High incidence of metabolic diseases and sedentary lifestyle underline the need for regular counseling in LTFU for CCS- results from a monocentric prospective study

doi:10.21203/rs.3.rs-2947105/v1

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High incidence of metabolic diseases and sedentary lifestyle underline the need for regular counseling in LTFU for CCS- results from a monocentric prospective study

https://doi.org/10.21203/rs.3.rs-2947105/v1

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Background

Many childhood cancer survivors (CCS) develop treatment-related late effects years after the end of treatment, including increased risk of obesity, metabolic syndrome and related diseases. A healthy lifestyle can reduce the risk of associated comorbidities. Lifestyle counseling during regular long term follow up (LTFU) care could benefit these at-risk CCS.

Methods

Lifestyle counseling was implemented within LTFU care over the study period of one year. Metabolic markers and activity levels were prospectively evaluated as screening parameters for different risk groups. Perspectives of CCS, Physician and sports scientist were compared to identify those in need of counseling. Additionally, a follow-up appointment after one month was performed.

Results

During the counseling offer, 155 CCS (65% female, 35% male) aged between 18 and 63 years (median:30 years) were contacted. Among them, 112 CCS (72%) had an indication for lifestyle counseling based on assessments from physicians, sports scientists, or CCS themselves. 45% were affected by metabolic disorders, 25% met the criteria through BMI and 46% did not meet the recommended activity levels. A total of 120 CCS (77%) received lifestyle counseling, with those who underwent intensive cancer treatment showing the highest need. During the follow-up appointment, CCS indicated high adherence to recommendations and successful implementation into their daily lives.

Conclusion

Metabolic disorders and reduced physical activity impact around two-thirds (68%) of CCS. Nearly all survivors (97%) find the provision of lifestyle counseling during regular LTFU beneficial. Incorporating specialized healthcare professionals into survivorship care enhances the multidisciplinary approach and can aid in promoting a healthy lifestyle, potentially reducing long-term morbidity among CCS.

lifestyle counseling

long-term follow up

childhood cancer survivors

physical activity

metabolic disorders

Due to improved treatment modalities, the proportion of patients surviving childhood and adolescent cancer has been steadily increasing in recent decades. Currently, more than 40,000 former patients are included in the long-term follow up (LTFU) cohort of the German Childhood Cancer Registry (GCCR) (1). These childhood cancer survivors (CCS) have been diagnosed with cancer at least five years ago, so that regular oncological follow-up has usually already been completed. During their lifetime, many of these survivors are affected by further health problems and diseases caused by the cancer and its therapy, so-called late effects (2). These can manifest in different organs of the entire body. Due to hormonal changes and altered body composition that may occur during or after therapy, the risk of obesity and associated diseases such as diabetes mellitus, cardiovascular disease, and hypertension increases (3). Cardiovascular disease, in turn, is among the most common nonmalignant causes of death in cancer survivors, with some entities such as Hodgkin lymphoma survivors having a particularly high risk (4, 5). Long-term sequelae may not only manifest in physical form; many CCS develop psychological problems, particularly depression or fatigue syndrome, during or even years after cessation of cancer treatment (6, 7). For these CCS at-risk, it is particularly important to develop interventions or treatments that can positively influence their long-term health.

According to Smith et al. (2014) over 70% of CCS do not meet the lifestyle guidelines of the World Cancer Research Fund and in more than 30% of the adult CCS (median age: 32.7 years, 1598 participants), metabolic syndrome was already prevalent, which is a combination of metabolic parameters associated with increased cardiovascular risk (8). Consequently, multiple studies evaluated the effect of counseling on the CCS lifestyle and could demonstrate a reduction in co-morbidities as well as a better quality of life due to a healthy lifestyle (9, 10). Furthermore, CCS improved in blood pressure due to lifestyle counseling in previous studies (11). Therefore, a healthier lifestyle could result in less co-morbidities including the metabolic syndrome among CCS (9). A healthy lifestyle in this context includes in general no smoking, the awareness of alcohol consumption, regular physical activity as well as a vitamin and nutrition rich diet (12).

