Associations of various medical nutrition therapy strategies with body composition, and physical and clinical outcomes in acute myeloid leukemia patients undergoing intensive remission-induction treatment: a multicenter prospective correlational study

BACKGROUND & AIMS: Medical nutrition therapy (MNT) is commonly used in patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) undergoing intensive remission-induction treatment to prevent malnutrition, particularly the loss of fat-free mass (FFM)/muscle mass, as well as associated adverse outcomes. However, studies examining the associations between proactive versus wait-and-see approaches toward MNT and nutritional, physical, and clinical outcomes in these patients are lacking. Therefore, this study aimed to explore the associations between these different MNT approaches and body composition changes, as well as physical and clinical outcomes in AML/MDS patients undergoing intensive remission-induction treatment. Additionally, the study aimed to explore the relationships between body composition changes and physical and clinical outcomes, and whether these associations varied between the proactive and wait-and-see strategies. METHODS: In this multicenter prospective correlational study, newly diagnosed AML/MDS patients undergoing intensive remission-induction treatment were included. Patients were treated in one of five hospitals using a proactive approach toward MNT, initiating MNT when nutritional intake became inadequate, or in the single hospital in the Netherlands that followed a wait-and-see strategy, limiting the use of MNT to exceptional and severe cases only. Body composition was assessed at the start of treatment, weekly during admission and at discharge, and handgrip strength, and patient-reported physical functioning and fatigue at treatment initiation and discharge. Information on number of complications, and duration of fever and LOS was collected from medical records. Within-group changes in body composition and between-group differences were tested using paired or independent t, Wilcoxon signed-rank or two-sample tests, respectively, or chi-square/Fisher's exact tests for proportions. The longitudinal patterns between proactive MNT approach/wait-and-see strategy hospitals were compared by means of linear mixed effects models. Associations between body composition changes and physical and clinical outcomes were explored using multiple linear regression models, and compared between proactive MNT approach/wait-and-see strategy hospitals. RESULTS: In this study, 204 AML/MDS patients (54% male, mean age: 56.3±13.0 years) were included, of whom 140 underwent treatment in a hospital using a proactive approach toward MNT and 64 in the hospital following a wait-and-see strategy. In the proactive MNT approach hospitals, 57% of patients received MNT during the first chemotherapy cycle versus 8% of patients in the wait-and-see hospital (p < 0.0001). Both approaches toward MNT were associated with significant decreases in body weight, FFM/muscle mass, and muscle strength. However, body weight loss was lower with the proactive approach (estimated between-group difference during the first cycle: 0.44 kg/week (95% CI 0.18 - 0.70 kg/week, p = 0.0008), primarily due to better preservation of fat mass (FM) (p < 0.05). Additionally, the proactive MNT strategy was associated with fewer nutrition impact symptoms (p < 0.0001), fewer complications (p = 0.01), and shorter LOS (first cycle: 33 days (IQR: 27-41) vs 29 days (IQR: 26-34), p = 0.009). Similar results were observed during the second chemotherapy cycle. Furthermore, better maintenance of body weight and indicators of FFM/muscle mass and FM were significantly associated with shorter LOS and fever duration, fewer complications, improved physical functioning and/or reduced fatigue. Several associations differed significantly between the two MNT strategies, given that decreased body composition parameters were associated with worse physical and clinical outcomes in the wait-and-see hospital, while in the proactive MNT approach hospitals these associations were opposite or attenuated and non-significant. CONCLUSION: In AML/MDS patients undergoing intensive remission-induction treatment, a proactive approach toward MNT should be used, as it was associated with fewer nutrition impact symptoms, fewer complications, shorter LOS, and better body weight maintenance, mainly through better preservation of FM, compared to a wait-and-see strategy. Maintenance of body weight, FFM/muscle mass and/or FM was associated with improved physical and clinical outcomes. Given that proactive use of MNT could not prevent loss of FFM/muscle mass and muscle strength, future research should focus on combined nutritional and physical exercise interventions aimed at reducing these losses.