Preventing weight gain in children with acute lymphoblastic leukemia by early nutritional intervention

Abstract

In this issue, Walters et al. report the results of a pilot study examining the feasibility and impact on weight gain of a nutritional intervention thatwas initiated during induction and continued through the first 6months of therapy for acute lymphoblastic leukemia (ALL).1Although the survival rate of pediatric ALL is greater than 90% in high-income countries,2 children with ALL still experience disease-related and treatment-related toxicities that negatively affect their quality of life. Significant weight gain is a common side effect and is associated with inferior survival rates and increased incidences of other adverse effects.3 Overweight or obesity in childhood incurs greater risk for overweight or obesity throughout adolescence and into adulthood,4 which can lead tometabolic complications such as dyslipidemia, type II diabetes, and cardiovascular disease. Multiple studies have confirmed that thegreatestweight gainoccurs during induction therapy, andearly intervention has been recommended to prevent weight gain.5–8 However, such intervention has been considered difficult because the children are acutely ill and their families are still coping with the ALL diagnosis. Therefore, in most previous studies, interventions were performed during maintenance therapy or after completion of therapy,6,9 but such a strategy makes it difficult to reverse the excessive weight gain earlier in therapy.6 To our knowledge, the study by Walters et al. is the first nutritional intervention study undertaken during the induction phase of pediatric ALL therapy.1 This multi-institutional study was conducted in person or via telemedicine in English or Spanish and offered nutritional counseling and educational materials adapted to the diet preferences of the ethnically and socioeconomically diverse population. Participants represented all four categories of body mass index (BMI) at baseline, with approximately 30% being overweight or obese. The intervention educated patients about the glycemic index and counseled them on making low-glycemic food choices. This strategy focused on dietary quality rather than on quantity and mirrored evidence-based recommendations for obesity prevention in general pediatrics, such as increasing fiber and lean protein intake anddecreasing consumption of added sugars.10 Approximately 80%of the patients approached to participate enrolled in the study, and 83% of the participants chose to begin the intervention during the first week of induction instead of later in that phase. After study completion, 85% of the participants indicatedan intention to continue following thenutritional guidelines. This might indicate that preventing weight gain is an important priority for parents of children with ALL. Compared to baseline, study participants significantly increased their consumption of protein, fruit, vegetables, and whole grains and reduced their consumption of sugar and energy-adjusted glycemic load at the end of induction, with no significant differences being observed between Spanish-speaking and non-Spanish-speaking participants. Notably, although calorie intake was significantly increased, there were no significant changes in BMI z-scores at the end of induction, as compared with those at diagnosis. This represents a departure from most previous studies, in which excess weight gain was observed during induction. Some of these dietary changes and BMI z-scores were sustained over the next 6 months as sessions changed from weekly to monthly. Feasibility parameters of patient retention, dietary guideline adherence, and intervention acceptability were measured. Participants rated the materials as being easy to understand (90%), affordable (95%), and easy to follow (60%). The percentage of sessions conducted via telemedicine was not captured, but the innovative use of telemedicine is of interest during this time when opportunities for in-person nutritional counselingmay be limited because of coronavirus disease 19 (COVID-19) pandemic restrictions. Given the paucity of studies examining interventions to prevent weight gain during therapy, we are excited by this study and look