Body Composition After Bone Marrow Transplantation in Childhood

Kathy Ruble

Matthew J. Hayat

Kerry J. Stewart

Allen Chen

children, bone marrow transplant, bone marrow transplantation
ONF 2012, 39(2), 186-192. DOI: 10.1188/12.ONF.186-192

Purpose/Objectives: To describe the body composition and fat distribution of childhood bone marrow transplantation (BMT) survivors at least one year post-transplantation and examine the ability of the Centers for Disease Control and Prevention criteria to identify survivors with elevated body fat percentage.

Design: Cross-sectional, descriptive.

Setting: Pediatric oncology program at a National Cancer Institute-designated comprehensive cancer center.

Sample: 48 childhood BMT survivors (27 males and 21 females).

Methods: Measurements included dual-energy x-ray absorptiometry scan, height, weight, and physical activity. Descriptive statistics were reported and mixed-model linear regression models were used to describe findings and associations.

Main Research Variables: Total body fat percentage and central obesity (defined as a ratio of central to peripheral fat of 1 or greater).

Findings: Fifty-four percent of survivors had body fat percentages that exceeded recommendations for healthy body composition and 31% qualified as having central obesity. Previous treatment with total body irradiation was associated with higher body fat percentage and central obesity, and graft-versus-host disease was associated with lower body fat percentage. The body mass index (BMI) criteria did not correctly identify the BMT survivors who had elevated body fat percentage.

Conclusions: Survivors of childhood BMT are at risk for obesity and central obesity that is not readily identified with standard BMI criteria.

Implications for Nursing: Nurses caring for BMT survivors should include evaluation of general and central obesity in their assessments. Patient education materials and resources for healthy weight and muscle building should be made available to survivors. Research is needed to develop appropriate interventions.

