Kinga Jeziernicka1, Monika Bartyzel1, Aleksandra Bartyzel2, Marcin Czop3, Daniel Pruszkowski1, *Marzena Samardakiewicz4
The evaluation of changes in body mass index (BMI) of children diagnosed with leukemia or lymphoma before and after treatment in consideration of age at diagnosis and patient’s lifestyle**
Ocena zmian wartości indeksu masy ciała (BMI) u dzieci z rozpoznaniem białaczek i chłoniaków przed leczeniem i po leczeniu z uwzględnieniem wieku w momencie rozpoznania i stylu życia pacjentów
1Student’s Scientific Society, Department of Pediatric Hematology, Oncology and Transplantation, Medical University in Lublin
Head of Department: Professor Jerzy R. Kowalczyk, MD, PhD
2Faculty of Medicine, Medical University of Warsaw
Head of Faculty: Professor Krzysztof J. Filipiak, MD, PhD
3Department of Clinical Genetics, Medical University in Lublin
Head of Department: Janusz Kocki, MD, PhD
4Department of Pediatric Hematology, Oncology and Transplantation, Medical University in Lublin
Head of Department: Professor Jerzy R. Kowalczyk, MD, PhD
Wstęp. U dzieci z rozpoznaniem białaczki lub chłoniaka, które zakończyły systemowe leczenie, obserwowano znaczący wzrost indeksu masy ciała (BMI). Leczenie obejmujące jedynie chemioterapię nie powoduje takiego wzrostu BMI, ale w połączeniu ze steroidoterapią lub profilaktycznym napromienianiem OUN może prowadzić do znaczącego wzrostu BMI.
Cel pracy. Celem pracy była retrospektywna ocena zmian wartości indeksu masy ciała u dzieci z rozpoznaniem ostrej białaczki limfoblastycznej (ALL) i chłoniaka nieziarniczego (NHL) w trakcie leczenia podtrzymującego remisję lub po zakończonym leczeniu kompleksowym oraz analiza zależności między indeksem masy ciała a prowadzonym stylem życia przez pacjentów i środowiskiem rodzinnym.
Materiał i metody. Badaniem objęto w sumie 173 osoby, w tym przebadano 82 pacjentów Kliniki Hematologii, Onkologii i Transplantologii Dziecięcej USD w Lublinie oraz grupę kontrolną liczącą 91 osób, którą stanowiło rodzeństwo pacjentów. U każdego badanego obliczono wskaźnik masy ciała (BMI) jako proporcję masy ciała i wzrostu. Uzyskano te wartości z bazy danych Kliniki z lat 2007-2014 w chwili rozpoznania ALL/NHL oraz z wywiadu z rodzicami w 2016 roku na podstawie pomiarów domowych lub z danych z ostatniej kontroli lekarskiej. Rozmowa z rodzicami pacjentów prowadzona była telefonicznie na podstawie standaryzowanej ankiety zawartej w sporządzonym Kwestionariuszu do oceny Masy Ciała (Kwestionariusz M-C).
Wyniki. U dzieci po leczeniu ALL/NHL stwierdzono znaczący statystycznie wzrost wartości BMI. W grupie dzieci w przedziale wiekowym 0-5 lat, które zakończyły leczenie, u 5,9% osób stwierdzono niedowagę, u 70,6% prawidłowe wartości BMI, u 3,9% odnotowano nadwagę, a u 19,6% otyłość. Istotne statystycznie różnice w wartościach BMI w badania występowały pomiędzy grupą pacjentów w przedziale wiekowym 6-12 lat a grupą pacjentów w przedziale wiekowym 13 lat i więcej. Z przeprowadzonych badań wynika, iż nie ma istotnych różnic w BMI zarówno w momencie rozpoznania, jak i w momencie badania pomiędzy dziewczynkami a chłopcami. Wartości BMI pomiędzy pacjentami a ich rodzeństwem są na podobnym poziomie, u większości badanych mieszczą się w zakresie normy według pediatrycznych standardów WHO. Nie wykazano istotnego statystycznie wpływu częstotliwości aktywności fizycznej i nawyków żywieniowych na BMI pacjentów onkologicznych.
Wnioski. W momencie rozpoznania waga większości ocenianych dzieci mieściła się w normie według dziecięcych norm WHO. W wyniku terapii onkologicznej stwierdzono znaczący przyrost masy ciała. Z upływem czasu od zakończenia leczenia u większości pacjentów występuje normalizacja wskaźników rozwoju fizycznego, zwłaszcza BMI. W badanej grupie dzieci po leczeniu ALL/NHL średnia wartość BMI nie wykazywała tendencji do otyłości.
