Feasibility
Twenty participants (87%) completed the End of Study Survey. Sixty
percent of participants agreed that the diet was easy to follow during
treatment and believed that they were successful at doing so. Further,
95% of participants found the diet affordable and 90% agreed it was
easy to understand. Eighty-five percent of participants planned to
continue the diet after the intervention ended.
DISCUSSION
To our knowledge, our results are the first to suggest that a dietary
intervention initiated during the initial phases of treatment for
childhood ALL is feasible, and may improve diet quality and stabilize
weight. Despite an observed increase in calories, potentially due to
administration of steroids, participants were able to improve dietary
quality through increased intake of vegetables and decreased intake of
added sugars. With the sustainability and long-term efficacy of
calorie-restricted diets being questioned, emphasizing the quality over
the quantity of calories consumed is becoming increasingly important in
interventions targeting weight management.23,24 This
finding is especially important in light of a recent article
highlighting the importance of diet quality, rather than calorie
counting, in reducing acute toxicities in childhood
ALL.25
Few published studies have investigated a nutrition intervention during
treatment for childhood ALL. All of the existing studies have initiated
the nutrition intervention during the maintenance phase of therapy,
which is after the initial onset of obesity.26-29 Our
intervention was not designed to be a weight-loss intervention. The
nutrition education focused on dietary quality and avoidance of
excessive consumption of obesity-promoting foods. Thus, an important
finding of our study is the reduction of obesity-promoting foods and
nutrients, mostly notably added sugar.30,31 This
builds upon our previous work that found an increased intake from
carbohydrates, more so than total calories, predicted higher BMI at
continuation.22 Aligned with the dietary principles
relied upon in this study, increased dietary fiber intake through
consumption of fruit, vegetables, whole grains, and legumes is a
well-established strategy to prevent and treat childhood
obesity.32 We observed a notable increase in intake of
total vegetables over the study period. Though we did not find a
significant change in GI values throughout the study, we did observe
significant reductions in GL. The GL reflects the quantity and quality
of carbohydrate and has been found to be a better indicator of glycemic
response compared to GI.33 Taken together, our results
emphasize the need to focus on dietary quality versus traditional
calorie counting approaches. Additional research is warranted.
The available literature examining weight gain during childhood ALL
treatment consistently reports excessive weight gain during the
induction and maintenance phases of therapy.6,7,34,35Previous studies also have found that weight gain during induction
predicts weight gain in the later phases of treatment, which further
underscores the importance of the findings of our intervention. In
contrast to the existing literature, our analyses did not reveal a
significant increase in BMI early on treatment. However, our findings
must be interpreted considering the pilot nature of the study.
There are several strengths of our study. This was a standardized
nutrition intervention provided at multiple centers with an ethnically
diverse population. A standardized dietary approach was implemented and
was able to be personalized based on variation in regional location,
ethnicity, and socioeconomic status. Rather than focusing on calorie
counting or weight reduction, our intervention focused on improving
dietary quality within the sociodemographic variables of the
participant, which made the intervention easy to follow. A dietitian was
not always the staff member to provide dietary counseling due to
understaffing at certain sites, demonstrating that the intervention can
be delivered especially with the expansion of telehealth. The high
percentage of participants who reported the diet to be easy to follow
and economical suggests this study could be replicated and received with
interest in a larger, multi-center setting.
Our results should be interpreted in light of limitations. Dietary
intake was self-reported; therefore, we cannot exclude the possibility
of misreporting.36 However, this was minimized by the
collection of two 24-hour recalls within one week of each other. We did
not collect information on physical activity, although we believe that
this is a small effect as most patients are sedentary during the
initial, most intensive, phases of treatment for childhood ALL.
Socioeconomic status was not considered in this analysis, but will be
included in subsequent studies.37 Finally, despite
similar approaches for childhood ALL treatment, participants were
diagnosed with either B- or T-cell ALL and treated on COG and DFCI
protocols, both of which consist of varying doses and duration of
steroids. While our limited sample size precluded a comprehensive
analysis of these features, our results suggest that this intervention
is feasible regardless of treatment regimen, risk group, or ALL
phenotype, further improving its generalizability in a larger,
multi-center setting.
This study demonstrates that a six-month nutrition intervention
initiated in the earliest phase of treatment for childhood ALL is
feasible and well-received. Preliminary analysis indicates that our
dietary intervention may prevent the excessive weight gain typically
seen during the initial phases of treatment. Larger lifestyle
intervention studies focused on early prevention of weight gain should
be prioritized. Efforts to confirm our findings in a larger, randomized
controlled trial within several cooperative groups settings are
underway.
Conflict of interest : None of the authors have any conflict of
interest to report.