The effect of an online exercise programme on bone health in paediatric cancer survivors (iBoneFIT): study protocol of a multi-centre randomized controlled trial

Every Move Counts to Improve Bone Health at Clinical Sites in Young Pediatric Cancer Survivors: The iBoneFIT Project

PURPOSE

We aimed to examine the associations of 24-h movement behaviors (moderate to vigorous physical activity [MVPA], light physical activity [LPA], sedentary behavior [SB], and sleep) with age-, sex-, and race-specific areal bone mineral density (aBMD) z -score parameters at clinical sites in young pediatric cancer survivors.

METHODS

This cross-sectional multicenter study was carried out within the iBoneFIT framework in which 116 young pediatric cancer survivors (12.1 ± 3.3 yr old; 42% female) were recruited. We obtained anthropometric and body composition data (i.e., body mass, stature, body mass index, and region-specific lean mass), time spent in movement behaviors over at least seven consecutive 24-h periods (wGT3x-BT accelerometer, ActiGraph), and aBMD z -score parameters (age-, sex-, and race-specific total at the body, total hip, femoral neck and lumbar spine). Survivors were classified according to somatic maturity (pre or peri/postpubertal depending on the estimated years from peak height velocity). The adjusted models' coefficients were used to predict the effect of reallocating time proportionally across behaviors on the outcomes.

RESULTS

In prepubertal young pediatric cancer survivors, reallocating time to MVPA from LPA, SB, and sleep was significantly associated with higher aBMD at total body ( B = 1.765, P = 0.005), total hip ( B = 1.709, P = 0.003), and lumbar spine ( B = 2.093, P = 0.001). In peri/postpubertal survivors, reallocating time to LPA from MVPA, SB, and sleep was significantly associated with higher aBMD at all sites ( B = 2.090 to 2.609, P = 0.003 to 0.038). Reallocating time to SB from MVPA or LPA was significantly associated with lower aBMD at most sites in prepubertal and peri/postpubertal survivors, respectively. Finally, reallocating time to sleep from MVPA, LPA, and SB was significantly associated with lower aBMD at total body ( B = -2.572, P = 0.036) and total hip ( B = -3.371, P = 0.015).

CONCLUSIONS

These findings suggest that every move counts and underline the benefits of increasing MVPA or LPA, when low MVPA levels are present, for bone regeneration after pediatric cancer treatment completion.

Muscle strength deficits are associated with low bone mineral density in young pediatric cancer survivors: The iBoneFIT project

BACKGROUND

Pediatric cancer survivors are at increased risk of muscle weakness and low areal bone mineral density (aBMD). However, the prevalence of muscle strength deficits is not well documented, and the associations of muscle strength with aBMD are unknown in this population. Therefore, this study aimed to investigate the prevalence of upper- and lower-body muscle strength deficits and to examine the associations of upper- and lower-body muscle strength with age-, sex, and race-specific aBMD Z-scores at the total body, total hip, femoral neck, and lumbar spine.

METHODS

This cross-sectional study included 116 pediatric cancer survivors (12.1 ± 3.3 years old, mean ± SD; 42.2% female). Upper- and lower-body muscle strength were assessed by handgrip and standing long jump test, respectively. Dual‑energy X‑ray absorptiometry was used to measure aBMD (g/cm2). Associations between muscle strength and aBMD were evaluated in multivariable linear regression models. Logistic regression was used to evaluate the contribution of muscle strength (1-decile lower) to the odds of having low aBMD (Z-score ≤ 1.0). All analyses were adjusted for time from treatment completion, radiotherapy exposure, and body mass index.

RESULTS

More than one-half of survivors were within the 2 lowest deciles for upper- (56.9%) and lower- body muscle strength (60.0%) in comparison to age- and sex-specific reference values. Muscle strength deficits were associated with lower aBMD Z-scores at all sites (B = 0.133-0.258, p = 0.001-0.032). Each 1-decile lower in upper-body muscle strength was associated with 30%-95% higher odds of having low aBMD Z-scores at all sites. Each 1-decile lower in lower-body muscle strength was associated with 35%-70% higher odds of having low aBMD Z-scores at total body, total hip, and femoral neck.