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    Baer, H. J., Colditz, G. A., Willett, W. C., & Dorgan, J. F. (2007). Adiposity and sex hormones in girls. Cancer Epidemiology, Biomarkers and Prevention, 16, 1880-1888. doi:10.1158/1055-9965.EPI-07-0313
    Brauner, R., Adan, L., Souberbielle, J. C., Esperou, H., Michon, J., Devergie, A., … Zucker, J. M. (1997). Contribution of growth hormone deficiency to the growth failure that follows bone marrow transplantation. Journal of Pediatrics, 130, 785-792.
    Browning, B., Thormann, K., Seshadri, R., Duerst, R., Kletzel, M., & Jacobsohn, D. A. (2006). Weight loss and reduced body mass index: A critical issue in children with multiorgan chronic graft-versus-host disease. Bone Marrow Transplantation, 37, 527-533.
    Castro, J., Lázaro, L., Pons, F., Halperin, I., & Toro, J. (2000). Predictors of bone mineral density reduction in adolescents with anorexia nervosa. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1365-1370. doi:10.1097/00004583-200011000-00010
    Centers for Disease Control and Prevention. (2011). Assessing your weight. Retrieved from
    Chamorro-Viña, C., Ruiz, J. R., Santana-Sosa, E., González Vicent, M., Madero, L., Pérez, M., … Lucía, A. (2010). Exercise during hematopoietic stem cell transplant hospitalization in children. Medicine and Science in Sports and Exercise, 42, 1045-1053.
    Daniels, S. R., Arnett, D. K., Eckel, R. H., Gidding, S. S., Hayman, L. L., Kumanyika, S., … Williams, C. L. (2005). Overweight in children and adolescents: Pathophysiology, consequences, prevention, and treatment. Circulation, 111, 1999-2012. doi:10.1161/01.CIR.0000161369.71722.10
    Dwyer, T., & Blizzard, C. L. (1996). Defining obesity in children by biological end point rather than population distribution. International Journal of Obesity and Related Metabolic Disorders, 20, 472-480.
    Eisenmann, J. C., DuBose, K. D., & Donnelly, J. E. (2007). Fatness, fitness, and insulin sensitivity among 7- to 9-year-old children. Obesity, 15, 2135-2144. doi:10.1038/oby.2007.254
    Flegal, K. M., Carroll, M. D., Ogden, C. L., & Curtin, L. R. (2010). Prevalence and trends in obesity among U. S. adults, 1999-2008. JAMA, 303, 235-241. doi:10.1001/jama.2009.2014
    Flegal, K. M., Graubard, B. I., Williamson, D. F., & Gail, M. H. (2007). Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA, 298, 2028-2037. doi:10.1001/jama.298.17.2028
    Frisk, P., Rössner, S. M., Norgren, S., Arvidson, J., & Gustafsson, J. (2011). Glucose metabolism and body composition in young adults treated with TBI during childhood. Bone Marrow Transplantation, 46, 1303-1308. doi:10.1038/bmt.2010.307
    Gallagher, D., Heymsfield, S. B., Heo, M., Jebb, S. A., Murgatroyd, P. R., & Sakamoto, Y. (2000). Healthy percentage body fat ranges: An approach for developing guidelines based on body mass index. American Journal of Clinical Nutrition, 72, 694-701.
    Garmey, E. G., Liu, Q., Sklar, C. A., Meacham, L. R., Mertens, A. C., Stovall, M. A., … Oeffinger, K. C. (2008). Longitudinal changes in obesity and body mass index among adult survivors of childhood acute lymphoblastic leukemia: A report from the Childhood Cancer Survivor Study. Journal of Clinical Oncology, 26, 4639-4645. doi:10.1200/JCO.2008.16.3527
    Gonzalez-Barcala, F. J., Takkouche, B., Valdes, L., Leis, R., Alvarez-Calderon, P., Cabanas, R., … Tojo, R. (2007). Body composition and respiratory function in healthy non-obese children. Pediatrics International, 49, 553-557. doi:10.1111/j.1442-200X.2007.02420.x
    Hayes, S., Davies, P. S., Parker, T., & Bashford, J. (2003). Total energy expenditure and body composition changes following peripheral blood stem cell transplantation and participation in an exercise programme. Bone Marrow Transplantation, 31, 331-338. doi:10.1038/sj.bmt.1703867
    Iannuzzi, A., Licenziati, M. R., Acampora, C., De Michele, M., Iannuzzo, G., Chiariello, G., … Rubba, P. (2008). Carotid artery wall hypertrophy in children with metabolic syndrome. Journal of Human Hypertension, 22, 83-88. doi:10.1038/sj.jhh.1002289
    Iannuzzi, A., Licenziati, M. R., Acampora, C., Renis, M., Agrusta, M., Romano, L., … Trevisan, M. (2006). Carotid artery stiffness in obese children with the metabolic syndrome. American Journal of Cardiology, 97, 528-531. doi:10.1016/j.amjcard.2005.08.072
