BACKGROUND The effect of body mass index (BMI) on treatment outcome of children with acute myeloid leukemia (AML) is unclear and needs further evaluation. METHODS Children with AML (n=314) enrolled in 4 consecutive St. Jude protocols were grouped according to BMI (underweight, <5th percentile; healthy weight, 5th to 85th percentile; and overweight/obese, ≥ 85th percentile). RESULTS Twenty-five (8.0%) patients were underweight, 86 (27.4%) overweight/obese, and 203 (64.6%) had healthy weight. Five-year overall survival of overweight/obese patients (46.5±7.3%) was lower than that of patients with healthy weight (67.1±4.3%, P < .001); underweight patients also tended to have lower survival rates (50.6±10.7%, P = .18). In a multivariable analysis adjusting for age, leukocyte count, FAB type, and study protocols, patients with healthy weight had the best survival rate among the 3 groups (P = .01). When BMI was considered as continuous variable, patients with lower or higher BMI percentiles had worse survival (P = .03). There was no difference in the occurrence of induction failure or relapse among BMI groups but underweight and overweight/obese patients had a significantly higher cumulative incidence of treatment-related mortality, especially due to infection (P = .009). CONCLUSIONS An unhealthy BMI is associated with worse survival and more treatment-related mortality in children with AML. Meticulous supportive care, with nutritional support and education, infection prophylaxis, and detailed laboratory and physical examination is required for these patients. These measures, together with pharmacokinetics-guided chemotherapy dosing may improve outcome.

Background Survivors of childhood acute lymphoblastic leukemia (ALL) are vulnerable to exaggeration of the aging process including decreased bone mineral density (BMD). As little is known about their dietary or nutrient intake that may affect their long-term bone health, we examined nutrient intake in long-term survivors of childhood ALL. Procedure Survivors (n=164) of childhood ALL who had completed treatment for at least 5 years and were in continuous remission, completed a 110-item food questionnaire that reflected dietary intake over the previous year. The analyzed cohort comprised 34 females and 38 males younger than 19 years and 45 females and 47 males at least 19 years. Reported nutrient intake and food selection were compared with age-specific Recommended Dietary Allowance and USDA Pyramid Food Guide. Body mass index was compared to the general US population, adjusted for age, gender, Tanner stage and race. Results Less than 30% of participants met recommended dietary intakes for vitamin D, calcium, potassium or magnesium regardless of age. Mean daily caloric intake was 2204 Kcal (51% from carbohydrates) for younger and 2160 Kcal (49% from carbohydrates) for older participants. Energy intake from sweets was 70% higher than recommended. Participants <19 years were less likely to have a healthy weight (Odds Ratio.0.48, 95% CI 0.30-0.79); < 19 years more likely to be overweight (Odds Ratio 1.95, 95% CI 1.11-3.32, p<0.002) Conclusions Survivors of childhood ALL need careful dietary intervention to optimize long-term health.

Background We sought to improve lumbar spine bone mineral density (LS-BMD) in long-term survivors of childhood acute lymphoblastic leukemia (ALL) using calcium and cholecalciferol supplementation. Procedure This double-blind, placebo-controlled trial randomized 275 participants (median age, 17 (9 –36.1) years) with age- and gender-specific LS-BMD Z-scores < 0 to receive nutritional counseling with supplementation of 1000 mg/day calcium and 800 IU cholecalciferol or placebo for 2 years. The primary outcome was change in LS-BMD assessed by quantitative computerized tomography (QCT) at 24 months. Linear regression models were employed to identify the baseline risk factors for low LS-BMD and to compare LS-BMD outcomes. Results Pre-randomization LS-BMD below the mean was associated with male gender (p=0.0024), white race (p=0.0003), lower body mass index (p<0.0001), and cumulative glucocorticoid doses of ≥5,000 mg (p=0.0012). One hundred eighty-eight (68%) participants completed the study; 77% adhered to the intervention. Mean LS-BMD change did not differ between survivors randomized to supplements (0.33±0.57) or placebo (0.28±0.56). Participants aged 9 – 13 years and those 22–35 years had the greatest mean increases in LS-BMD (0.50±0.66 and 0.37±0.23, respectively). Vitamin D insufficiency [serum 25(OH)D <30 ng/mL] found in 296 (75%), was not associated with LS-BMD outcomes (p=0.78). Conclusion Cholecalciferol and calcium supplementation provides no added benefit to nutritional counseling for improving LS-BMD among adolescent and young adult survivors of ALL (93% of whom had LS-BMD Z-scores above the mean at study entry).

The BONEII study is a large two-phase study. The baseline study (Study 1) aims to estimate the prevalence of diminished bone mineral density (BMD) in patients treated for childhood acute lymphoblastic leukemia (ALL) and identify risk factors for BMD deficits. The interventional phase (Study 2) of BONEII has a placebo-controlled double-blind randomized longitudinal design to evaluate the effects of nutritional counseling and calcium and vitamin D supplementation on changes in BMD and serum and urine markers of bone metabolism. The extensive information being collected through this large study will serve as a repository of relational data about BMD and bone turnover and will support further investigations to assess the association of calcium metabolism, bone turnover, nutritional intake, lifestyle factors (such as exercise and the use of alcohol and tobacco),

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