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.