Changes in nutritional status in childhood cancer patients: A prospective cohort study

doi:10.1016/j.clnu.2014.01.013

Clinical Nutrition

Volume 34, Issue 1, February 2015, Pages 66-73

https://doi.org/10.1016/j.clnu.2014.01.013 Get rights and content

Summary

Background & aims

Under- and overnutrition are linked to adverse outcomes during and after childhood cancer treatment. Therefore, understanding the timing of weight loss and weight gain and their contributory factors is essential for improving outcomes. We aimed to determine in which period of treatment changes in nutritional status occurred and which factors contributed to these changes.

Methods

A prospective cohort study of 133 newly diagnosed cancer patients with hematological, solid, and brain malignancies was performed. Anthropometric data and related factors were assessed at 0, 3, 6 and 12 months after diagnosis.

Results

Despite initial weight loss at the beginning of treatment in patients with hematological and solid malignancies, body mass index (BMI) and fat mass (FM) increased within 3 months with 0.13 SDS (P < 0.001) and 0.05 SDS (P = 0.021) respectively. Increase continued during the following months and resulted in a doubling of the number of overnourished patients. Fat free mass (FFM), which was already low at diagnosis, remained low. During the entire study period about 17% of the patients were undernourished on the basis of low FFM. Tube feeding and diminished activity level were related to increases in BMI and %FM respectively. No relationship was found between energy intake or corticosteroids and increase in BMI or %FM.

Conclusions

BMI and FM increased during and after the period of intensive treatment, while FFM remained low. Improvement of nutritional status might be accomplished by increasing physical activity from the early phase of treatment.

Introduction

Poor nutritional status is linked to adverse outcomes both during treatment of childhood cancer and during survivorship. During cancer treatment under- and overnutrition result in more complications, higher relapse rates, and lower survival rates.1, 2 During survivorship, overnutrition is one of the risk factors for diabetes mellitus type II, hypertension, and cardiovascular diseases.³ This is especially a problem in cancer survivors, who run the additional risk of developing cardiovascular disease due to treatment with potential cardiotoxic chemotherapy or radiotherapy.⁴ Undernutrition in the general population is also associated with morbidity and increased all-cause mortality.⁵ Although previous studies have presented data of under- and overnutrition in childhood cancer patients, little is known about the timing of the onset of under- and overnutrition and their respective causes. It is therefore necessary to study the timing and the causes of changes in nutritional status in order to develop adequate intervention strategies.

Nutritional status can be represented by both body size and body composition. Body size is measured using weight, height, and body mass index (BMI), and represents the general impression of the child's growth. Body composition is expressed in fat mass (FM) and fat free mass (FFM), which represent the nutritional stores of the body.6, 7 Body composition can be measured both by complex methods, such as air-displacement plethysmography (ADP) or simple methods such as bioelectrical impedance analyses (BIA). Patients can be undernourished because of low BMI and/or low FFM, or overnourished because of high BMI and/or high FM. Both criteria are not necessarily present at the same time. For example, low FFM can be present in patients with normal BMI. In this study both body size and body composition are considered to be relevant.

Presumably, changes in nutritional status are caused by the malignancy or its treatment and continue into survivorship. Therefore, it is important to gain insight in the course of weight loss or weight gain and changes in body composition during treatment, but also to determine the factors related to these changes. Up till now, most studies assessing nutritional status relied on cross-sectional data.⁷ The few prospectively conducted longitudinal studies that did report on changes in nutritional status predominantly concerned patients with acute lymphoblastic leukemia (ALL) and described time intervals of 6 months or more, making a detailed analysis of the timing of changes difficult.8, 9 Longitudinal studies in patients with solid and brain malignancies are scarce.⁷ Therefore, we conducted a prospective cohort study among newly diagnosed cancer patients with heterogeneous malignancies and registered body size, body composition, and related factors during 12 months after diagnosis. Our research questions were:

1.
In which period of treatment do changes in body size and body composition arise?
2.
Which factors contribute to those changes in body size and body composition?

Section snippets

Participants

All children newly diagnosed with cancer, who were consecutively admitted to the Pediatric Oncology Department of the University Medical Center Groningen (UMCG) between September 2007 and December 2009 were asked to participate in a prospective cohort study called the Pecannut (Pediatric Cancer and Nutrition) study. The follow-up period was 12 months and ended in December 2010. Eligible patients were between 0 and 17.99 years of age, had no prior diagnosis of cancer, had sufficient command of

Characteristics of the cohort

A total of 133 patients with hematological (39.8%), solid (33.1%), or brain (27.1%) malignancies were included in the study. Their median age was 8.1 years (0.1–17.7) and 52.6% were female (Table 1). During the study period, 18 patients left the study because they became too ill (n = 3), died (n = 6), moved (n = 3), felt too much burden (n = 4), or experienced lack of motivation (n = 2) (drop-out rate 13.5%) (Fig. 1). The 9 patients who left the study because of death or increased severity of

Discussion

This is the first study to describe the trajectories of changes in nutritional status during treatment of children with hematological, solid and brain malignancies. The greatest changes occurred within 3 months after diagnosis. Tube feeding and diminished activity level were identified as the significant contributory factors to increases in BMI and %FM respectively.

Statement of authorship

The authors' responsibilities were as follows: AB participated in study design, collected data, conducted data analysis, and drafted the manuscript. PFR participated in study design, supervised its execution. ES collected data, participated in interpretation of data. WAK participated in study design, supervised its execution. ESJMB participated in study design, supervised its execution. AMB performed statistical analyses. JGMB performed statistical analyses, participated in interpretation of

Conflict of interest

The authors have declared no conflict of interest.

Funding sources

None of the authors received funding for this study.

Acknowledgments

The authors wish to thank all children and their parents for participating in the Pecannut study and Sonja Hintzen of the University Medical Center Groningen for her constructive advice and editing service.

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Initially, this weight gain was denoted as catch-up growth. However, in PeCanNut I we also found indications for overfeeding, particularly in the beginning of treatment [21,42]. Regrettably, it is sometimes difficult to draw a line between desirable catch-up growth and undesirable weight gain.
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^☆: Conference presentation: MASCC, New York 2012; SIOP, London 2012; SIOP, Hong Kong 2013.

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Original articleChanges in nutritional status in childhood cancer patients: A prospective cohort study☆

Summary

Background & aims

Methods

Results

Conclusions

Introduction

Section snippets

Participants

Characteristics of the cohort

Discussion

Statement of authorship

Conflict of interest

Funding sources

Acknowledgments

Am J Clin Nutr

Crit Rev Oncol Hematol

J Pediatr

Am J Clin Nutr

Am J Clin Nutr

J Pain Symptom Manage

Nutrition

Crit Rev Oncol Hematol

Mortality in overweight and underweight children with acute myeloid leukemia

J Am Med Assoc

Obesity and outcome in pediatric acute lymphoblastic leukemia

J Clin Oncol

The impact of childhood obesity on morbidity and mortality in adulthood: a systematic review

Obes Rev

The late effects of childhood cancer therapy

Pediatrics

Cause-specific excess deaths associated with underweight, overweight, and obesity

J Am Med Assoc

Osteopenia, excess adiposity and hyperleptinaemia during 2 years of treatment for childhood acute lymphoblastic leukaemia without cranial irradiation

Clin Endocrinol (Oxf)

Continuing positive secular growth change in The Netherlands 1955–1997

Pediatr Res

Paediatric morphometrics. A reference manual

Predicting basal metabolic rate, new standards and review of previous work

Hum Nutr Clin Nutr

Original article
Changes in nutritional status in childhood cancer patients: A prospective cohort study☆