymphoblastic leukemia: a multicenter cohort study

BACKGROUND

Mexico City has one of the highest incidences and mortality rates of acute lymphoblastic leukemia (ALL) in the world and a high frequency of early relapses (17%) and early mortality (15%). Otherwise, childhood overweight and obesity are reaching epidemic proportions. They have been associated with poor outcomes in children with ALL. The aim of present study was to identify if overweight and obesity are predictors of early mortality and relapse in Mexican children with ALL.

METHODS

A multicenter cohort study was conducted. ALL children younger than 15 years old were included and followed-up during the first 24 months after diagnosis. Overweight and obesity were classified according World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) criteria. Early mortality and early relapses were the main outcomes.

RESULTS

A total of 1070 children were analyzed. Overweight/obesity at diagnosis were predictors of early mortality (WHO: HR = 1.4, 95%CI:1.0-2.0; CDC: HR = 1.6, 95%CI:1.1-2.3). However, no associations between overweight (WHO: HR = 1.5, 95%CI:0.9-2.5; CDC: HR = 1.0; 95% CI:0.6-1.6) and obesity (WHO: HR = 1.5, 95%CI:0.7-3.2; CDC: HR = 1.4; 95%CI:0.9-2.3) with early relapse were observed.

CONCLUSIONS

Overweight and obese patients embody a subgroup with high risk of dying during leukemia treatment.

Food habits during treatment of childhood cancer: a critical review

Several factors can affect the nutritional status of children undergoing cancer therapy. The present review aims to describe children’s food intake during cancer treatments and to explore the contributing determinants. It also assesses the nutritional educational interventions developed for this clientele. Scientific literature from January 1995 to January 2018 was searched through PubMed and MEDLINE using keywords related to childhood cancer and nutritional intake. Quantitative and qualitative studies were reviewed: forty-seven articles were selected: thirty-eight related to food intake and parental practices and nine related to nutritional interventions. Patients’ intakes in energy, macronutrients and micronutrients were compared with those of healthy controls or with requirement standards. Generally, patients ate less energy and proteins than healthy children, but adhered similarly to national guidelines. There is a lack of consensus for standard nutrient requirement in this population and a need for more prospective evaluations. Qualitative studies provide an insight into the perceptions of children, parents and nurses on several determinants influencing eating behaviours, including the type of treatment and their side effects. Parental practices were found to be diverse. In general, savoury and salty foods were preferred to sweet foods. Finally, most interventional studies in childhood cancer have presented their protocol or assessed the feasibility of an intervention. Therefore, because of the variability of study designs and since only a few studies have presented results, their impact on the development of healthful eating habits remains unclear. A better understanding of children’s nutritional intakes and eating behaviours during cancer treatment could guide future nutritional interventions.

Dietary intake and diet quality in children receiving treatment for cancer

This narrative synthesis aims to examine the dietary intake, diet quality, and dietary preferences of pediatric cancer patients during cancer treatment. Thirteen studies were eligible for review. Studies mostly investigated nutrient intake, with 7 reporting on children's food intake. There was consensus among studies, which reported suboptimal fruit and vegetable intake and a preference for savory, carbohydrate-based foods. Results suggest that pediatric cancer patients consume a limited variety of foods, with a high intake of noncore foods. Future research should aim to examine dietary food data against dietary guidelines to assess adequacy and variety within core food groups.

A prospective study on changes in body composition and fat percentage during the first year of cancer treatment in children

BACKGROUNDS/OBJECTIVES

Cancer treatment may lead to significant body composition changes and affect growth and disease outcomes in pediatric cancer patients. This prospective study aimed to evaluate short- and long-term body compositions changes focused on body fat during the first year of cancer treatment in children.

