Variations in Energy and Nutrient Specific Consumption Over the Course of Therapy in Children with Acute Lymphoblastic Leukemia.

Few research studies have investigated the nutritional status of children with acute lymphoblastic leukemia (ALL). Preliminary studies have found that malnutrition is associated with lower 5-year survival, increased relapse rates and more frequent reductions in chemotherapy dose. The extent of malnutrition has not been well characterized. Results of a prospective multi-institution study investigating dietary micronutrient intake over the course of treatmentfor ALL are reported.

Assessment of dietary intake was collected for participants enrolled on the DFCI ALL Consortium Protocol 05-001 from 2005–2011. Institutional review board approval was obtained by each of the 9 participating centers. Dietary intake was assessed at three timepoints in therapy: diagnosis (T1), Day 32 (end) of induction therapy (T2), and 15 months post-diagnosis (T3) (during maintenance therapy) with the Harvard Service Food Frequency Questionnaire for children ages 1–5 years and the Youth and Adolescent Harvard Food Frequency Questionnaire for children ages 5–18 years. Questionnaires were self-administered and were completed by parents or primary care takers when children were below age 6 years. Dietary intake was examined by comparing energy and nutrient specific consumption above and below recommended intake using age specific values for Dietary Reference Intake (DRI).

Among 794 patients with ALL registered on the 05-001 Protocol, dietary intake questionnaires were availablefor 622, 564, and 423 patients at T1, T2, and T3, respectively. Median age of participants at T1 was 5 yrs (range 1–17.9 yrs) and 272 (44%) were female, 350 (56%) were male. Initial leukemia risk classification included 363 standard risk (58%) and 259 (42%) high risk. At diagnosis, the majority of children reported consuming more than the age and gender specific DRI. For 388 children (62%), reported caloric intake was >25% the DRI, while another 81 (13%) reported caloric consumption >10% the DRI. In contrast, only 116 (19%) did not meet the DRI. At T2, similar findings were observed, despite administration of a 32 day prednisone course which would have been expected to result in a higher proportion of children exceeding recommended caloric intake. Of those responding at T2, 128 (23%) were not meeting the DRI, while 65 (12%) and 335 (59%) exceeded the recommended caloric intake by >10% and >25% respectively. During maintenance therapy (T3), total caloric intake declined with a greater proportion of participating children reporting intake below the DRI (30%) and a smaller proportion reporting intake >25%DRI (49%), while the proportion consuming recommended intake or >10% DRI remained stable. Distribution of children reporting nutrient consumption below, at, or above age and gender specific DRI values for key micronutrients is summarized in Figure 1. The majority of patients did not meet the DRI for vitamin E and vitamin D at all 3 time points, while nearly half the participants exceeded the DRI for zinc and folate.

The majority of children with newly diagnosed ALL have evidence of overnutrition or malnutrition, as demonstrated by overconsumption of calories, or deficiency or overconsumption of key micronutrients, which may be associated with increased risk for treatment related toxicities. Increased consumption of folate during the maintenance phase in which methotrexate is a major component of treatment also needs further study. Additional analyses are underway to explore these relationships.

Figure 1.

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Proportion of patients reporting nutrient intake below, at, or above the age and gender specific Dietary Reference Intake values for select micronutrients at the 3 time points evaluated during therapy for acute lymphoblastic leukemia

Figure 1.

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Proportion of patients reporting nutrient intake below, at, or above the age and gender specific Dietary Reference Intake values for select micronutrients at the 3 time points evaluated during therapy for acute lymphoblastic leukemia

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No relevant conflicts of interest to declare.