Additionally, previous studies demonstrated that the occurrence of late effects can be positively influenced by regular physical activity, exercise, and a healthy diet (2, 13). Especially avoiding overweight and obesity has a significant impact on the severity of late effects associated with the metabolic syndrome (10). The American College of Sports Medicine and the American Cancer Society recommend that cancer survivors engage in at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity physical activity weekly. However, only 46% of CCS meet the physical activity recommendations according to Ness et al. (2009), although all CCS are able to return to physical activity after cancer treatment, taking into account their physical condition and interests (14). Both the type and intensity of exercise may differ from the type of sport practiced before the disease, but physical activity in general has a benefit (13) as it not only improves body composition and reduces the risk of future health conditions; it also often positively affects mental health (14). Additional factors such as age, gender and the socioeconomic status (that correlates inversely with the risk of obesity) also need to be considered in lifestyle counselling (15–17). As interest in lifestyle counseling may decrease with increasing time interval from diagnosis and late effects often do not manifest until adulthood, it is especially important to inform and counsel children, adolescents and young adults about the importance of prevention in terms of a healthy lifestyle (18). The earlier the education about a healthy lifestyle including physical activity and healthy nutrition starts, the more likely this behavior will be sustained in future life (19). Therefore, implementation of regular lifestyle counseling within the framework of the LTFU care could be a useful and practical approach to inform CCS about a healthy lifestyle in order to prevent future diseases.

In 2014, an interdisciplinary long-term follow-up clinic for CCS (“LTFU clinic”) has been established at the University Medical Center Schleswig-Holstein, Campus Luebeck (20). Among others, we were a consortium partner in the multicenter study CARE for CAYA that took place from 2018 to 2021 and provided specialized lifestyle counselling for high-risk CCS (21). Based on these experiences, we decided to implement lifestyle counseling as part of standard care for every CCS during their regular visit in our LTFU clinic. Additionally, we performed an analysis to determine how many CCS are in need of lifestyle counseling according to current guidelines (12, 22) due to pre-existing metabolic diseases and how they accepted and implemented counseling into their daily life (at a follow up appointment four weeks later). Furthermore, we aimed to develop and establish a lifestyle counseling program with reliable screening parameters, taking into account the physician’s, the sports scientist’s and CCS perspective on who could benefit most and how we should implement this offer in the future that, due to limited resources, will be mainly limited to at-risk CCS in most setting.

In this study, lifestyle counseling as a routine care offer was implemented within the regular LTFU care. All CCS visiting our late effects clinic from February 2022 to end of January 2023 were offered to participate in lifestyle counseling. Every counseling was scheduled for 30 minutes and took place in the LTFU clinic right after the regular LTFU visit. The CCS were informed about the appointment with the sports scientist before they attended their appointment in the LTFU clinic. Medical and anthropometric data was documented in the clinic’s database. Additionally, CCS were asked to answer a set of lifestyle questions to evaluate the implementation of lifestyle recommendations from the American College of Sports Medicine and the American Cancer Society in their daily life (22). Due to those guidelines, cancer survivors should be physically active for at least 150 minutes per week with moderate intensity or 75 minutes of vigorous intensity. Physical activity should be performed for at least 10 minutes at a time, and sedentary activities should be avoided or reduced. It is also recommended that adults perform strength exercises at least twice a week for the major muscle groups (22, 23). Every CCS was asked to assess their subjective requirement for the need of a nutrition or sports counseling. Nutrition behavior was assessed by subjective questioning, and the sports scientist referred to the recommendations of the American Cancer Society (22) as well as the German Nutrition Society (https://www.dge.de/ernaehrungspraxis/vollwertige-ernaehrung/10-regeln-der-dge/en/ assessed date: 17.04.2023). In addition, CCS were asked if they were willing to change their sports and nutrition behavior. If CCS were not interested in study participation, no further counseling took place. If CCS already met the recommendations for physical activity, counseling focused on general lifestyle advices according to the guidelines from Rock et al. (2022) such as smoking cessation and nutrition counseling (10).

This study was approved by the ethics committee of the University of Luebeck. Informed consent was obtained from all participants included in the study.

Table 1 presents the inclusion criteria for the lifestyle counseling. Additionally, the hemoglobin A1c (HbA1c) was assessed in order to check if CCS were in a prediabetic condition (HbA1c level between 5.7 and 6.4) (24). Each lifestyle counseling included general recommendations for physical activity (based on Rock et al. 2012) as well as an assessment of individual preferences and barriers for implementation of a healthy lifestyle (22). After four weeks, every CCS received a follow up appointment, to check whether they were able to implement the recommendations in their daily life and whether they benefited from the counseling.

Table 1

Inclusion criteria for lifestyle counseling
Physician	Sports scientist	CCS
BMI ≤ 18.5 or ≥ 30kg/m²	BMI ≤ 18.5 or ≥ 30kg/m²	Expressed need for counseling
Hypercholesterolemia	< 150 min moderate or < 75 min vigorous activity per week
Diabetes mellitus
BMI; body mass index (kg/m²).

