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ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 2  |  Page : 219-223
 

Nutritional status in survivors of childhood cancer: Experience from Tata Memorial Hospital, Mumbai


1 Department of Medical Oncology, Tata Memorial Hospital; Department of Paediatric Oncology, After Completion of Therapy Clinic, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India

Date of Web Publication5-Feb-2016

Correspondence Address:
P Kurkure
Department of Medical Oncology, Tata Memorial Hospital; Department of Paediatric Oncology, After Completion of Therapy Clinic, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175814

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 » Abstract 

Background: Survivors of childhood cancer are at increased risk for several cardiometabolic complications. Obesity/overweight and metabolic syndrome have been widely reported in Western literature, but data from India are lacking. Aims: To perform an objective assessment of nutritional status in a cohort of childhood cancer survivors (CCSs) and to find risk factors for extremes in nutritional status. Settings And Design: The study was a retrospective chart review of CCSs who attended the late effects clinic of a referral pediatric oncology center over the period of 1 year. Materials And Methods: An objective assessment of nutritional status was done, and results were analyzed in two groups: Adult survivors (present age <18 years) and child and adolescent survivors (CASs) (<18 years). The data were then analyzed for possible risk factors. Results: Six hundred and forty-eight survivors were included in the study; of these, 471 were <18 years at follow-up, and 177 were 18 years or older. The prevalence of obesity, overweight, normal, and undernutrition was 2.6%, 10.8%, 62.7%, and 28.8% (CASs) and 0%, 8.5%, 62.7%, and 28.8% (adult survivors), respectively. Factors predictive of overweight/obesity were an initial diagnosis of acute lymphoblastic leukemia, or brain tumor and follow-up duration of >20 years or current age >30 years in adult survivors. Conclusions: The prevalence of obesity/overweight is lower in our cohort when compared to Western literature. It remains to be clarified whether this reflects the underlying undernutrition in our country, or whether our cohort of survivors is indeed distinct from their Western counterparts. Comparison with age/sex-matched normal controls and baseline parameters would yield more meaningful results.


Keywords: Childhood cancer survivors, metabolic syndrome, nutrition


How to cite this article:
Prasad M, Arora B, Chinnaswamy G, Vora T, Narula G, Banavali S, Kurkure P. Nutritional status in survivors of childhood cancer: Experience from Tata Memorial Hospital, Mumbai. Indian J Cancer 2015;52:219-23

How to cite this URL:
Prasad M, Arora B, Chinnaswamy G, Vora T, Narula G, Banavali S, Kurkure P. Nutritional status in survivors of childhood cancer: Experience from Tata Memorial Hospital, Mumbai. Indian J Cancer [serial online] 2015 [cited 2020 Nov 29];52:219-23. Available from: https://www.indianjcancer.com/text.asp?2015/52/2/219/175814



 » Introduction Top


Advances in all fields of oncology have led to an improvement in outcomes and in the majority of pediatric malignancies, the 5-year survival rates approach 80%.[1] This has resulted in an increasing focus on the late effects of therapy and quality of life in the growing population of childhood cancer survivors (CCSs). Approximately, 2 of every 3 CCSs will experience at least one late effect, and 40% may develop a “severe, disabling, or life-threatening condition” 30 years after cancer diagnosis.[2] CCSs have been noted to have a higher prevalence of obesity/overweight as compared to their peers.[3],[4],[5],[6] The pathogenesis of this complication is multifactorial and places the CCS at an increased risk of cardiopulmonary and metabolic sequelae.[7],[8],[9],[10],[11] Accepted risk factors for overweight/obesity include a diagnosis of acute lymphoblastic leukemia (ALL) or brain tumors (BT), host factors such as female gender and young age at diagnosis, treatment such as cranial radiation and stem cell transplantation and hormonal issues such as growth hormone deficiency and leptin sensitivity.[12],[13],[14],[15],[16],[17],[18] Lifestyle changes such as maladaptive eating behaviors, reduced physical activity as well as reduced energy expenditure also contribute to overweight/obesity in survivors of childhood cancer.[19],[20],[21]

Most of the research and publications regarding the nutritional status in CCS (mainly describing the prevalence of obesity) is from Western countries and focuses on survivors with ALL [7],[8],[9],[13],[14],[15],[16],[17],[18],[22],[23],[24],[25],[26],[27],[28],[29] who have received cranial irradiation and in survivors of BT.[30],[31] There are limited data from resource – limited settings, especially India.[32] This study aimed to objectively assess the nutritional status in a cohort of Indian CCSs.