Introduction. In childhood leukemia and lymphoma survivors, after systemic treatment, a significant increase in body mass index (BMI) was reported. Chemotherapy alone did not cause a significant increase in BMI; however, the addition of the steroidotherapy or prophylactic radiotherapy resulted in a significant increase in BMI.
Aim. The purpose of the study was to assess the changes in the body mass index of children with acute lymphoblastic leukemia (ALL) and lymphomas (NHL) at the time of diagnosis, during remission sustaining therapy or after the end of complex treatment and the analysis of the relationship between the body mass index and lifestyle led by the patients.
Material and methods. The study concerned a total of 173 people: the 82 patients who were treated in the Department of Pediatric Hematology, Oncology and Transplantation in Children’s University Hospital in Lublin and a noncancer control group of 91 people who were the healthy siblings of those patients. For each of the participants BMI was calculated as a ratio of weight and height (BMI; kg/m2). These values were obtained from the database of the department in 2007-2014 at the time of diagnosis ALL/NHL and from information obtained from parents in 2016 based on home measurements or from the last medical examination. The parents were interviewed on a telephone and the interview based on a standardized survey included in the prepared B-W (Body-Weight) Questionnaire.
Results. BMI values at the time of the study were significantly higher than the BMI at the time of the diagnosis. In the age group 0-5 years, 5.9% of children were underweight, 70.6% in the normal range of BMI, 3.9% were overweight and for 19.6% obesity was reported at the time of the measurement. There is a significant statistical difference in BMI at the time of the study between the group of patients aged 6-12 years, and a group of patients aged 13 years and more. The study shows that there are no significant differences in BMI both at diagnosis and at the time of the study between girls and boys. BMI-SDS between patients and their siblings are at a similar level and are within the normal range according to WHO pediatric standards. There were no statistically significant effects of the frequency of physical activity and dietary habits on BMI in patients group.
Conclusions. At the moment of the diagnosis most of the children were in the group of normal range, according to WHO pediatric standards. After the end of the therapy their indicators of physical development of most patients normalized with time, especially BMI. In the group of children under study the average BMI value showed no tendency to obesity.
The proper physical development is conditioned by the harmonious interaction of exogenous elements: environmental conditions, nutrition, physical activity and the body’s internal factors, such as genetic predisposition or the proper function of various organs and systems. Neoplastic disease as a catabolic process interferes with the normal functions of the body metabolism. Nowadays, due to the complex antineoplastic treatment it is possible to achieve 5-year survival rate of 80% in children, and in cases of acute lymphoblastic leukemia (ALL) even up to 90% (1). Due to the modification of chemotherapy programs, it was possible to improve surgical techniques, the use of modern methods of radiotherapy and in some cases – megachemotherapy with autologous bone marrow transplantation (2).
At the same time, along with advances in anticancer therapy there is an increase in the risk of health problems that may interfere with the psychophysical development of patients. Oeffinger et al. state that one third of people treated with anticancer therapy will experience acute or chronic side effects within 30 years from diagnosis (3). Long-term as it lasts on average approx. 2.5 years remission sustaining therapy, with months in the reduction of physical activity can lead to abnormal energy and endocrine balance of the body. The result of that is improper physical development including fatigue, pain, growth and puberty disturbances, tendency to obesity and osteoporosis (4-6). Health problems after treatment extend on cognitive functions, cardiovascular and neuromusculoskeletal systems, but also they can lead to secondary neoplasms (3).
Some authors state that steroid therapy can cause a tendency to excess weight. These abnormalities are usually observed during or immediately after treatment. Physical development indicators especially the body mass index and the rate of growth (so-called catch-up) are normalized with time since the end of treatment (4-6). However, according to CCSS (Childhood Cancer Survivor Study Group) conducted by the American Society of Clinical Oncology, underwent steroid therapy does not affect the male BMI level or affects, but not significantly, the growth in the level of BMI in women (7). In this study there was a comparison between the BMI’s in the group of patients treated for ALL in childhood and their unaffected siblings. The CCSS results lead to observation that the effect on BMI depended on the type of treatment provided. Chemotherapy alone did not cause a significant increase in BMI; however, the addition of the therapeutic radiation to the protocol resulted in a significant increase in BMI of patients compared to the BMI’s of the healthy siblings (7).
Another factor that may influence the value of BMI is physical activity. Tseng-Tien et al. state that exercise are beneficial for the treatment of patients with ALL, especially when they are conducted in a hospital setting, where there is a proper frequency and regularity assured (8). Cox et al. also emphasize the importance of physical activity in the treatment process (9). CCSS research shows that regular activity initiated during therapy and continued for years after treatment can modify and prevent late side effects of anticancer therapy (10).
The purpose of the study was to assess the changes in the body mass index of children with acute lymphoblastic leukemia (ALL) and lymphomas (NHL) at the time of diagnosis, during remission sustaining therapy or after the end of complex treatment and the analysis of the relationship between the body mass index and lifestyle led by the patients.