Most CCS were measured wearing clothes as well as with their prothesis, if needed. Only one CCS came to the LTFU care without a prothesis, therefore we used a formula to correct the BMI for CCS with amputated limbs (25). Additionally, we calculated the BMI with the Amputee Coalition BMI Calculator Widget (amputee-coalition.org). Risk-stratification into three different risk groups, based on survivors’ initial cancer diagnosis and treatment and their risk for late effects and need for LTFU examinations, was performed according to Gebauer et al. (2020) with risk group 1 corresponding to a low, group 2 to a medium and group 3 to a high risk for late effects (26).

Statistical analysis

For descriptive statistics, the median and range are calculated for continuous variables. For categorical variables, the absolute number as well as the relative number of the respective category are presented.

For further analysis, the following subgroups were defined:

Subgroup 1 is considered to include the CCS who have a need for counseling based only on the criteria of the sports scientist and not from the physician's point of view.
Subgroup 2 are CCS who request lifestyle counseling but do not need it based on the inclusion criteria.
Subgroup 3 includes CCS who met the inclusion criteria but rejected the offer for counseling.

The programming language R with version 4.2.2 is used for the entire analysis of the data (27).

Survivors’ characteristics

Overall, lifestyle counseling was offered to 155 CCS (65% female, 35% male), who had a median age of 30 years with a range of 18 to 63 years. Most CCS underlying diseases were lymphoma (29%), leukemia (27%), and brain tumors (22%). The median age at first diagnosis was 12 years with a range of 0 to 35 years. Survivors who had undergone treatment for pediatric oncology in their adulthood, such as young adults with medulloblastoma, were analyzed as part of the study, even though they survived cancer as adults. In terms of diagnosis and therapy, 18 CCS (12%) were assigned to risk group 1, 42 CCS (27%) to risk group 2, and 95 CCS (61%) to risk group 3. 61% survivors of risk group 1 had an indication for lifestyle counseling and 45% of those assigned to risk group 2. In the group with the highest risk for late effects (risk group 3), 72% had need for lifestyle counseling. 82 CCS (53%) had previous experience with sports or nutritional counseling. Detailed information on the characteristics of the CCS is shown in Table 2. In addition, 29 survivors (19%) were in a prediabetic condition, which led not to inclusion for lifestyle counseling, but should be noted as well.

Table 2. Survivors characteristics (n = 155).

Characteristics	Survivors (n = 155)
Sex Female Male	100 (64.52%) 55 (35.48%)
Age at counseling, years Median (Range)	30 (18-63)
Age at cancer diagnosis, years Median (Range)	12 (0-35)
Primary cancer diagnosis^a Lymphomas Leukemias Brain tumors Sarcomas Embryonic tumors Rare tumors	45 (29.03%) 42 (27.10%) 34 (21.94%) 19 (12.26%) 7 (4.52%) 8 (5.16%)
Radiatio Total body or skull irradiation	95 (61.29%) 61 (39.35%)
Chemotherapy	142 (91.61%)
Stem cell transplantation (SCT)	25 (16.13%)
Operation	75 (48.39%)
Recurrence/relapse	27 (17.42%)
Risk group 1 2 3	18 (11.61%) 42 (27.1%) 95 (61.29%)
Highest education degree In education No school degree Certificate of a special school Certificate of Secondary Education General Certificate of Secondary Education Subject-related entrance qualification General Certificate of Education	8 (5.16%) 2 (1.29%) 6 (3.87%) 11 (7.1%) 37 (23.87%) 20 (12.9%) 71 (45.81%)
Previous lifestyle counseling	82 (52.9%)
Desire of lifestyle counseling
Sports & nutrition	39 (25.16%)
Sports	27 (17.42%)
Nutrition	15 (9.68%)
None	74 (47.74%)
Lifestyle counseling performed	120 (77.42%)
Recommendations
Sports & nutrition	65 (54.17%)
Sports	43 (35.83%)
Nutrition	8 (6.67%)
None	4 (3.33%)

Needs analysis

Almost all CCS (150 of 155 CCS (97%)) indicated that a general offer of lifestyle counseling would be useful in the context of LTFU. Lifestyle counseling was provided to 120 survivors (77%) because of a need from either the physician's, the sports scientist's, or the CCS perspective (Fig. 1). For 27 survivors (17%), there was no need for counseling, while the remaining 8 survivors (5%) did not want counseling even though there was a need. The opinions of the CCS, the physician, and the sports scientist regarding the need for counseling of the CCS were in agreement in only 39 CCS (35%) (Fig. 2). The median duration of the consultation was 25 minutes, with a range of 10 to 60 minutes. Most frequently, 65 CCS (54%) were advised to change their lifestyle in the areas of diet and exercise (Fig. 3).

