Abstract: This study attempts to determine interrelationship between nutritional status and quality of life among leukemic children. Cross sectional study involved 34 children aged 5-15 years old. Anthropometric measurements and biochemical data were obtained. A Multiple Pass 24-h Diet Recall for nutritional assessment was attained. Quality of Life (QoL) is measured using Cancer Module PedsQL. The findings revealed that leukemic children have normal development like healthy children of the same age. Majority of them had normal percentiles of height-for-age and weight-for-age with 91.2 and 97.1%, respectively and only 5.9% were stunted. Indicators of protein-energy malnutrition showed that triceps skinfold 64.7%, MUAC 73.5% and arm muscle area 73.5% were in normal percentiles. Where else, for biochemical assessment, most of them have normal albumin and total protein level, 91.8 and 79.4%, respectively but 55.9% have low hemoglobin level. There were significant difference between QoL with socioeconomic status and time of diagnose. QoL was positively correlated with weight and body mass index but negatively correlated with total protein and albumin. In conclusion, it is learned that weight, BMI, total protein and albumin were not a predictor of QoL among leukemic children.
INTRODUCTION
Leukemia is a type of cancer of the blood or bone marrow characterized by an abnormal increase of white blood cells. Leukemia is a broad term covering a spectrum of diseases. In turn, it is part of the even broader group of diseases called hematological neoplasms (Jameson et al., 2005).
Cancer incidence and mortality have been steadily rising throughout the last century in most areas of the world (Gursoy and Kinik, 2006). Although mortality rates are highly divergent across pathological subtypes, the 5-year survival rate for all childhood cancers combined increased from 55.7% (1974-1976) to 77.1% (1992-1997) (Lim et al., 2002). In Malaysia, cancer is a leading cause for death, it is estimated that 40,000 cases were diagnosed every year (MAKNA, 2003). There are approximately 3567 new cases of childhood leukemia in Malaysia each year (MAKNA, 2006).
However, children with cancer are at high risk of major nutritional problems both from the tumor itself and from the treatment administered. A significant number of children are found to be malnourished at the time they are diagnosed. Furthermore, the nutritional problems from the cancer may soon be intensified by iatrogenic nutritional problems as consequences of surgery, chemotherapy and/or radiotherapy because the interventions itself may affect functional ability and further, will compromise with their nutritional intake to worst. Moreover, the interaction between nutritional status and intake and symptoms or disease and treatment-related factors which is a complex combination, may dictate a patient’s quality of life (QoL). QoL is actually a multifaceted construct of physical, emotional, psychological and social components (Ferrell et al., 1991) or multidimensional measure where it is not restricted to either physical or psychological effects of treatment (Jain et al., 2010).
This study attempts to determine the relationship between nutritional status from anthropometric indices, biochemical assessment, dietary intake and quality of life which encompass physical, psychological and psychosocial well-beings among leukemic children.
MATERIALS AND METHODS
Study design: This cross-sectional study, approved by Ministry of Health Ethics Committee, was designed to investigate the relationship between nutritional status and quality of life among leukemic children at Pediatric Institute, Hospital Kuala Lumpur. Informed consent was obtained from their parents or caretakers.
Study subjects: Thirty-four children with leukemia (18 boys and 16 girls) aged 5 to 15 years old were enrolled in this study. Inclusion criteria were children with leukemia aged 5 to 15 years old, able to speak and literate well and consumes diet orally. Exclusion criteria were patients with other chronic diseases, receiving nutritional support on tube feeding or parenteral nutrition and patients with mental retardation.
Anthropometric measurement: The anthropometric measurements taken were body weight, height, triceps skinfold and Mid-Upper Arm Circumference (MUAC). All the measurements were collected by the same investigator to avoid inter-observer error and to maintain uniformity and accuracy in techniques. Heights of the children were measured using SECA Bodymeter (Germany). The reading was taken to the nearest 0.1 cm. Electronic scales (Tanita) were used to measure weight of the children wearing minimum clothing and recorded to the nearest 0.1 kg (Azuan et al., 2010). The anthropometric indices were calculated using Quatelet’s Index and CDC’s gender specific growth charts 2-20 years. Those, having BMI-for-age-percentile 5th-<85th percentile were declared as normal weight and obese with>95th percentile (Ramzan et al., 2011). Children who were less than 5th percentiles or two standard deviations below the reference median (<-2 SD) were considered as underweight (weight-for-age), stunted (height-for-age) and wasted (weight-for-height) respectively (Raheela Mian et al., 2002). A non-stretchable tape was used to measure the circumference of the mid-upper arm. The circumference was measured at the midpoint of the upper left arm between the acromion process and the tip of the olecranon. After locating the mid-point, the left arm was extended and hung loosely by the side with the palm facing inwards. The tape was wrapped gently but firmly around the arm at the mid-point and the measurement was recorded. This was repeated three times and the mid-upper arm circumference was obtained by averaging the three values. Values less than 5th percentile based on Frisancho and Tracer (1987) will be considered as muscle wasting. Skinfold thickness is measured to the nearest mm, except for low values (usually 5mm or less) when it is taken to the nearest 0.5 mm. Triceps skinfold were measured using Harpendens calipers at the midpoint of non-dominant upper posterior arm. Measurements are usually done on the right side of the body with the subject standing in a relaxed condition.
