Poor Diet Quality in Children with Cancer During Treatment

A cross-sectional study of nutritional status and dietary intake of paediatric oncology patients in Indonesia: Comparison between cancer aetiologies

Background: Adequate energy and protein intakes are required to maintain nutritional status and prevent clinical deterioration in paediatric oncology patients. There are limited investigations of malnutrition and dietary intake adequacy during treatment in developing countries. Aim: This study aimed to assess the nutritional status and macro- and micronutrient intake adequacy in paediatric oncology patients undergoing therapy. Methods: This cross-sectional study was conducted at Dr Sardjito Hospital, Indonesia. Sociodemographic, anthropometry, dietary intake, and anxiety status were collected. Patients were grouped based on cancer aetiology (haematological malignancy (HM) or solid tumour (ST). Variables between groups were compared. P-values of <0.05 were considered statistically significant. Results: 82 patients aged 5-17 years (65.9% HM) were analysed. The prevalence of underweight was 24.4% (ST vs HM: 26.9% vs 23.2%), overweight 9.8% (ST vs HM: 11.5% vs 8.5%), and obesity 6.1% (ST vs HM: 0.0% vs 8.5%) according to BMI-for-age z-score. Mid-upper-arm circumference identified undernutrition in 55.7% and overnutrition in 3.7% of the patients. Stunted growth was found in 20.8% of the patients. Percentages of children with inadequate energy and protein intake were 43.9% and 26.8%, respectively. The percentages of participants meeting the national micronutrient requirements were low, ranging from 3.8% to 56.1%, with the highest adherence rate observed for vitamin A and the lowest for vitamin E. Appetite loss was associated with lower overall intake. Conclusion: This study confirmed that malnutrition is prevalent in paediatric patients treated for cancer. Inadequate intakes of macro- and micro-nutrients were also common, highlighting the need for early nutritional assessment and intervention.

Nutritional status at diagnosis and its relationship with survival and relapse in Mexican children with acute lymphoblastic leukemia: a retrospective study

BACKGROUND & AIMS

Childhood acute lymphoblastic leukemia (ALL) is a malignancy with varying survival rates across countries with low, middle, and high income. The assessment of nutritional status (NS) using anthropometric indicators has been explored for its potential relationship on treatment outcomes. This study analyzed a 3-year retrospective cohort of Mexican pediatric patients with ALL, exploring the association between NS at diagnosis and relapse/mortality.

METHODS

Retrospective observational study. Medical records from 252 pediatric patients with ALL were included; anthropometric indicators (Z-scores) of body weight, height, mid-upper arm circumference (MUAC), and triceps and subscapular skinfolds (TSF and SSF, respectively) measurements were used to assess NS. The relapse/mortality data were collected from medical records. Kaplan-Meier (KM) functions and Cox regression models were performed to evaluate the effect of indicators on survival, relapse, and event (death or disease relapse).

RESULTS

Patients with malnutrition showed a significantly lower survival rate according to their BMI (76% vs 63%, p = 0.049), while relapses were higher in the group with TSF < -2 SD (41% vs 12%, p = 0.007). Patients with stunting and TSF < -2 SD showed a higher risk of mortality (HR:6.214, 95%CI: 1.372 to 28.154; HR:2.91, 95%CI: 1.27 to 6.68, respectively), while in patients with higher MUAC Z-score showed a decrease in the mortality risk (HR:0.85, 95%CI:0.73 to 1.00).

CONCLUSIONS

The nutritional status assessed by anthropometric measurements was a strong predictor of survival and relapse outcomes 3y post/diagnosis in this cohort of pediatric patients with ALL.

The evolution of nutritional care in children and young people with acute lymphoblastic leukaemia: a narrative review

BACKGROUND

Acute lymphoblastic leukaemia (ALL) is the most common paediatric malignancy in the world. Advances in treatment protocols have resulted in survival rates of >80% in most high-income countries (HIC); however, children and young people (CYP) with ALL continue to face significant nutrition-related challenges during treatment.