    Jacobsohn, D. A., Margolis, J., Doherty, J., Anders, V., & Vogelsang, G. B. (2002). Weight loss and malnutrition in patients with chronic graft-versus-host disease. Bone Marrow Transplantation, 29, 231-236. doi:10.1038/sj.bmt.1703352
    Janiszewski, P. M., Oeffinger, K. C., Church, T. S., Dunn, A. L., Eshelman, D. A., Victor, R. G., … Ross, R. (2007). Abdominal obesity, liver fat, and muscle composition in survivors of childhood acute lymphoblastic leukemia. Journal of Clinical Endocrinology Metabolism, 92, 3816-3821. doi:10.1210/jc.2006-2178
    Kahn, H. S., Imperatore, G., & Cheng, Y. J. (2005). A population-based comparison of BMI percentiles and waist-to-height ratio for identifying cardiovascular risk in youth. Journal of Pediatrics, 146, 482-488. doi:10.1016/j.jpeds.2004.12.028
    Kavey, R. E., Allada, V., Daniels, S. R., Hayman, L. L., McCrindle, B. W., Newburger, J. W., … Interdisciplinary Working Group on Quality of Care and Outcomes Research. (2007). Cardiovascular risk reduction in high-risk pediatric patients: A scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Journal of Cardiovascular Nursing, 22, 218-253.
    Kyle, U. G., Chalandon, Y., Miralbell, R., Karsegard, V. L., Hans, D., Trombetti, A., … Pichard, C. (2005). Longitudinal follow-up of body composition in hematopoietic stem cell transplant patients. Bone Marrow Transplantation, 35, 1171-1177. doi:10.1038/sj.bmt.1704996
    Lustig, R. H., Post, S. R., Srivannaboon, K., Rose, S. R., Danish, R. K., Burghen, G. A., … Merchant, T. E. (2003). Risk factors for the development of obesity in children surviving brain tumors. Journal of Clinical Endocrinology and Metabolism, 88, 611-616. doi:10.1210/jc.2002-021180
    Martarelli, D., Martarelli, B., & Pompei, P. (2008). Body composition obtained from the body mass index: An Italian study. European Journal of Nutrition, 47, 409-416. doi:10.1007/s00394-008-0742-7
    Mertens, A. C., Yasui, Y., Neglia, J. P., Potter, J. D., Nesbit, M. E., Jr., Ruccione, K., … Robison, L. L. (2001). Late mortality experience in five-year survivors of childhood and adolescent cancer: The Childhood Cancer Survivor Study. Journal of Clinical Oncology, 19, 3163-3172.
    Miller, T. L., Lipsitz, S. R., Lopez-Mitnik, G., Hinkle, A. S., Constine, L. S., Adams, M. J., … Lipshultz, S. E. (2010). Characteristics and determinants of adiposity in pediatric cancer survivors. Cancer Epidemiology, Biomarkers and Prevention, 19, 2013-2022. doi:10.1158/1055-9965.EPI-10-0163
    Ness-Abramof, R., & Apovian, C. M. (2008). Waist circumference measurement in clinical practice. Nutrition in Clinical Practice, 23, 397-404. doi:10.1177/0884533608321700
    Neville, K. A., Cohn, R. J., Steinbeck, K. S., Johnston, K., & Walker, J. L. (2006). Hyperinsulinemia, impaired glucose tolerance, and diabetes mellitus in survivors of childhood cancer: Prevalence and risk factors. Journal of Clinical Endocrinology and Metabolism, 91, 4401-4407. doi:10.1210/jc.2006-0128
    Nysom, K., Holm, K., Michaelsen, K. F., Hertz, H., Jacobsen, N., Müller, J., & Mølgaard, C. (2001). Degree of fatness after allogeneic BMT for childhood leukaemia or lymphoma. Bone Marrow Transplantion, 27, 817-820. doi:10.1038/sj.bmt.1703012
    Nysom, K., Holm, K., Michaelsen, K. F., Hertz, H., Müller, J., & Mølgaard, C. (2003). Degree of fatness after treatment of malignant lymphoma in childhood. Medical and Pediatric Oncology, 40, 239-243. doi:10.1002/mpo.10260
    Oeffinger, K. C., Mertens, A. C., Sklar, C. A., Yasui, Y., Fears, T., Stovall, M., … Robison, L. L. (2003). Obesity in adult survivors of childhood acute lymphoblastic leukemia: A report from the Childhood Cancer Survivor Study. Journal of Clinical Oncology, 21, 1359-1365. doi:10.1200/JCO.2003.06.131
    Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M., & Flegal, K. M. (2010). Prevalence of high body mass index in U. S. children and adolescents, 2007-2008. JAMA, 303, 242-249. doi:10.1001/jama.2009.2012
    Piers, L. S., Soares, M. J., Frandsen, S. L., & O'Dea, K. (2000). Indirect estimates of body composition are useful for groups but unreliable in individuals. International Journal of Obesity and Related Metabolic Disorders, 24, 1145-1152. doi:10.1038/sj.ijo.0801387
    Pietilä, S., Mäkipernaa, A., Sievänen, H., Koivisto, A. M., Wigren, T., & Lenko, H. L. (2009). Obesity and metabolic changes are common in young childhood brain tumor survivors. Pediatric Blood and Cancer, 52, 853-859. doi:10.1002/pbc.21936