Biochemical profiles: Biochemical profiles of serum albumin and haemoglobin levels were obtained from patients’ medical records. Normal range for total protein, serum albumin and hemoglobin were 60 to 80 g L-1, 30 to 54 g L-1 and 11-14 g dL-1, respectively. Any values less than that reflected malnutrition.
Dietary status: A multiple pass 24 h recall been used to obtain dietary intake. It is a combination of 24 h diet recall, diet history and food frequency questionnaire which will effectively minimized under reporting from occurred. First, obtain a complete list of all foods and beverages consumed during the preceding day. Next, detailed descriptions of all foods and beverages consumed are attained like cooking methods, brand names, time and place of consumption, type of cooking vessels used. Estimate the amounts of all foods and beverages consumed and the frequency. Lastly, review the recall to ensure all the items have been recorded correctly. This can be conducted on adults and children over 8 years of age but for children between 4-8 years should be interviewed along with their primary caretaker. Data obtained were analyzed using NutriPro.
Statistical analysis: Descriptive and statistical analyses were done using SPSS version 13.0. Values were expressed as percentage and Mean values±SD. For comparison, Mann-Whitney was used and Kruskal-Wallis. Spearman correlation was used to look at the relationship between nutritional status and quality of life. The differences were considered significant if p<0.05.
RESULTS
Table 1 shows characteristics of 34 leukemic children by sex, age group and ethnicity. Of the 34 subjects, 52.9% were male and 47.1% were female. The age group was divided into three groups: of 5 to 7 years old. Classification by ethnicity showed that majority of the subjects are Malays (58.8%) followed by Chinese (29.4%), Indians (8.8%) and others (2.9%). Majority of the subjects were diagnosed as Acute Lymphoblastic Leukemia (ALL) (94.1%) followed by Acute Myeloid Leukemia (AML) (5.9%). The 64.7% of the subjects were newly diagnosed with less than 12 months. According to Table 2, it shows that majority of the subjects had an optimum nutritional status depending on their anthropometric measurement and biochemical status. Only one subject is classified as underweight (2.9%) compared to WHO growth chart at the same age, stunting (8.8%) and wasting (5.9%). Meanwhile, almost a quarter of the subjects (23.5%) were wasting with their mid-upper arm circumference-for-age less than 3rd percentile when compared to Frisancho (1981) at the same age.
The mean dietary intake for energy, protein, calcium and ferum among children and adolescents according to age groups are presented in Table 3. Majority of the subjects had low intake of energy and there was significant difference in energy intake for male 1354.1±216 kcal day-1 (p = 0.012) and female 1310.8±144.1 kcal day-1 (p = 0.002). Apart from this, most subjects had an overall percentage of RNI above 100% for dietary protein. However, there were obvious significant difference between dietary calcium and ferum intake.
| Table 1: | Characteristics of study subjects |
| Table 2: | Prevalence of malnutrition in children with leukemia |
Table 4 presents the differences in mean of Quality of Life (QoL) scores between age groups and related factors. As expected, family income and time since diagnosis are closely associated with QoL. The total QoL score were seen statistically low in young age subjects (5 to 7 years old) with average family income (RM1000-RM3000) and relapses subjects with total QoL score of 48.69±15.22 (p = 0.029) and 41.94±6.20 (p= 0.032), respectively. Conversely, gender, ethnics, type of diagnosis and treatment status was not related to any of the outcomes. According to Table 5, it shows the differences in mean of Quality of Life (QoL) scores for each domain between gender and age groups. Subjects had better score in psychological well-being (60.18±17.86) which includes procedural and treatment anxiety, worry and cognitive status. And they perceived lowest score in social well-being (56.01±21.96) such as body image perception and communication. Statistical tests also proved that boys had lower QoL score in procedural anxiety (35.65±38.33) compared to girls.
Lastly, Table 6 presents relationship between nutritional status and total score of Quality of Life (QoL). Weight and BMI status reflect a significant positive relationship between nutritional status and total QoL score with r value of 0.371 (p = 0.031), 0.405 (p = 0.017), whereas total protein shows a significant negative relationship with r value of-0.0385 (p = 0.25).
| Table 3: | Comparison of mean macronutrients intake with RNI in 2005 and age group |
| aBased on recommended nutrient intake’s for Malaysia 2005 (NCCFN, 2005). bp<0.05 there significant difference between mean intake and RNI Malaysia in 2005 | |
DISCUSSION
In this study, the overall prevalence of malnutrition among children with leukemia aged between 5 to 18 years, based on anthropometric measurements was 8.8% stunting, 2.9% underweight and 5.9% wasted. Approximately, 23.5% showed signs of malnutrition for MUAC-for-age criterion. Though the prevalence of malnutrition (height-for-age) is low (8.8%) in this study, but it is supported by other studies done among 17 cancer children in HUKM (76.5%) as reported by Aini et al. (2007), among 128 children in Brazil (76.5%) as reported by Viana et al. (1994) and in another study from India on 44 children in India (25%) as reported by Jain et al. (2003). According to interpretation of anthropometric indices by FANTA (2003), lower height-for-age indicates past undernutrition or chronic malnutrition. But, it cannot measure short term changes in malnutrition.