METHODS

This narrative review outlines the changing landscape of treatment and survivorship for CYP with ALL and the advances in nutrition knowledge that call for changes to clinical nutrition practice.

RESULTS

The incidence of ALL has remained stable in HIC; however, there have been significant advances in survival over the past 30 years. Overweight and obesity are increasingly prevalent in CYP with ALL at diagnosis, during treatment and in survivorship. Coupled with poor diet quality, high-energy and saturated fat intakes, altered eating behaviours and inactivity, this necessitates the need for a shift in nutrition intervention. Undernutrition remains a concern for CYP with high-risk treatment protocols where oral or enteral nutrition support remains a cornerstone of maintaining nutrition status.

CONCLUSIONS

With improved treatment protocols and high survival rates, a shift to focusing on diet quality, prevention of excessive weight gain and obesity during treatment and survivorship is necessary.

Impact of Early Nutritional Intervention During Cancer Treatment on Dietary Intakes and Cardiometabolic Health in Children and Adolescents

BACKGROUND/OBJECTIVES

Pediatric cancer survivors are at greater risk of cardiometabolic complications than their peers. This study evaluates the preliminary impact of the VIE (Valorization, Implication, Education) intervention, which integrates nutrition, physical activity, and psychological support, on dietary intake and cardiometabolic health among children and adolescents during cancer treatment.

METHODS

This comparative study includes pediatric cancer patients recruited to either the VIE intervention group or a control group receiving standard care. Post-treatment data on dietary intake, anthropometric measures, blood pressure, and biochemical parameters were compared between groups and stratified by level of involvement in the nutritional intervention and age at diagnosis (children and adolescents).

RESULTS

In the intervention group, 45 participants were included (51.1% male, mean age at evaluation 10.2 ± 4.5 years, mean time since end of treatment of 1.3 ± 0.8 years), and the control group comprised 77 participants (44.2% male, mean age at evaluation 12.0 ± 5.6 years, mean time since end of treatment of 1.4 ± 0.8 years). The intervention group had lower total caloric intake (mean: 1759 ± 513 vs. 1997 ± 669 kcal, p = 0.042) and higher calcium intake (mean: 567 ± 240 vs. 432 ± 197 mg/1000 kcal, p = 0.001). The participants who were highly involved in the nutritional intervention had greater protein-derived energy intake than the controls (mean: 17 ± 5 vs. 15 ± 4%, p = 0.029). While there was a tendency for a lesser proportion of cardiometabolic risk factors in the adolescents from the intervention group, the differences did not reach statistical significance.

CONCLUSIONS

The VIE intervention improved some specific dietary intakes in the medium term after treatment completion but did not significantly impact cardiometabolic health outcomes. Additional strategies are needed to improve the diet of pediatric cancer patients, and further research is warranted to assess the long-term impact of such interventions.

Comparison of nutritional screening tools in pediatric oncology patients receiving chemotherapy treatment

BACKGROUND

Malnutrition in pediatric oncology patients is a complex and multifactorial process, and the most appropriate screening tool to determine the risk of malnutrition is not clear. The study aimed to compare the Screening Tool for Risk on Nutritional Status and Growth (StrongKids), Pediatric Yorkhill Malnutrition Score (PYMS), Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP), which are commonly used in the general pediatric population, with the Nutrition Screening Tool for Childhood Cancer (SCAN), which was specifically validated for pediatric cancer, in determining the risk of malnutrition.

METHODS

This cross-sectional study included 92 children aged 2-18 years who were admitted to the hematology-oncology unit and were receiving chemotherapy. The prevalence of nutritional risk was determined using the SCAN, StrongKids, PYMS, STAMP, and anthropometric assessments were performed. Sensitivity and specificity values, and the degree of agreement between screening tools were calculated.

RESULT

The SCAN identified nutritional risk in 69.6 % of the children. According to StrongKids, PYMS and STAMP, the high nutritional risk in children was 43.5 %, 56.5 % and 64.1 %, respectively. The sensitivity of STAMP (81.2 %) was higher than that of StrongKids (60.9 %) and PYMS (79.7 %). The specificity of StrongKids, PYMS and STAMP was 96.4 %, 96.4 %, and 75.0 %, respectively. There was substantial agreement between SCAN and PYMS.