    Raitakari, O. T., Juonala, M., & Viikari, J. S. (2005). Obesity in childhood and vascular changes in adulthood: Insights into the Cardiovascular Risk in Young Finns Study. International Journal of Obesity, 29(Suppl. 2), S101-S104. doi:10.1038/sj.ijo.0803085
    Remberger, M., Ringden, O., & Markling, L. (1995). TNF alpha levels are increased during bone marrow transplantation conditioning in patients who develop acute GVHD. Bone Marrow Transplantation, 15, 99-104.
    Rourke, K. M., Brehm, B. J., Cassell, C., & Sethuraman, G. (2003). Effect of weight change on bone mass in female adolescents. Journal of the American Dietetic Association, 103, 369-372.
    Ruble, K., Hayat, M. J., Stewart, K. J., & Chen, A. R. (2010). Bone mineral density after bone marrow transplantation in childhood: Measurement and associations. Biology of Blood and Marrow Transplantation, 16, 1451-1457. doi:10.1016/j.bbmt.2010.04.010
    San Juan, A. F., Chamorro-Viña, C., Moral, S., Fernández del Valle, M., Madero, L., Ramírez, M., … Lucía, A. (2008). Benefits of intrahospital exercise training after pediatric bone marrow transplantation. International Journal of Sports Medicine, 29, 439-446.
    Savva, S. C., Tornaritis, M., Savva, M. E., Kourides, Y., Panagi, A., Silikiotou, N., … Kafatos, A. (2000). Waist circumference and waist-to-height ratio are better predictors of cardiovascular disease risk factors in children than body mass index. International Journal of Obesity and Related Metabolic Disorders, 24, 1453-1458. doi:10.1038/sj.ijo.0801401
    Schiel, R., Beltschikow, W., Radón, S., Kramer, G., Perenthaler, T., & Stein, G. (2007). Increased carotid intima-media thickness and associations with cardiovascular risk factors in obese and overweight children and adolescents. European Journal of Medical Research, 12, 503-508.
    Schwartz, M. W., Woods, S. C., Porte, D., Jr., Seeley, R. J., & Baskin, D. G. (2000). Central nervous system control of food intake. Nature, 404, 661-671. doi:10.1038/35007534
    Shalitin, S., Phillip, M., Stein, J., Goshen, Y., Carmi, D., & Yaniv, I. (2006). Endocrine dysfunction and parameters of the metabolic syndrome after bone marrow transplantation during childhood and adolescence. Bone Marrow Transplantation, 37, 1109-1117. doi:10.1038/sj.bmt.1705374
    Stewart, K. J., Bacher, A. C., Hees, P. S., Tayback, M., Ouyang, P., & Jan de Beur, S. (2005). Exercise effects on bone mineral density relationships to changes in fitness and fatness. American Journal of Preventive Medicine, 28, 453-460. doi:10.1016/j.amepre.2005.02.003
    Trost, S. G., Ward, D. S., McGraw, B., & Pate, R. R. (1999). Validity of the Previous Day Physical Activity Recall (PDPAR) in fifth-grade children. Pedatric Exercise Science, 11, 341-348.
    Warner, J. T. (2008). Body composition, exercise and energy expenditure in survivors of acute lymphoblastic leukaemia. Pediatric Blood and Cancer, 50(2, Suppl.), 456-461. doi:10.1002/pbc.21411
    Warner, J. T., Bell, W., Webb, D. K., & Gregory, J. W. (1997). Relationship between cardiopulmonary response to exercise and adiposity in survivors of childhood malignancy. Archives of Disease in Childhood, 76, 298-303. doi:10.1136/adc.76.4.298
    Weston, A. T., Petosa, R., & Pate, R. R. (1997). Validation of an instrument for measurement of physical activity in youth. Medicine and Science in Sports and Exercise, 29, 138-143. doi:10.1097/00005768-199701000-00020
    Williams, D. P., Going, S. B., Lohman, T. G., Harsha, D. W., Srinivasan, S. R., Webber, L. S., & Berenson, G. S. (1992). Body fatness and risk for elevated blood pressure, total cholesterol, and serum lipoprotein ratios in children and adolescents. American Journal of Public Health, 82, 358-363. doi:10.2105/AJPH.82.3.358
    Woo, K. S., Chook, P., Yu, C. W., Sung, R. Y., Qiao, M., Leung, S. S., … Celermajer, D. S. (2004). Overweight in children is associated with arterial endothelial dysfunction and intima-media thickening. International Journal of Obesity and Related Metabolic Disorders, 28, 852-857. doi:10.1038/sj.ijo.0802539
    Zauner, C., Rabitsch, W., Schneeweiss, B., Schiefermeier, M., Greinix, H. T., Keil, F., … Kalhs, P. (2001). Energy and substrate metabolism in patients with chronic extensive graft-versus-host disease. Transplantation, 71, 524-528. doi:10.1097/00007890-200102270-00007