For motivational reasons and to check whether CCS were able to implement the recommendations, all CCS with counseling were asked whether they wanted a second interview. In 14 CCS (12%), no second interview was scheduled as they already met the activity recommendations and therefore had no need in a follow up appointment. In 2 CCS (2%) a second interview was not desired, and in 53 (44%) it could not be performed due to difficulties with the appointment arrangement outside of the regular LTFU interval. A second interview was performed in 51 CCS (43%) within one month. 49 (96%) of these CCS reported to have implemented the recommendations of the sports scientist in at least one of the areas, consisting of exercise and diet (Table 3). 33 CCS (65%) reported to have improved their lifestyle in both areas, although only 21 CCS (41%) received counseling in both areas. In addition, 33 CCS (65%) desired further support and counseling. Moreover, 50 CCS attending the follow up appointment initially indicated that lifestyle counseling should be part of the LTFU care and confirmed this statement in the second consultation. One CCS indicated that lifestyle counseling would be useful only in the follow up appointment.

Table 3

Characteristics of survivors who participated in the follow-up (n = 51).
Assessed at first counseling	Survivors (n = 51)
Inclusion criteria (sports scientist)	36 (70.89%)
Inculsion criteria (physician)	30 (58.82%)
Desire of counseling	32 (62.75%)
Characteristics at follow-up
Subjective Benefit
No	2 (3.90%)
Yes	47 (92.20%)
Unclear	2 (3.90%)
Implementation of the recommendations
Both	33 (64.70%)
Sports	8 (15.70%)
Nutrition	8 (15.70%)
No	2 (3.90%)
Duration of the counseling, minutes
Median (Range)	12 (8–40)
Effect perceived	38 (74.5%)
Yes, weight loss Yes, quality of life Yes, both No	2 (3.90%) 26 (50.98%) 8 (15.69%) 15 (29.41%)

Subgroup Analysis

Although the physician’s and sports scientist’s inclusion criteria overlapped, 26 CCS (17%) need for counseling was only identified based on the sports scientist’s perspective (subgroup 1). A second interview was conducted with 13 of these CCS one month later, during which 12 CCS (92%) reported having benefited from counseling.

In addition, 14 CCS (9%) expressed a need for counseling from a personal point of view, although they did not meet the inclusion criteria from the physician’s or sports scientist’s perspective (subgroup 2). A second interview (recommended for 9 of these CCS) was conducted with 5 CCS, 4 of whom (80%) stated that they had benefited from the counseling.

Furthermore, 31 CCS (20%) did not express a need for counseling, although they met the inclusion criteria (subgroup 3). 23 CCS (74%) agreed to receive lifestyle counseling. One month later, 15 of 16 participating CCS (94%) reported having benefited from counseling. These subgroups are also shown in more detail in Table 4.

Table 4

Characteristics of subgroups.
Characteristics	Subgroup 1 (n = 26)	Subgroup 2 (n = 14)	Subgroup 3 (n = 31)
Sex
Female	19 (73.08%)	10 (71.43%)	16 (51.61%)
Male	7 (26.92%)	4 (28.57%)	15 (48.39%)
Risk group
1	3 (11.54%)	3 (21.43%)	2 (6.45%)
2	7 (26.92%)	4 (28.57%)	6 (19.35%)
3	16 (61.54%)	7 (50.00%)	23 (74.19%)
Indication for counseling by sports scientist	26 (100%)	0 (0%)	25 (80.65%)
Indication for counseling by physician	0 (0%)	0 (0%)	23 (74.19%)
Desire of counseling	18 (69.23%)	14 (100%)	0 (0%)
Counseling performed	25 (96.20%)	13 (92.90%)	23 (74.20%)
Follow-up appointment
Performed	13 (50.00%)	5 (35.71%)	16 (51.61%)
Not indicated by sports scientist or survivor	2 (7.70%)	5 (35.71%)	9 (29.03%)
Not feasible	11 (42.32%)	4 (28.57%)	6 (19.35%)
Implementation of the recommendations
Both	7 (26.92%)	3 (21.43%)	9 (29.03%)
Sports	4 (15.38%)	0 (0%)	4 (12.90%)
Nutrition	1 (3.85%)	1 (7.14%)	3 (9.68%)
No	1 (3.85%)	1 (7.14%)	0 (0%)
No follow-up	0 (0%)	9 (64.29%)	15 (48.39%)
Subgroup 1: survivors who have a need for counseling based only on the inclusion criteria of the sports scientist and not from the physician's point of view; subgroup 2: survivors who want lifestyle counseling but do not need it based on the criteria; subgroup 3: survivors who need counseling based on the criteria but do not feel so.

