br Discussion br Childhood cancer occurs
Childhood cancer occurs during the critical period of growth and development so both the cancer treatment and behaviours developed during this time may affect long term nutritional health. This study aimed to examine the physical activity, dietary intake and body composition of children, adolescents and young adults who had completed cancer treatment and the impact of clinical and lifestyle factors on body composition in CCS.
The weight and BMI Z-scores of the CCS were not significantly different to their peers, and despite being significantly shorter than the controls, the height Z-score was within expected range. Ac-cording to BMI, 25% of the CCS were overweight or obese compared to 8% of the controls. The prevalence of overweight and obesity according to BMI in the CCS was the same as the reported preva-lence of overweight and obesity in Australian children of around 25% , but was lower than previous studies have reported in young CCS [34e36]. As previous studies have shown, BMI is not an accurate assessment of nutritional status in children and survivors with cancer [37e39], so it is essential to report on FM and FFM components when evaluating the impact of cancer on nutritional health. Our study showed that the CCS had significantly higher %FM and FMI compared to controls, which is in agreement with previous studies who examined FM in CCS by dual Etoposide x-ray absorpti-ometry [40e42]. The survivors in this study also had significantly reduced BCMI, which we have shown previously with a cohort of 53 of the current 74 subjects . More research is needed to examine the clinical implications of decreased BCM and increased FM on clinical outcomes for CCS.
Although obesity is a recognised late effect of childhood cancer, the important finding of this study is that under nutrition, as indicated by reduced BCM, is actually more prevalent than obesity in this group of CCS, with 59% of survivors considered under nourished compared to 27% who were obese. The clinical impli-cations of these findings are that CCS clinics be aware that both malnutrition and obesity may be a late effect for CCS and should screen for both. It is also highlights an important consideration for diet and exercise intervention programs for CCS, which is that the intervention needs to not only target obesity, but also on improving the metabolically active lean tissues.
In this study the only clinical variable that was associated with body composition, was that having received a BMT was related to low BCMI and FFMI. The conditioning regimens, mucositis and gut graft-versus-host disease can result in poor functional integrity of the gastrointestinal tract during BMT, which affects nutritional status in the short term [44,45]. Our study demonstrates that having had a BMT continues to influence nutritional status in the long term and that consequently nutritional support should be an important consideration before, during and after BMT.
Sixty-one percent of the CCS had energy intake between 75% and 110% of predicted energy requirements, with around 1 in 5 consuming above and 1 in 5 consuming below the predicted re-quirements. The energy intake of this cohort of paediatric cancer survivors appears comparable to that of the general Australian population which is consistent with previous research in CCS . The macronutrient distribution of total energy intake consisted of 46% carbohydrates, 34% fat and 20% protein, which demonstrated that the survivors consumed more energy from fat and protein and less from carbohydrates than Australian population . Our study showed that 48% of the CCS population consumed energy from fat above the upper end of the recommended range compared to 15% of Australian population (4e18 year olds) and that 38% of CCS had a usual intake of carbohydrate as a proportion of total energy below the lower limit of the AMDR, compared to the 19% of Australian 4e18 year olds . The results of this study demonstrate that CCS have overall energy intake that meets energy requirements, but that the CCS consumed high amount of calories from fat and low amount of calories from carbohydrates. Although no dietary vari-ables were related to body composition in this study, consuming higher fat than AMDR may be a contributing factor to the increased fat mass seen in our subjects.
We observed a high intake of sodium (77% exceeded upper limit) in CCS, which is consistent with the Australian Health Sur-vey in which 91% of males and 74% of females aged 2e18 years exceeded the upper limit . Our study found that a high per-centage of the CCS were not meeting needs for intake of calcium (61%), magnesium (46%), iodine (38%) and folate (38%), which were consistent with findings in previous CCS cohorts [20,47]. The inadequate intakes of calcium and magnesium were consistent