SUBJECTS/METHODS

A prospective study was conducted in 30 pediatric cancer patients (19 hematologic malignancies and 11 solid tumors) and 30 age- and sex-matched healthy controls. Anthropometric measurements and body composition analysis using whole body dual energy X-ray absorptiometry were performed at baseline and 1, 6, and 12 month(s) of cancer treatment. Kruskal-Wallis tests, Wilcoxon paired t tests, and generalized estimation equation (GEE) were applied for statistical analysis.

RESULTS

At baseline, no differences in weight, height, body mass index, abdominal circumferences, body fat, and fat-free mass were observed between 30 controls and 30 pediatric cancer patients. Total fat mass (P < 0.001) and body fat percentage (P = 0.002) increased significantly during the first month, but no changes were observed from 1 to 12 months; however, no changes in the total mass were observed during the first year of cancer treatment. Meanwhile, the total fat-free mass decreased during the first month (P = 0.008) and recovered between 6 and 12 months of follow-up (P < 0.001). According to GEE analysis, there was a significant upward trend in body fat percentage during the first year, especially the first month, of cancer treatment in children with hematologic malignancies, but not in those with solid tumors.

CONCLUSIONS

Our results indicate that cancer treatment is related to significant body composition changes and rapid body fat gain, particularly during the first month after initiating cancer treatment, in children with hematologic malignancies. Therefore, individualized dietary strategies to prevent excessive fat gain are needed in pediatric cancer patients for better outcomes.

Limitations of body mass index to assess body composition due to sarcopenic obesity during leukemia therapy

Obesity as defined by body mass index percentile (BMI%) is strongly associated with relapse and poorer survival in childhood ALL. Whether BMI% accurately reflects body fat percentage (BF%) in this population is unknown. We conducted a prospective study assessing body composition during frontline ALL therapy. Dual-energy X-ray absorptiometry measured BF% and lean muscle mass (LMM) at diagnosis, end of Induction, and end of Delayed Intensification. Sarcopenic obesity (gain in BF% with loss of LMM) was surprisingly common during ALL treatment, resulting in poor correlation between changes in BMI% (expressed as Z-score) and BF% overall (r = -0.05) and within patients (r = -0.09). BMI Z-score and BF% changed in opposite directions in >50% of interval assessments. While BMI% at diagnosis is a suitable predictor of obesity/BF% for epidemiological studies, change in BMI% (as expressed as Z-score) does not reflect body composition. Studies evaluating obesity in leukemia should consider using direct measures of body composition.

Application of Glutamine-enriched nutrition therapy in childhood acute lymphoblastic leukemia

BACKGROUND

We investigated the effects of glutamine (Gln)-enriched nutritional therapy during chemotherapy on the nutritional status and immune function of children with acute lymphoblastic leukemia (ALL).

METHODS

We enrolled 48 children who were newly diagnosed with ALL in our department during the period of 2013.1-2014.12. The patients (follow random number table) were randomly divided into the control group (peptamen) and the treatment group (peptamen + glutamine), 24 cases in each group. The remission induction regimens were all based on VDLP (D) chemotherapy (VCR (Vincrisstine), DNR (Daunomycin), L-ASP (L-Asparagiase), Prednisolone and Dexamethasone). The treatment group received Gln-enriched nutritional therapy every day during the full course of chemotherapy,and the control group is as same as the treatment group except without glutamine. The indicators of general nutritional status, such as weight, height, and triceps skinfold thickness, and the indicators of biochemical tests, such as serum albumin, prealbumin, creatinine-height index, retinol binding protein, and urinary hydroxyproline index, were compared between the two groups at the end of the first, second, third and the fourth week when the chemotherapy was completed. And in the fourth week, flow cytometry was applied to detect the levels of T cell subsets and the activities of natural killer (NK) cells in peripheral blood of the two groups.