Worldwide, as a result of advances in cancer treatment and diagnostics, the proportion of long-term cancer survivors is rapidly increasing (28). As many of these survivors develop chronic health conditions later in life, prevention measures gain in importance in follow-up care and management of these CCS in order to reduce long-term morbidity and to maintain a good health-related quality of life. Regular physical activity can have major impact on metabolic health and reduces risk factors for metabolic syndrome (10, 14, 29). As shown in previous studies, long-term sequelae like diabetes mellitus and obesity occurring more often in CCS than in the general population and contributing to the elevated morbidity and mortality risk in this CCS cohort can be diminished by implementing a healthy lifestyle based on regular physical activity and a healthy diet (30, 31).

In this study, indication for as well as feasibility of regular lifestyle counseling in an unselected cohort of long-term CCS in a specialized LTFU care setting were prospectively evaluated. In addition, we aimed to establish screening parameters and risk groups of CCS who could particularly benefit from counseling based on three different perspectives (physician’s, CCS and sport scientist’s view).

During the study, over 77% of the CCS (120 out of 155) received a lifestyle counseling with special focus on physical activity and nutrition. About 48% of these CCS expressed no need for counseling initially (n = 74), but were either interested in lifestyle recommendations or had indicators for counseling (based on metabolic risk constellations or reduced physical activity). Consequently, 39 CCS received a lifestyle counseling who initially did not state a need for it. In a follow up appointment almost all of these CCS (94%) indicated that they benefited from the lifestyle counseling which is in line with previous studies that underlined the importance of a lifestyle counseling in an unselected CCS cohort as it resulted into higher activity levels after seeing a health practitioner (30).

Furthermore, our results show that especially CCS with a high risk for late effects (risk group 3 according to Gebauer et al. (2020)) are in higher need of a lifestyle counseling (26). According to Rock et al. (2015), survivors of pediatric acute lymphoblastic leukemia have an increased risk of becoming overweight throughout their life (22). Due to cancer treatment in childhood like radiation, metabolic late effects such as overweight, obesity and changes in body composition like increase in fat mass are common in CCS and could also be demonstrated in our cohort with 46,5 percent of the survivors being affected by metabolic disorders (8, 32, 33). In detail, anthracycline chemotherapy and chest radiation are risk factors for cardiomyopathy and cardiovascular damage (2, 8, 16). Cranial radiation often leads to endocrine disorders which in turn may result in overweight or obesity (33, 34). Of note, although the proportion of CCS with indication for lifestyle counseling was high across all risk groups, CCS with the lowest risk for late effects (risk group 1 according to Gebauer et al. (2020)) appeared to be affected more often than CCS in risk group 2 (medium risk for late effects) which is most likely due the small number of CCS in risk group 1 included in this study resulting in a selection bias. This finding should be verified in further studies with more participants representing the different risk groups (based on cancer treatment exposure) in a more balanced way. However, the study findings suggest that lifestyle counseling should be considered more strongly for individuals in higher risk groups. Consequently, CCS in risk group 3, in particular, should be given serious consideration for regular lifestyle counseling as already proposed by Nathan et al. (34).

The fact that almost all CCS (97%) considered lifestyle counseling to be beneficial and those who reported benefits from it in the follow up appointment (92%), support the idea of incorporating lifestyle counseling into regular LTFU care. In addition, 70% of CCS receiving a second counseling stated a positive effect on weight and/or quality of life. These findings are consistent with previous studies that have shown high levels of acceptance and adherence to lifestyle counseling (9, 30). Zhang et al. (2017; 2015) suggest that it is crucial to educate CCS about weight management and healthy lifestyle as early as possible, but older CCS may require more lifestyle counseling (13, 35). Moreover, men may have a greater need for lifestyle counseling (based on the presence of metabolic diseases and/or a sedentary lifestyle) as demonstrated in this study but often do not perceive this need. Furthermore, the study revealed that CCS with a normal weight who do not meet the inclusion criteria can still derive benefits from counseling. Additionally, there were 29 CCS (19%) with a prediabetic metabolic condition, of which 10 (6%) would not be included in the needs analysis, but could still benefit from the counseling. In our study, we classified CCS into three distinct subgroups. Our findings demonstrated that lifestyle counseling can be beneficial for CCS, even if only one perspective recognizes the indication for it.

Given the constraints of limited resources, it’s crucial to deliberate on the inclusion criteria for lifestyle counseling. As demonstrated in this study, factors such as higher risk groups (risk group 3) on late effects based on treatment exposure, older age, male gender, reduced physical activity as well as established risk factors such as presence of obesity, diabetes mellitus or hypercholesterolemia could serve as potential indicators for lifestyle counseling.