CONCLUSION

Muscle strength deficits are prevalent in young pediatric cancer survivors, and such deficits are associated with lower aBMD Z-scores at all sites. These results suggest that interventions designed to improve muscle strength in this vulnerable population may have the added benefit of improving aBMD.

Determinants of bone parameters in young paediatric cancer survivors: the iBoneFIT project

BACKGROUND

Bone health is remarkably affected by endocrine side effects due to paediatric cancer treatments and the disease itself. We aimed to provide novel insights into the contribution of independent predictors of bone health in young paediatric cancer survivors.

METHODS

This cross-sectional multicentre study was carried out within the iBoneFIT framework in which 116 young paediatric cancer survivors (12.1 ± 3.3 years old; 43% female) were recruited. The independent predictors were sex, years from peak height velocity (PHV), time from treatment completion, radiotherapy exposure, region-specific lean and fat mass, musculoskeletal fitness, moderate-vigorous physical activity and past bone-specific physical activity.

RESULTS

Region-specific lean mass was the strongest significant predictor of most areal bone mineral density (aBMD), all hip geometry parameters and Trabecular Bone Score (β = 0.400-0.775, p ≤ 0.05). Years from PHV was positively associated with total body less head, legs and arms aBMD, and time from treatment completion was also positively associated with total hip and femoral neck aBMD parameters and narrow neck cross-sectional area (β = 0.327-0.398, p ≤ 0.05; β = 0.135-0.221, p ≤ 0.05), respectively.

CONCLUSION

Region-specific lean mass was consistently the most important positive determinant of all bone parameters, except for total hip aBMD, all Hip Structural Analysis parameters and Trabecular Bone Score.

IMPACT

The findings of this study indicate that region-specific lean mass is consistently the most important positive determinant of bone health in young paediatric cancer survivors. Randomised clinical trials focused on improving bone parameters of this population should target at region-specific lean mass due to the site-specific adaptations of the skeleton to external loading following paediatric cancer treatment. After paediatric cancer diagnosis, years from peak height velocity (somatic maturity) is critical for bone development.

International fitness scale (IFIS): association with motor performance in children with obesity

Background

Overweight and obesity are defined as abnormal or excessive fat accumulation that presents a risk to health; and compared with their normal-weight peers, these individuals tend to have a lower level of self-confidence, and consequently lower physical activity adherence. Due to these self-perceived barriers, the aim of our study was to evaluate the efficacy of an online training program on self-reported physical fitness (SRPF) in children with obesity (OB).

Methods

A total of 32 children with OB carried out physical fitness (PF) tests and were asked to complete the International Fitness Enjoyment Scale (IFIS) questionnaire. The physical fitness tests were the Standing Broad Jump (SBJ), the 6-Min Walking Test (6MWT) and the 4 × 10 m sprint test. Children participated in a 3-weekly 60-min training session through Zoom platform. Before the beginning of the training protocol, OB children were compared with normal weight (NW) ones for PF batteries and the IFIS questionnaire. Changes in performances after the training were assessed by paired Student t and Wilcoxon tests.

Results

After the online training program children increased their performance in 6MWT (mean difference (MD) = 54.93; p < 0.0001) in SBJ (MD = 10.00; p = 0.0001) and in 4 × 10 m sprint test (MD = -0.78; p < 0.0001). No differences were found in children's physical fitness perception.

Discussion

Our study highlighted how a structured online training program can lead to improvements in PF of children with OB. Instead, the lack of differences in SRPF after the training suggests interesting questions to be explored on the aspects linked to self-perception. Therefore, even if our training protocol could not directly improve SRPF in children with obesity, the enhancement of their PF could be a starting point for achieving this result with a longer training period and consequently improve PA participation for children with OB.

Telehealth multicomponent exercise and health education in breast cancer patients undergoing primary treatment: rationale and methodological protocol for a randomized clinical trial (ABRACE: Telehealth)

BACKGROUND

Current guidelines emphasize cancer patients should increase their physical activity levels, encouraging physical exercise practice as a complementary therapy to mitigate adverse effects during treatment. Telehealth can be a feasible method to improve adherence and interventional support for breast cancer patients, of which most do not meet sufficient physical activity levels after diagnosis. The Adaptations to Breast Cancer and Exercise Using Telehealth (ABRACE: Telehealth) study aims to investigate the effects of a 12-week telehealth multicomponent training program plus a health education program (MTHE), compared to a health education program alone (HE), on physical and psychological outcomes in breast cancer patients undergoing treatment.