RESULTS

1. after 4 weeks nutritional therapy, there is no significant difference (p > 0.05) between the two groups of children in weight, height and other indicators. 2. At the end of 2 weeks treatment, the level of prealbumin (PA) and retinol-binding protein (RBP) is higher in treatment group than that in the control group (P <0.05), at the end of 3 weeks treatment, the thickness of triceps skinfold is higher (P <0.05) than that in the control group; 3. At the end of 3 and 4 weeks, the concentrations serum ALB, PA, RBP and UHI were higher than in the control group (P <0.05); 4. There is statistically significant (p < 0.05) between the two groups in edema incidence; 5. At the end of treatment (4 weeks), the percentages of CD3 +, CD4 +, CD4 +/CD8 +, NK cell are significantly decreased in the two groups (P <0.05).

CONCLUSION

Gln-enriched nutritional therapy can effectively improve the systemic nutritional status of children with leukemia, improve immune function.

Dietary Protein Intake and Lean Muscle Mass in Survivors of Childhood Acute Lymphoblastic Leukemia: Report From the St. Jude Lifetime Cohort Study

BACKGROUND

Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for low lean muscle mass and muscle weakness, which may contribute to inactivity and early development of chronic diseases typically seen in older adults. Although increasing protein intake, in combination with resistance training, improves lean muscle mass in other populations, it is not known whether muscular tissue among survivors of ALL, whose impairments are treatment-related, will respond similarly.

OBJECTIVE

The aim of this study was to evaluate associations among dietary protein intake, resistance training, and lean muscle mass in survivors of ALL and age-, sex-, and race-matched controls.

DESIGN

This was a cross-sectional study.

METHODS

Lean muscle mass was determined with dual-energy x-ray absorptiometry, dietary information with 24-hour recalls, and participation in resistance training with a questionnaire. Participants were 365 survivors of ALL (52% male; 87% white; median age=28.5 years, range=23.6-31.7) and 365 controls with no previous cancer.

RESULTS

Compared with controls, survivors of ALL had lower lean muscle mass (55.0 versus 57.2 kg, respectively) and lower percentage of lean muscle mass (68.6% versus 71.4%, respectively) than controls. Similar proportions of survivors (71.1%) and controls (69.7%) met recommended dietary protein intake (0.8 g/kg/d). Survivors (45.4%) were less likely to report resistance training than controls (53.8%). In adjusted models, 1-g higher protein intake per kilogram of body mass per day was associated with a 7.9% increase and resistance training ≥1×wk, with a 2.8% increase in lean muscle mass.

LIMITATIONS

The cross-sectional study design limits temporal evaluation of the association between protein intake and lean muscle mass.

CONCLUSIONS

The findings suggest that survivors of childhood ALL with low lean muscle mass may benefit from optimizing dietary protein intake in combination with resistance training. Research is needed to determine whether resistance training with protein supplementation improves lean muscle mass in survivors of childhood ALL.

Metabolomics identifies the intersection of phosphoethanolamine with menaquinone-triggered apoptosis in an in vitro model of leukemia

Altered metabolism is increasingly acknowledged as an important aspect of cancer, and thus serves as a potentially fertile area for the identification of therapeutic targets or leads. Our recent work using transcriptional data to predict metabolite levels in cancer cells led to preliminary evidence of the antiproliferative role of menaquinone (vitamin K2) in the Jurkat cell line model of acute lymphoblastic leukemia. However, nothing is known about the direct metabolic impacts of menaquinone in cancer, which could provide insights into its mechanism of action. Here, we used metabolomics to investigate the process by which menaquinone exerts antiproliferative activity on Jurkat cells. We first validated the dose-dependent, semi-selective, pro-apoptotic activity of menaquinone treatment on Jurkat cells relative to non-cancerous lymphoblasts. We then used mass spectrometry-based metabolomics to identify systems-scale changes in metabolic dynamics that are distinct from changes induced in non-cancerous cells or by other chemotherapeutics. One of the most significantly affected metabolites was phosphoethanolamine, which exhibited a two-fold increase in menaquinone-treated Jurkat cells compared to vehicle-treated cells at 24 h, growing to a five-fold increase at 72 h. Phosphoethanolamine elevation was observed prior to the induction of apoptosis, and was not observed in menaquinone-treated lymphoblasts or chemotherapeutic-treated Jurkat cells. We also validated the link between menaquinone and phosphoethanolamine in an ovarian cancer cell line, suggesting potentially broad applicability of their relationship. This metabolomics-based work is the first detailed characterization of the metabolic impacts of menaquinone treatment and the first identified link between phosphoethanolamine and menaquinone-induced apoptosis.