Limitations and strengths of the study

Limitations of our study were heterogeneity within the study cohort such as predominance of female gender (65%) and risk group 3 (61%) as a consequence from an unselected inclusion of every CCS receiving regular LTFU care in our specialized clinic which renders comparison of different risk groups more difficult. In addition, 53% of all CCS already received a previous nutrition or sports counseling, either organized by themselves, during rehabilitation stays or while being part of the study CARE for CAYA (21). Furthermore, in 53 CCS (43%), a follow up appointment could not be performed due to difficulties of time and reachability by phone. Some measurements were based solely on information provided by the CCS such as nutrition habits and weight loss after counseling and could not be validated clinically. The small number of CCS experiencing nutritional issues (n = 15) may be attributed to the fact that the assessment of nutritional parameters relied solely on subjective questioning. Especially for evaluation of activity time, it would have been useful to collect either objective data by accelerometry or the moderate and vigorous activity minutes in the follow up counseling. The assessment of the quality of life did not involve the use of questionnaires; instead, CCS provided subjective responses.

However, to our knowledge, this is the first study to implement a regular lifestyle counseling for every CCS in a specialized setting with many years of experience within LTFU care. We collected the data from an unselected cohort in a prospective manner, which allowed us to include all CCS receiving LTFU care and gain an overall understanding of their needs.

In this study, almost all CCS (97%) consider lifestyle counseling useful as part of LTFU care. It is important to inform CCS about their increased risk of developing metabolic diseases such as dyslipidemia, hypertension, diabetes mellitus or obesity (8, 11). A healthy lifestyle including regular physical activity and nutrient and vitamin rich diet can reduce this risk (36). It is important to include health care professionals in survivorship care to support a healthy lifestyle among this cohort (37). Generally, due to limited resources, regular lifestyle counseling might not be feasible for every CCS during LTFU which is why it is particularly important to identify CCS at risk for metabolic complications. CCS can adopt health promoting lifestyle while previous studies indicated the importance of an early implementation of these changes in order to reduce long-term morbidity (31). However, as demonstrated in this study, older as well as male CCS were especially in need of a lifestyle counseling and should be actively screened for established risk factors such as hypertension, diabetes mellitus and hypercholesterolemia. Additionally, cancer treatment exposure was confirmed as an independent risk factor for poor metabolic outcome.

For further research it might be useful to analyze CCS after lifestyle counseling over a period of one year to see whether they sustained health promoting lifestyle. Furthermore, it would be useful for future studies to promote a mobile health intervention for CCS that might increase adherence in adopting a healthier lifestyle (38).

There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding

This work was supported by “Team DoppelPASS e.V.”.

Author’s contribution

Study concept: F.R., J.G. and T.L. Data collection: F.R. Data analysis and creation of figures and tables: L.L.K. and I.R.K. Initial draft of manuscript: F.R., L.L.K. and J.G. Writing – review and editing: F.R., L.L.K. and J.G. Critical revision and approval of final version: all authors. All authors have read and agreed to the published version of the manuscript.

Acknowledgements

We thank Lea Hildebrand for her assistance with recruitment.