Furthermore, this study reports that only 8.8% of the subjects showed malnutrition according to biochemical assessment. Serum albumin has been used in the past as an indicator of nutritional status (Secker and Jeejeebhoy, 2007). However, Marshall (2000) also reported that serum albumin was not a sensitive indicator of nutritional status as it had short half-life and maybe altered by underlying disease and/or treatment.
| Table 4: | Difference in mean of QoL score between age groups and related factors |
| ap<0.05 There are significant difference of QoL scores between age groups | |
| Table 5: | Differences in mean of quality of life scores between age groups and gender |
| Domain 1: Pain, 2: Nausea, 3: Procedural anxiety, 4: Treatment anxiety, 5: Worry, 6: Cognitive status, 7: Body perception, 8: Communication. bp<0.05 There are significant difference of quality of life scores between age groups and gender | |
| Table 6: | Relationship between nutritional status and quality of life (QoL) |
| ap<0.05 There are significant correlation between nutritional status and quality of life | |
Therefore, serum albumin does not merely reflect the nutritional status among children with leukemia. The results also showed that hemoglobin was low in more than half of the subjects (55.9%) which suggest that the deficiency may be related directly to the disease and the treatment. Young et al. (1990) reported anemia is the most common problem among cancer children and closely associated with poor nutrition status, infection, blood loss and drugs response.
In terms of dietary assessment, energy, protein, calcium and iron intake was assessed among the subjects. Majority of the subjects did not meet the requirements for energy and calcium, but had achieved more than 100% of protein and ferum requirements. This is because majority (73.5%) of subjects were on chemotherapy during study was done. Nausea and vomiting are the most common immediate manifestations of chemotherapy and it will dictate patient’s appetite. Thus, they tend to have low energy intake (Pui et al., 2004). Other nutritional effects will be fatigue that frequently experienced by cancer patient undergone chemotherapy, though the mechanism is hardly understood. But it is pressuring and interfering with body functions as well as negatively influenced patient’s quality of life (Boman and Bodegarrd, 2000).
In overall, majority of the subjects had an optimum quality of life score though girls (52.3±15.43) had higher score than boys (63.29±19.86). Furthermore, it was proved that family socioeconomic status did influence patient’s quality of life significantly. Subjects from higher class of socioeconomic had highest score compared to low and middle class. This was supported by Hudson et al. (2003), stated that the lower the socioeconomic status and educational background of the family, the lower quality of life of cancer children would have. Studies done by Boman and Bodegarrd (2000) also discovered children with cancer reported having lower psychological score were from low socioeconomic status and educational background family.
When looking at psychosocial perspectives, the subjects had lowest total QoL score compared to physical and psychological perspectives especially the boys. Few studies also proved gender and age were closely related to development of psychosocial problem and it was a crucial factor in influencing self esteem (Stern and Alvarez, 1992). Lower self esteem is associated with lower QoL too (Langeveld et al., 2004). However, procedural anxiety ranked the lowest score of QoL for both genders. Kazak et al. (1996) also stated invasive and frequent treatment procedures will not only pressuring the leukemic children but are traumatic to the parents too.
In overall, there were positive relationship between weight and Body Mass Index (BMI) with quality of life as presented in Table 6. It shows that increasing body weight and BMI value in cancer children were associated with rising quality of life score. Hillner et al. (2003) also reported in their studies, continuous loss of body weight will cause decreasing in quality of life which will interfere with the efficiency of treatment, delay wound healing and worsen the complications.
Since leukemia is the most common cancer in children and is now a curable disease, it is therefore important for them to have better nutritional status early to ensure optimal treatment and outcome, as well as promoting better quality of life. This study provides objective evidence that nutritional status mainly weight status and dietary intake are determinants of patient’s QoL.
CONCLUSION
Prevalence of malnutrition among the leukemic children can be seen based on anthropometry measurement but it was not clearly presumed through biochemical and dietary assessment. Hence, it was not significantly described the malnutrition incidence among them and more or less it was not much different with normal and healthy children It was concluded that malnutrition is the outcome of the disease itself, the treatment and side effects as well as nutritional consequences and will finally dictate patient’s quality of life. But it can be prevented by early adequate nutritional support as well as by psychological health status. However, further studies with larger sample sizes and multi-centered approach are required for a better understanding of the effect of cancer on the nutritional status and quality of life of children with leukemia.
ACKNOWLEDGMENTS
This research was supported financially by Universiti Teknologi MARA through the Dana Kecemerlangan grant. The authors gratefully acknowledge the patients and their caretakers for commitment and willingness; and also staff from the Oncology Ward of Pediatrics Institute of Kuala Lumpur for their assistance.