Body composition of children with cancer during treatment and in survivorship

BACKGROUND

Malnutrition as assessed with the use of body-composition measurements is a poorly understood short- and long-term complication of childhood cancer.

OBJECTIVES

We aimed to evaluate the body composition of 2 childhood cancer cohorts as follows: 1) children currently undergoing cancer treatment and 2) childhood cancer survivors. We also aimed to compare the prevalence of obesity and undernutrition between the cancer groups and investigate the impact of cancer type on body composition.

DESIGN

Eighty-two children during the treatment of cancer and 53 childhood cancer survivors were involved in the study. Height, weight, body cell mass, percentage of fat, fat mass index, and fat-free mass index were assessed. Subjects were compared with age- and sex-matched healthy controls.

RESULTS

The on-treatment group had a higher percentage of fat (P = 0.0001) and fat mass index (P = 0.0001) and a significantly lower body cell mass index (P = 0.0001) and fat-free mass index (P = 0.003) than did matched controls. The survivor group had a significantly higher percentage of fat (P = 0.03) and fat mass index (P = 0.04) and significantly lower body cell mass index (P = 0.0001) than did matched controls. The prevalence of undernutrition was high in both groups with 48% (95% CI: 36%, 60%) of the on-treatment group and 53% (95% CI: 40%, 66%) of the survivors considered undernourished. According to the percentage of fat cutoffs, significantly more on-treatment patients were obese (55%; 95% CI: 40%, 60%) than were survivors (26%; 95% CI: 14%, 38%) (P = 0.005). There were no statistically significant differences in body composition between cancer types in either the on-treatment or the survivor group.

CONCLUSIONS

Overnutrition and undernutrition are major concerns in the short and long term for children with cancer. Children treated for cancer have increased fat mass and decreased body cell mass, which are evident during treatment and in survivorship. This trial was registered at http://www.ANZCTR.org.au as ACTRN12614001279617 and ACTRN12614001269628.

Skeletal, neuromuscular and fitness impairments among children with newly diagnosed acute lymphoblastic leukemia

This study describes skeletal, neuromuscular and fitness impairments among 109 children (median age 10 [range 4-18] years, 65.1% male, 63.3% white) with acute lymphoblastic leukemia (ALL). Outcomes were measured 7-10 days after diagnosis and compared to age- and sex-specific expected values. Associations between function and health-related quality of life (HRQL) were evaluated with logistic regression. Children with ALL had sub-optimal bone mineral density (BMD) Z-score/height (mean ± standard error: - 0.53 ± 0.16 vs. 0.00 ± 0.14, p < 0.01), body mass index percentile (57.6 ± 3.15 vs. 50.0 ± 3.27%, p = 0.02), quadriceps strength (201.9 ± 8.3 vs. 236.1 ± 5.4 N, p < 0.01), 6 min walk distance (385.0 ± 13.1 vs. 628.2 ± 7.1 m, p < 0.001) and Bruininks-Oseretsky Test of Motor Proficiency scores (23 ± 2.5 vs. 50 ± 3.4%, p < 0.01). Quadriceps weakness was associated with a 20.9-fold (95% confidence interval 2.5-173.3) increase in poor physical HRQL. Children with newly diagnosed ALL have weakness and poor endurance and may benefit from early rehabilitation that includes strengthening and aerobic conditioning.