Erdmann F, Kaatsch P, Grabow D, Spix C. German Childhood Cancer Registry - Annual Report 2019 (1980–2018).
Oeffinger KC, Mertens AC, Sklar CA, Kawashima T, Hudson MM, Meadows AT, et al. Chronic health conditions in adult survivors of childhood cancer. N Engl J Med. 2006 Oct 12;355(15):1572–82. https://doi.org/10.1056/NEJMsa060185
Gebauer J, Higham C, Langer T, Denzer C, Brabant G. Long-Term Endocrine and Metabolic Consequences of Cancer Treatment: A Systematic Review. Endocrine Reviews. 2019 Jun 1;40(3):711–67. https://doi.org/10.1210/er.2018-00092
Jones LW, Liu Q, Armstrong GT, Ness KK, Yasui Y, Devine K, et al. Exercise and risk of major cardiovascular events in adult survivors of childhood hodgkin lymphoma: a report from the childhood cancer survivor study. J Clin Oncol. 2014 Nov 10;32(32):3643–50. https://doi.org/10.1200/JCO.2014.56.7511
Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, et al. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol. 2015 Mar;16(3):e123-136. https://doi.org/10.1016/S1470-2045(14)70409-7
Brinkman TM, Recklitis CJ, Michel G, Grootenhuis MA, Klosky JL. Psychological Symptoms, Social Outcomes, Socioeconomic Attainment, and Health Behaviors Among Survivors of Childhood Cancer: Current State of the Literature. JCO. 2018 Jul 20;36(21):2190–7. https://doi.org/10.1200/JCO.2017.76.5552
van Deuren S, Boonstra A, van Dulmen-den Broeder E, Blijlevens N, Knoop H, Loonen J. Severe fatigue after treatment for childhood cancer. Cochrane Childhood Cancer Group, editor. Cochrane Database of Systematic Reviews [Internet]. 2020 Mar 3 [cited 2020 Apr 16]; Available from: http://doi.wiley.com/10.1002/14651858.CD012681.pub2
Smith WA, Li C, Nottage KA, Mulrooney DA, Armstrong GT, Lanctot JQ, et al. Lifestyle and metabolic syndrome in adult survivors of childhood cancer: a report from the St. Jude Lifetime Cohort Study. Cancer. 2014 Sep 1;120(17):2742–50. https://doi.org/10.1002/cncr.28670
de Lima Melo B, Vieira DCA, de Oliveira GC, Valente J, Sanchez Z, Ferrari G, et al. Adherence to healthy lifestyle recommendations in Brazilian cancer survivors. J Cancer Surviv [Internet]. 2022 Jun 24 [cited 2023 Mar 20]; Available from: https://doi.org/10.1007/s11764-022-01228-6
Rock CL, Thomson CA, Sullivan KR, Howe CL, Kushi LH, Caan BJ, et al. American Cancer Society nutrition and physical activity guideline for cancer survivors. CA Cancer J Clin. 2022 May;72(3):230–62. https://doi.org/10.3322/caac.21719
Javalkar K, Huang Y, Lyon SM, Palfrey H, Hartz J, Chen MH, et al. Clinical response to lifestyle counseling for dyslipidemia and elevated blood pressure in childhood cancer survivors. Pediatr Blood Cancer. 2023 Jan;70(1):e30034. https://doi.org/10.1002/pbc.30034
Clinton SK, Giovannucci EL, Hursting SD. The World Cancer Research Fund/American Institute for Cancer Research Third Expert Report on Diet, Nutrition, Physical Activity, and Cancer: Impact and Future Directions. J Nutr. 2020 Apr 1;150(4):663–71. https://doi.org/10.1093/jn/nxz268
Zhang FF, Kelly MJ, Must A. Early Nutrition and Physical Activity Interventions in Childhood Cancer Survivors. Curr Obes Rep. 2017 Jun;6(2):168–77. https://doi.org/10.1007/s13679-017-0260-0
Ness KK, Leisenring WM, Huang S, Hudson MM, Gurney JG, Whelan K, et al. Predictors of inactive lifestyle among adult survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer. 2009 May 1;115(9):1984–94. https://doi.org/10.1002/cncr.24209
Devries MC, Jakobi JM. Importance of considering sex and gender in exercise and nutrition research. Appl Physiol Nutr Metab. 2021 Jun;46(6):iii–vii. https://doi.org/10.1139/apnm-2021-0298
de Haas EC, Oosting SF, Lefrandt JD, Wolffenbuttel BH, Sleijfer DT, Gietema JA. The metabolic syndrome in cancer survivors. The Lancet Oncology. 2010 Feb;11(2):193–203. https://doi.org/10.1016/S1470-2045(09)70287-6
Danielzik S, Czerwinski-Mast M, Langnäse K, Dilba B, Müller MJ. Parental overweight, socioeconomic status and high birth weight are the major determinants of overweight and obesity in 5–7 y-old children: baseline data of the Kiel Obesity Prevention Study (KOPS). Int J Obes. 2004 Nov;28(11):1494–502. https://doi.org/10.1038/sj.ijo.0802756
Jones LW, Demark-Wahnefried W. Diet, exercise, and complementary therapies after primary treatment for cancer. The Lancet Oncology. 2006 Dec;7(12):1017–26. https://doi.org/10.1016/S1470-2045(06)70976-7
Dimitri P, Joshi K, Jones N, Moving Medicine for Children Working Group. Moving more: physical activity and its positive effects on long term conditions in children and young people. Arch Dis Child. 2020 Nov;105(11):1035–40. https://doi.org/10.1136/archdischild-2019-318017