METHODS

This study is a randomized controlled trial. Women undergoing primary treatment (during or after chemotherapy) for breast cancer (stages I-III) will be randomly assigned to MTHE (twice a week) or HE (once a week). MTHE components are mobility, aerobic, balance, resistance, and flexibility home-based exercises, supervised by video call. The primary study outcome is cancer-related fatigue. The secondary outcomes are quality of life, symptoms of depression and anxiety, physical activity level, cancer-related cognitive impairment, and functional capacity. Other outcomes are adherence to interventions and a follow-up questionnaire evaluating the individual perception in motivation, lifestyle changes, and main barriers to participation. All outcomes will be remotely assessed before and after intervention. Our analysis will follow the intention-to-treat approach and per-protocol criteria, with additional sub-group analysis.

DISCUSSION

To our knowledge, this is the first randomized clinical trial in breast cancer patients using a face-to-face videoconference strategy to supervise physical exercise. Our hypothesis is of superiority for the effects of MTHE on primary and secondary outcomes compared to the effects of only the health education intervention.

TRIAL REGISTRATION

Adaptations to Breast Cancer and Exercise Using Telehealth (ABRACE: Telehealth), NCT04641377. Registered on 23 November 2021, https://clinicaltrials.gov/ct2/show/NCT04641377.

Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus

BACKGROUND & AIMS

The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation.

METHODS

A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool.

RESULTS

The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised.

CONCLUSION

The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.

Combatting Sedentary Behaviors by Delivering Remote Physical Exercise in Children and Adolescents with Obesity in the COVID-19 Era: A Narrative Review

The coexistence of childhood obesity (or its risk) and COVID-19 pandemic put children and adolescents in greater risk to develop respiratory and cardiovascular diseases. In fact, the restrictions introduced to limit the spread of the virus had detrimental effects on various lifestyle components, especially in young population. This resulted in augmented levels of physical inactivity and sedentary behaviors and a reduced time spent in play outdoors or sport practices. Contrariwise, the increased use of technology led clinicians, teachers, and trainers to maintain relations with obese children/adolescents so as to reduce sedentary behaviors and the associated health risks. This narrative review aims to describe the role of Telehealth and Tele-exercise as useful tools in the management of pediatric obesity during COVID-19 pandemic. Telehealth and Tele-exercise were effective in promoting self-monitoring and behavioral changes, including adherence to exercise training programs in children and adolescents. Moreover, tele-exercise platforms such as applications or exergames allowed flexible scheduling, limiting the infection risks.

Telehealth: A Useful Tool for the Management of Nutrition and Exercise Programs in Pediatric Obesity in the COVID-19 Era

The COVID-19 pandemic has led to the implementation of policies that mandate various restrictions on daily life, including social distancing, the closure of public services and schools, and movement limitations. Even though these restrictive measures decreased the COVID-19 spread, they may have detrimental effects on various lifestyle components such as physical inactivity, sedentary behavior, and dietary habits, influencing the maintenance of weight and contributing to obesity among children and adolescents. The coexistence of childhood obesity and COVID-19 and changes in the bioecological environment have put children and adolescents at increased risk for developing obesity and exacerbating the severity of this disorder. The use of telehealth technology is a modern approach useful for the delivery of health care services by health care professionals, where distance is a critical factor. Telehealth is effective in promoting increased self-monitoring and behavioral change, and provides the opportunity to perform online nutritional support and exercise training programs to promote a healthy lifestyle and reduce sedentary behaviors in children and adolescents. Telehealth, including tele-exercise and tele-nutrition, has the potential to address many of the key challenges in providing health services, including in patients with obesity during the COVID-19 outbreak. This narrative review aims to describe the role of telehealth as an opportunity in the management of pediatric obesity in the COVID-19 era, and to deliver nutrition and exercise programs for the maintenance of health.