CONCLUSION

PYMS has the best specificity and sensitivity in identifying patients at risk of malnutrition as determined by SCAN.

IMPLICATIONS FOR PRACTICE

In addition to anthropometric measurements, population-specific or highly sensitive nutritional screening tools should be used to determine the risk of malnutrition.

Exploring the role of pain on physical activity among youth with acute lymphoblastic leukemia using the biopsychosocial model

BACKGROUND

Engaging in physical activity (PA) throughout cancer treatment offers many benefits, but may be challenging due to cancer-related pain. Pain research in pediatric cancer has primarily focused on procedural pain, with fewer studies exploring how pain affects PA. The current study qualitatively investigated the impact of pain on PA in youth with acute lymphoblastic leukemia (ALL) using a biopsychosocial framework.

PROCEDURE

As part of a larger study, caregivers (N = 17) of a child diagnosed with ALL and on treatment for less than 1 year completed a semi-structured interview about perceptions of their child's health behaviors during ALL treatment. This secondary analysis focused specifically on discussions about pain and its impact on PA. We followed Braun and Clarke's (2006) six-step thematic analysis framework to identify themes of pain-related barriers to PA.

RESULTS

Key pain-related barriers endorsed by caregivers included: interactions among pain and treatment effects, caregiver distress around seeing their child in pain, and fear of interfering with medical equipment. Despite these barriers, caregivers found creative solutions to adapt activities for their child. Caregivers were reassured by PA advice from their medical team; however, advice varied between teams.

CONCLUSION

The relationship between pain and PA during ALL treatment is influenced by an intricate system of biological (e.g., treatment effects), psychological (e.g., parental distress), and social (e.g., communication among families and medical teams) factors. Future directions include identifying evidence-based PA recommendations and exploring family-team communication dynamics. This study also highlights a need to prioritize ALL pain management and involve caregivers in behavioral treatment protocols to improve PA.

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

BACKGROUND

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

PROCEDURE

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

RESULTS

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

CONCLUSION

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

Nutritional 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.

Eating Behavior, Nutritional Status, and Taste Perception Alteration in Children with Cancer

The aim of this study was to investigate eating behavior, nutritional status, and taste alterations in children with cancer. The population of the study consisted of children 8 to 18 years of age and their parents who were followed up and received chemotherapy in the pediatric hematology and oncology clinic and outpatient clinic of a University Faculty of Medicine Oncology Hospital. Data were collected using the Child Identification Form, the Children's Eating Behavior Questionnaire (CEBQ), the Taste Alteration Scale for Children Receiving Chemotherapy (TAC-TAS), and the Subjective Total Taste Acuity Scale (STTA). Body Mass Index (BMI) Z score was between -2 and +2 (normal) in 92.5% of the children and below ≤-2 (malnutrition) in 7.5%. The mean CEBQ subdimensions scores were food craving 12.48±5.36, emotional overeating 5.28±1.45, enjoyment of food 16.83±5.41, passion for drinking 9.72±5.13, satiety enthusiasm 22.93±6.65, slow eating 9.81±4.95, emotional undereating 16.38±4.41, and food selectivity 10.72±2.86, and the mean total TAC-TAS score was 8.66±10.22. A negative, moderate correlation was determined between food craving and enjoyment of food and taste alteration, with food craving and enjoyment decreasing as food alteration increased. A positive moderate correlation was observed between slow eating and taste alteration, with eating slowing down as taste alteration increased.

Web-based nutrition: a useful resource for cancer patients?

Introduction

An accessible and affordable way to deliver behavior change programs to a large proportion of the growing community of cancer patients and survivors is through web-based methods of nutritional counselling.

Objective

The aim of this systematic review was to evaluate the effectiveness of web-based nutritional therapies targeting physical activity, diet, and/or weight control for cancer patients or survivors, primarily disseminated via modern technologies (mobile phone applications) or online.