 » Materials And Methods Top


The study was a retrospective chart review of CCSs, who attended the After Completion of Treatment (ACT) Clinic at our hospital over a 1-year period (September 2013–August 2014). The ACT Clinic was set up in 1991 for the comprehensive follow-up of CCSs at our center.[33] At present, there are 1730 survivors (disease free >2 years after cessation of therapy) who are registered, and around 2/3rd are under regular follow-up. The frequency of follow-up ranges from 6 months to 3 years. Data regarding initial diagnosis, treatment details, and late effects are maintained in the clinic database. At every visit, survivors are asked detailed history and undergo a physical examination and relevant laboratory investigations. Weight (in kilograms) and height (in centimeters) are measured in all patients; in children below 18 years of age, these parameters are plotted on WHO-Centers for Disease Control growth chart. Selected patients undergo investigations such as hemoglobin, Vitamin D levels, fasting and postprandial blood sugars, and fasting lipid profile. The parameters assessed as a part of this study were (1) nutritional status – defined by WHO body mass index (BMI)-for-age Z scores [34] and (2) metabolic syndrome (MS): Defined as per the International Diabetes Foundation Criteria.[35]

The results were analyzed in two groups: Adult survivors (present age >18 years) and child and adolescent survivors (CAS; present age <18 years). In adult survivors, BMI was calculated by dividing weight (in kilograms) by height (in meters) squared (kg/m 2). Participants were classified as normal weight, overweight, or obese at their most recent follow-up visit (BMI below 18.5-underweight; 18.5–24.9 - normal;

25–29.9 - overweight; 30 and above – obese). In CASs, WHO BMI Z scores were used to classify into: Normal: +1 to −1 standard deviation (SD), mild undernutrition: −1 SD to −2 SD, moderate undernutrition: −2 SD to −3 SD, severe undernutrition: <−3 SD, overweight: +1 to +2 SD, and obese: +2 to + 3 SD MS was defined as follows: In children-obesity >90th percentile as assessed by waist circumference, triglycerides (TGs) >150 mg/dL, high-density lipoprotein (HDL)-cholesterol <40 mg/dL in males and <50 mg/dL in females, hypertension, and raised fasting glucose >100 mg/dL.[35] In adults, the diagnostic criteria for MS were central obesity (defined as waist circumference >90 cm in males and >80 cm in females or BMI >30 kg/m2) plus any two of the following four factors: Raised TG level, reduced HDL cholesterol, raised blood pressure, raised fasting plasma glucose or previously diagnosed type 2 diabetes (diagnostic cutoffs the same as in children), or on drug treatment for any of the above.[35] In our study, criteria for MS were relaxed to include overweight as well as obese survivors.

Statistical analysis

The data were analyzed for possible risk factors (age at diagnosis, gender, diagnosis, anthracyclines, cranial irradiation, current age, and duration since diagnosis) for extremes of nutritional status, and metabolic status. Univariate analysis was used to screen for risk factors. Parameters found to be significant (P < 0.05 by univariate analysis) were selected for multivariate logistic regression analysis. The multiple logistic regression models were fit to the data by using a stepwise selection method. The Hosmer–Lemeshow test was used to evaluate the model's goodness-of-fit to the data. A P < 0.05 was considered significant by multivariate analysis. All “P” values were two-sided. For each variable found to be significant by logistic regression analysis, the odds ratio was calculated with the corresponding 95% confidence interval. Results for continuous variables were expressed as median with range. All statistical analyses were performed with PASW Statistics version 18 (SPSS, Inc., Chicago, IL, USA).


 » Results Top


Six hundred and forty-eight survivors were included in the study; 471 were <18 years at follow-up, and 177 were 18 years or older. The nutritional status was assessed separately in these two groups.

Child and adolescent survivors

This group included survivors who were <18 years at last follow-up. Four hundred and seventy-one survivors in our study were included in this group. The characteristics of this cohort are described in [Table 1].
Table 1: Baseline characteristics and nutritional profile of child and adolescent survivors (n=471)

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Those survivors with a diagnosis of ALL or BT had a higher prevalence of overweight/obesity (16.5% and 20.7%, respectively, P = 0.07) than the rest of survivors (13.6%). There was no association of nutritional status with age at diagnosis, duration of follow-up, gender, anthracycline treatment, or cranial irradiation. No child/adolescent survivor fit into the stringent criteria for MS; however, when the weight criteria were relaxed to include overweight as well as obese survivors, 11 (2.4%) survivors had features of MS. Dyslipidemia was seen in 18 (4%) of survivors-low HDL was the most common abnormality noted in all 18.

Adult survivors of childhood cancer

There were 177 survivors aged 18 years or above. The characteristics of this cohort are described in [Table 2]. Among adult survivors of childhood cancer, duration of follow-up over 20 years was associated with increased incidence of overweight status (10.3% vs. 8.1%; P = 0.015) than in those with duration of follow-up < 20 years. Similarly, those who are presently over 30 years of age had a higher prevalence of overweight compared to those younger than 30 years of age (22.2% vs. 6.9%; P = 0.004). There was no association of nutritional status with diagnosis, gender, age at diagnosis or treatment with either anthracyclines or cranial irradiation.
Table 2: Baseline characteristics and nutritional profile of adult survivors of childhood cancer

