Health promotion for adolescent leukemia survivors

I n this issue of Pediatric Blood & Cancer, Elliot et al. present ‘‘Health promotion in adolescent childhood leukemia survivors: building on prevention science and eHealth. ’’ This article, which is quite comprehensive in scope, reviews the medical and psychological risks faced by adolescent survivors of childhood leukemia, describes how the period of adolescence relates to health decision making, and appraises existing health promotion materials, especially electronic materials, which may be especially relevant to this population. As the authors summarize, adolescent and adult survivors of childhood leukemia are at high risk for late-occurring morbidity (so-called ‘‘late effects’’) as a result of cancer therapy. In particular, obesity, insulin resistance and type 2 diabetes mellitus are more prevalent among leukemia survivors (especially female survivors and those who received cranial radiotherapy) than in the general population [1–7]. Evidence suggests that diet may modify these risks in non-cancer populations [8]. As a group, survivors’ diet composition is similar to the general population. Specifically, most adolescent and adult survivors report consuming less than 5 servings of fruit and vegetables a day and greater than 30% of their calories from fat [9,10]. Physical activity levels among survivors appear to be lower than non-cancer groups. In addition, those who were inactive prior to being diagnosed appear to remain sedentary post-treatment. A small number of studies have reported on interventions designed to improve these health behaviors but the results have been modest at best, and recruitment and/or retention have been reported obstacles in all of the trials to date [11–15]. A recent review of the published literature addressing diet and physical activity in this population reveals the need for well-designed interventions [16]. Importantly, social media and other mobile/electronic technology may be ideally suited to address these issues. Furthermore, adolescence is a time when health interventions may be especially influential. Prior studies have suggested that health habits are often established during adolescence [17]. Peers (who may impact health behaviors) are very important to identity development during this time. Technology, as explained by the authors, also plays a major role in providing information, influencing choices, and establishing peer groups for adolescents. Among cancer survivors, technology may be especially valuable for constructing peer groups, as it can bring together those who are geographically, socially, or economically separated. Therefore, as the authors highlight, the internet is an intrinsically appealing tool for health promotion among this high-risk group of young people. In terms of the specifics of health promotion among adolescents, Elliot et al. emphasize that interventions for adolescents should avoid fear arousal, which may have a paradoxical effect of increasing the adverse behavior. Instead, health promotion should focus on proximal influences, such as improving communication and decision making and have goals such as increasing self-efficacy or empowerment. Therefore, as Elliot et al. make clear, a technology-based health behavior intervention would fit very nicely into the needs of the high-risk leukemia survivor adolescent community. Unfortunately, the challenge for research in this area is that technology is extremely expensive to develop and the field changes rapidly. As any researcher knows, applying for funding (and re-applying if necessary) can take years. By the time funding is acquired and in place, the intervention technology will most certainly be passé or out of date. The authors acknowledge that funding challenges (and their requisite delays) are problematic for video game production. It is very likely that no eHealth promotion project is immune to these concerns. Those interested in technology-based health promotion may have to turn to industry sponsorship. In fact, one of the better websites cited by Elliot et al. is one sponsored by a large corporation that makes feminine hygiene supplies. While the website has an overall message of positive health behavior (communicated via blogs, videos, and games), it also includes advertisements for the brand tampons and pads. Furthermore, some of the advertisements are disguised (or not) as educational videos and quizzes. While this type of website makes sense from a marketing perspective, should health care providers really refer their patients to an industry-sponsored website? Finally, any examination of this field must acknowledge that adolescent leukemia survivors who do not live in urban areas, who are of minority race/ethnicity, or who are otherwise marginalized and disenfranchised may be both at higher risk of late effects and less likely to have consistent access to computers or eHealth resources; a sizable portion of the minority survivor population will rely primarily on smartphones. Therefore, eHealth resources should be developed with responsive designs that function equally well on computers and smartphones.