Materials and methods

The authors conducted a structured search of the PubMed database. Studies that have focused on physical activity (PA) and dietary change and/or weight control in adolescent and adult cancer patients and survivors have reported outcomes conducted via a broad modality.

Results

Nine articles focused on web-based nutrition for patients with cancer and cancer survivors. They were conducted in the United States, Australia, Korea, China, and in the United Kingdom, and were published between 2018 and 2022 in a variety of scientific journals. The number of participants ranged from 20 to 159.

Conclusion

Web-based nutrition counselling helps cancer patients and survivors improve their dietary intake, impacts their weight and quality of life, and promotes a healthy lifestyle. Future research should evaluate (1) the differences in cost and coverage between face-to-face and web-based nutrition, (2) long-term outcomes, (3) cost-effectiveness, and last but not least, (4) the effectiveness of web-based nutrition in adolescents and children who suffer from cancer or who survived cancer, as nutritional status and body composition have a marked impact on clinical outcomes during and after treatment. The strength of this review lies in the large number of randomized controlled trials, which offer a guarantee of effectiveness and objectivity compared to cross-sectional studies.

Understanding the patient and family experience of nutrition and dietetic support during childhood cancer treatment

PURPOSE

This study aimed to understand the experience of families caring for a child with cancer in New Zealand (NZ) who received nutrition and dietetic support during cancer treatment and their preferences for the delivery, format, and timing of nutrition information.

METHODS

Childhood cancer patients and their families (N = 21) participated in a mixed-methods study at a specialist paediatric oncology centre in Auckland, NZ. Before the semi-structured interview, participants completed a questionnaire capturing demographic, disease, and treatment characteristics of their child, their nutrition concerns, and their information needs. Quantitative data were described, and qualitative thematic analysis of the semi-structured interviews was performed using NVivo data analysis software.

RESULTS

Eighty-six percent of participants indicated they had concerns about their child's nutrition during treatment. The most common concerns were anorexia, vomiting, and weight loss. While many were happy with the quality of the nutrition support received, one-third of the patients wanted more support. Four key themes emerged from the interviews: (1) patients experience significant and distressing nutrition challenges; (2) patients and families have mixed perceptions of EN; (3) there are gaps in the current nutrition support system for inpatients; and (4) a desire for more accessible nutrition support.

CONCLUSION

Childhood cancer patients and families experience significant and distressing nutrition challenges during treatment. Standardising information given to patients and their families may optimise nutrition support for paediatric oncology patients and reduce the discordance between families and health professionals. Future implementation of a nutrition decision aid in this population is warranted.

Improvement of Diet after an Early Nutritional Intervention in Pediatric Oncology

Pediatric cancer survivors may experience cardiometabolic sequelae over the course of their lives as a result of the treatments they have received. While nutrition consists of an actionable target for cardiometabolic health, few nutritional interventions have been documented in this population. This study assessed the changes in diet during a one-year nutritional intervention for children and adolescents undergoing cancer treatments and the participants’ anthropometric and cardiometabolic profiles. A total of 36 children and adolescents (mean age: 7.9 years, 52.8% male) newly diagnosed with cancer (50% leukemia) and their parents underwent a one-year individualized nutrition intervention. The mean number of follow-up visits with the dietitian during the intervention was 4.72 ± 1.06. Between the initial and one-year assessments, there was an improvement in diet quality reflected by the Diet Quality Index (5.22 ± 9.95, p = 0.003). Similarly, the proportion of participants with moderate and good adherence (vs. low adherence) to the Healthy Diet Index score almost tripled after one year of intervention (14% vs. 39%, p = 0.012). In parallel, there was an increase in the mean z-scores for weight (0.29 ± 0.70, p = 0.019) and BMI (0.50 ± 0.88, p = 0.002), and in the mean levels of HDL-C (0.27 ± 0.37 mmol/L, p = 0.002) and 25-hydroxy vitamin D (14.5 ± 28.1 mmol/L, p = 0.03). Overall, this study supports that a one-year nutritional intervention deployed early after a pediatric cancer diagnosis is associated with an improvement in the diets of children and adolescents.