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None of the adult survivors fit the stringent criteria of MS, but 17 (9.6%) fit the relaxed criteria which included overweight as well as obese survivors. Dyslipidemia alone was noted in 25 (14%) survivors; of these 8 were overweight, 10 were of normal BMI, and 7 were moderately or severely undernourished. The most common abnormality was low HDL cholesterol noted in 23 survivors. Hypertension alone was noted in 6 adult survivors, while 4 patients had type 2 diabetes mellitus. The prevalence of MS tended to be higher in patients more than 30 years of age (P = 0.068) but was not associated with age at diagnosis, duration of follow-up, gender, cranial irradiation, or anthracycline treatment. The prevalence of dyslipidemia was higher in those survivors who had received cranial irradiation (P = 0.04) and those with a diagnosis of Hodgkin lymphoma (P < 0.001).


 » Discussion Top


Most studies from Western centers have reported the incidence of overweight and obesity in survivors of childhood ALL [7],[8],[9],[13],[14],[15],[16],[17],[18],[22],[23],[24],[25],[26],[27],[28],[29] and BT,[30],[31] predominantly in adult survivors of childhood cancer, who have completed linear growth. The salient features of some of the larger studies are described in [Table 3] and [Table 4]. The wide variability in percentages could be due to several factors such as variability in patient characteristics (age, duration of follow-up, diagnosis) and study design. A recent large study showed that there was a significantly higher increase in mean BMI over time of certain CCSs (females, younger age, and cranial radiation) as compared to siblings.[15]
Table 3: Comparison with other studies of nutritional status among child/adolescent survivors of childhood cancer

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Table 4: Comparison with other studies of nutritional status among adult survivors of childhood cancer

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Our study has a relatively large sample size and gives a good idea regarding the nutritional status of CCSs in India. The prevalence of overweight/obesity in both child/adolescent survivors and adult survivors is much lower (and by extension, the prevalence of underweight is higher) than in studies from the West. Over 25% of child/adolescent survivors were in fact either moderate or severely malnourished, and a comparable number of adult survivors are underweight. However, survivors seem to have a lower proportion of underweight as compared to the general population in the country, where 43.5% of under-5 children are moderately/severely malnourished, and 1.9% of under-5 children are overweight (in affluent children, 12.64% are overweight and 3.3% are obese).[36],[37] Similarly, in general, Indian adult population, 34% of men and 36% of women are underweight (higher than our cohort) and 13% of women and 9% of men are obese.[38] However, it is not possible to make an accurate comparison between our cohort of cancer survivors and the normal population without having age- and sex-matched controls, preferably siblings.

This is only the second study on nutritional profiles in CCSs to be published from India. The earlier study from India [32] was a retrospective study of 118 ALL/non-Hodgkin's lymphoma survivors and 138 age/sex-matched controls and had a similar incidence of overweight survivors, but a larger proportion of obese survivors (8.6% as compared to 2.6% in our study), and no undernourished survivors in spite of having a shorter duration of follow-up. The results of these two studies underline the fact that nutritional profiles in CCSs from the West cannot be extrapolated to their counterparts in India. Hence, there is a need for prospective well-designed studies in our population.

The prevalence of MS in Indian adults has been found to range between 18% and 42% in various studies [39],[40],[41],[42] and has been mostly been noted in an affluent urban population with higher BMIs. Although the prevalence of MS in our survivors is lower than the above-mentioned figures, it is troubling since our survivor cohort consisted of relatively young adults; none of whom were obese. In addition, of concern is the fact that 2.4% of child survivors fit the relaxed criteria for MS and that 14% of adult survivors and 4% child/adolescent survivors were noted to have dyslipidemia. Indians are known to be a high-risk population with respect to diabetes and cardiovascular disease, with numbers consistently on the rise,[43] and our cohort of survivors is at an even higher risk due to other mechanisms of cardiometabolic complications.

This study has certain drawbacks in that there is no comparison with age/sex-matched normal controls, and baseline nutritional parameters which would yield more meaningful results. Moreover, in this study, we have not measured the body composition by densitometry scans (although CCSs are known to have elevated total, abdominal, and visceral adiposity),[8],[44] or taken into account physical activity levels or hormonal influences.


 » Conclusions Top


There is a lower prevalence of overweight/obesity in our cohort of CCSs when compared to Western studies and a previous Indian study. However, it is not certain whether this reflects the underlying undernutrition in our country, or whether our cohort of survivors is indeed distinct from their Western counterparts.

Despite the lower prevalence of overweight/obesity and MS in our cohort of survivors, they remain at high risk for cardiometabolic complications. In the future, pharmacogenetics is expected to help predict survivors at a higher risk of developing obesity and cardiometabolic complications, and help personalize treatment in order to decrease toxicities.[45],[46] Some of the risk factors for obesity and MS are still modifiable and in the hands of survivors themselves. There are several guidelines for health promotion in cancer survivors, including encouraging a healthy diet, physical exercise, and avoidance of high-risk behaviors.[47],[48],[49],[50]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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