Body composition changes and nutritional challenges in children with acute lymphoblastic leukaemia: Perspectives from low -resource settings

Acute lymphoblastic leukaemia (ALL) is the most common childhood cancer in India; despite improving survival in low-and middle-income countries (LMICs), outcomes remain inferior to those in high-income countries and are further complicated by the dual burden of undernutrition and treatment-related obesity. This narrative review synthesises evidence on nutritional status, body composition changes, and related challenges in children with ALL in low-resource settings, focusing on India. During treatment, weight and body mass index (BMI) may fluctuate, yet body-composition studies indicate that even when weight/BMI are stable or increase, lean mass can decline with concurrent fat gain. These alterations often persist into survivorship, increasing cardiometabolic and functional risks, highlighting the limitations of relying solely on anthropometric measurements, which may miss clinically important shifts in body composition. This issue is particularly relevant in South Asian children, who exhibit a ‘thin fat’ phenotype with relatively greater adiposity at a given BMI. Both undernutrition and overnutrition are associated with higher infection rates, chemotherapy toxicity, treatment delays, relapses, and mortality, yet nutritional care often remains peripheral within oncology services in LMICs. This review outlines the limitations of conventional anthropometry, summarises the feasibility and constraints of available body-composition techniques, and describes complementary biochemical, clinical, and dietary indicators to refine nutritional risk stratification. It also discusses health-system, socioeconomic, and cultural barriers, including gaps in caregiver nutrition knowledge. Collectively, the findings highlight the need to integrate routine nutrition screening, longitudinal body-composition monitoring, and individualised, culturally sensitive dietary interventions into standard paediatric ALL care, particularly in resource-limited settings.