Gebauer J, Rieken S, Schuster S, Hahn B, Gebauer N, Meidenbauer N, et al. Multidisciplinary Late Effects Clinics for Childhood Cancer Survivors in Germany - a Two-Center Study. Oncol Res Treat. 2018;41(7–8):430–6. https://doi.org/10.1159/000488203
Salchow J, Mann J, Koch B, von Grundherr J, Jensen W, Elmers S, et al. Comprehensive assessments and related interventions to enhance the long-term outcomes of child, adolescent and young adult cancer survivors - presentation of the CARE for CAYA-Program study protocol and associated literature review. BMC Cancer. 2020 Jan 6;20(1):16. https://doi.org/10.1186/s12885-019-6492-5
Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012 Aug;62(4):243–74. https://doi.org/10.3322/caac.21142
Schmitz KH, Courneya KS, Matthews C, Demark-Wahnefried W, Galvão DA, Pinto BM, et al. American College of Sports Medicine roundtable on exercise guidelines for cancer survivors. Med Sci Sports Exerc. 2010 Jul;42(7):1409–26. https://doi.org/10.1249/MSS.0b013e3181e0c112
Zand A, Ibrahim K, Patham B. Prediabetes: Why Should We Care? Methodist Debakey Cardiovasc J. 2018;14(4):289–97. https://doi.org/10.14797/mdcj-14-4-289
Frost AP, Norman Giest T, Ruta AA, Snow TK, Millard-Stafford M. Limitations of body mass index for counseling individuals with unilateral lower extremity amputation. Prosthet Orthot Int. 2017 Apr;41(2):186–93. https://doi.org/10.1177/0309364616650079
Gebauer J, Baust K, Bardi E, Grabow D, Stein A, van der Pal HJ, et al. Guidelines for Long-Term Follow-Up after Childhood Cancer: Practical Implications for the Daily Work. Oncol Res Treat. 2020;43(3):61–9. https://doi.org/10.1159/000504200
R Core Team. R: A Language and Environment for Statistical Computing [Internet]. Vienna, Austria: R Foundation for Statistical Computing; 2022. Available from: https://www.R-project.org/
Hudson MM, Bhatia S, Casillas J, Landier W, SECTION ON HEMATOLOGY/ONCOLOGY, CHILDREN’S ONCOLOGY GROUP, AMERICAN SOCIETY OF PEDIATRIC HEMATOLOGY/ONCOLOGY. Long-term Follow-up Care for Childhood, Adolescent, and Young Adult Cancer Survivors. Pediatrics. 2021 Sep;148(3):e2021053127. https://doi.org/10.1542/peds.2021-053127
Myers J, Kokkinos P, Nyelin E. Physical Activity, Cardiorespiratory Fitness, and the Metabolic Syndrome. Nutrients. 2019 Jul 19;11(7):1652. https://doi.org/10.3390/nu11071652
Tarasenko YN, Miller EA, Chen C, Schoenberg NE. Physical activity levels and counseling by health care providers in cancer survivors. Prev Med. 2017 Jun;99:211–7. https://doi.org/10.1016/j.ypmed.2017.01.010
Zhang FF, Kelly MJ, Must A. Early Nutrition and Physical Activity Interventions in Childhood Cancer Survivors. Curr Obes Rep. 2017 Jun;6(2):168–77. https://doi.org/10.1007/s13679-017-0260-0
Guolla L, Morrison KM, Barr RD. Adiposity in Survivors of Cancer in Childhood: How is it Measured and Why Does it Matter? J Pediatr Hematol Oncol. 2021 Jan;43(1):1–11. https://doi.org/10.1097/MPH.0000000000001988
Pradhan KR, Chen Y, Moustoufi-Moab S, Krull K, Oeffinger KC, Sklar C, et al. Endocrine and Metabolic Disorders in Survivors of Childhood Cancers and Health-Related Quality of Life and Physical Activity. J Clin Endocrinol Metab. 2019 Nov 1;104(11):5183–94. https://doi.org/10.1210/jc.2019-00627
Nathan PC, Ford JS, Henderson TO, Hudson MM, Emmons KM, Casillas JN, et al. Health behaviors, medical care, and interventions to promote healthy living in the Childhood Cancer Survivor Study cohort. J Clin Oncol. 2009 May 10;27(14):2363–73. https://doi.org/10.1200/JCO.2008.21.1441
Zhang FF, Parsons SK. Obesity in Childhood Cancer Survivors: Call for Early Weight Management. Adv Nutr. 2015 Sep;6(5):611–9. https://doi.org/10.3945/an.115.008946
Huang YJ, Lee SL, Wu LM. Health-Promoting Lifestyle and Its Predictors in Adolescent Survivors of Childhood Cancer. J Pediatr Oncol Nurs. 2021;38(4):233–41. https://doi.org/10.1177/1043454221992322
Bouwman E, Pluijm SMF, Stollman I, Araujo-Soares V, Blijlevens NMA, Follin C, et al. Healthcare professionals’ perceived barriers and facilitators of health behavior support provision: A qualitative study. Cancer Med. 2023 Mar;12(6):7414–26. https://doi.org/10.1002/cam4.5445
Kelley MM, Kue J, Brophy L, Peabody AL, Foraker RE, Yen PY, et al. Mobile Health Applications, Cancer Survivors, and Lifestyle Modification: An Integrative Review. Comput Inform Nurs. 2021 Jun 2;39(11):755–63. https://doi.org/10.1097/CIN.0000000000000781

No competing interests reported.

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High incidence of metabolic diseases and sedentary lifestyle underline the need for regular counseling in LTFU for CCS- results from a monocentric prospective study

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