Following research questions were investigated:
Does the history of oncological treatment in childhood affect the body mass index (BMI)?
Does the level of BMI of patients after treatment for ALL/NHL significantly differ from the level of BMI of their healthy siblings?
Do the patient's lifestyle have a significant impact on the value of BMI of children treated for ALL/NHL?
Material and methods
Design of the study
The plan of the research has been carried out in several stages. Using the hospital INFO MEDICA database we pre-selected 198 patients who have been treated for ALL or non-Hodgkin lymphoma in the Department of Hematology, Oncology and Transplantation, Children’s University Hospital in Lublin in 2007-2014. We chose patients with these two particular diagnoses due to the use of therapeutic protocols that included chemotherapy and steroid therapy.
The following inclusion criteria have been established: 1. The age of child at the time of the study must have been over 6 years due to the compulsory school attendance; 2. The initial measurement of weight and height must have been registered in the INFO MEDICA system during the admission to the hospital of the child with the suspicion of cancer; 3. The capability of telephone contact with a parent; 4. The consent to participate in the study.
We excluded a total of 116 people: 50 of them due to a lack of current phone number, 2 people who did not agree to participate in the study, 46 patients without preliminary measurements of weight and height registered in the INFO MEDICA system, 15 children who at the time of the study were less than 6 years and 3 people who died.
The control group consisted of the healthy siblings of the children who underwent anticancer therapy.
The survey was carried on a telephone. Before the start of the interview the information about the purpose of the study and a request for a consent to participate in the research have been provided. The body mass index (BMI) for each patient has been calculated based on the body weight and height obtained from the INFO MEDICA database registered at the time of diagnosis of a disease entity and at the time of the study on the basis of information obtained from the parents of the patients based on the authors’ questionnaire to assess the body weight (B-W Questionnaire). The measurements at the time of the diagnosis were performed in the hospital, while the ones at the time of the study were performed by their parents at home or taken and recorded during the last medical examination. The measurements of the body weight and height of the healthy siblings were made by parents at home. Information about the children were given by their parents.
As an indicator for the assessment of the physical development, the ratio of body weight in kilograms and height in meters were chosen. BMI was adjusted for age and gender providing BMI SDS (z-score) using WHO growth reference data for children aged 5-19 years. For children aged 0-5 years growth charts were used related to the child's age and sex. The obtained BMI values were related to the standards of the World Health Organization (WHO) that divides it into four categories: underweight (< -2SD), normal value, overweight (> +1SD), obesity (> +2SD).
Finally, the study involved 82 children who were treated for leukemia or lymphoma in the Department of Hematology, Oncology and Transplantation, Children’s University Hospital in Lublin in 2007-2014. The standard treatment protocols for ALL/NHL were used. In the study group were not children undergoing stem cell transplantation. The analysis of BMI values involved 39 girls (48%) and 43 boys (52%), and were provided also in three age groups: 0-5 years, 6-12 years, and 13+ years. At the time of the diagnosis the average age of the patients was 6.1 ± 4.2 years. Most of the respondents were from urban centers with more than 25 thousand residents (57%), while the rest from the rural or suburban areas.
The interviews were mainly carried out with the mothers of the patients (94%).
The control group consisted of the 91 healthy siblings of the patients. The average age in this group was 11.9 years. The analysis of BMI values involved 54 boys (59%) and 37 girls (41%).
Body Weight Questionnaire
In order to assess dietary habits, physical activity of patients, the presence of complications after cancer treatment and approach to physical activity of medical staff a standardized survey based on questions included in the Questionnaire to assess Body-Weight (B-W Questionnaire) has been carried out with the parent of each patient. The questionnaire consisted of 24 questions: 4 questions were related to the siblings of the patient (sex, age, height and weight at the present moment) and 20 questions were related to the patients including 13 closed questions (with answers yes or no) and 7 closed questions with several variants of possible answers. Within these questions 8 were related to eating habits: regularity and quantity of meals, eating fast food and sweets, focus on health while choosing food, counting calories and a frequency of weight measurements. The next 7 questions related to physical activity: participation in physical education classes and in extracurricular sports activities, the number of hours of physical activity a week, and changes in physical functions compared to the period before the disease. In addition, the questionnaire included one question on the presence of complications after anticancer treatment and 4 questions about the approach of medical staff and parents to the physical activity.
To compare the studied parameters between the two groups t-test was used. For comparison of the examined parameters among the three groups ANOVA test with Fisher’s least significant difference (LSD) test as post-hoc analysis was used. The statistical analysis was performed using STATISTICA 12.5 program. Three levels of confidence limits were accepted: p < 0.05, p < 0.01 and p < 0.001.
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