Impact of Omega-3 and Vitamin D Supplementation on Bone Turnover Markers in Children with Leukemia: Follow-Up During and After Supplementation

Abstract

Background/Objective: In patients with acute lymphoblastic leukemia (ALL), it has been demonstrated that the treatment has a negative effect on bone health. The n-3 polyunsaturated fatty acids (LCPUFAs-ω3) may attenuate bone resorption. We evaluated the effects of LCPUFAs-ω3, vitamin D, and calcium supplementation on bone turnover markers and changes in vitamin D concentrations during 6 weeks of supplementation and during 6 weeks of post-intervention follow-up in pediatric patients with ALL. Methods: Thirty-six pediatric patients with ALL were randomly assigned to the ω-3VDCa group (100 mg/kg/d LCPUFAs-ω3 + 4000 IU vitamin D + 1000 mg calcium) or the VDCa group (4000 IU vitamin D + 1000 mg calcium) for 6 weeks. Blood samples were collected to determine 25(OH)D, PTH, ICTP, and TRAP-5b (biomarkers of bone resorption) and osteocalcin (OC, a biomarker of bone production) levels at baseline, 6 weeks, and 12 weeks after supplementation. The 25(OH)D analysis was performed using ultra-high-performance liquid chromatography coupled to a mass spectrometer, and PTH and bone turnover markers were measured by ELISA. Results: The 25(OH)D concentration increased in both groups (ω3VDCa group: 19.4 ng/mL vs. 44.0 ng/mL, p < 0.0001; VDCa group: 15.3 ng/mL vs. 42.8 ng/mL, p = 0.018) and remained significantly higher at 12 weeks. At 12 weeks, ICTP showed lower concentrations in the ω-3VDCa group than in the VDCa group (0.74 ng/mL vs. 1.05 ng/mL, p = 0.024). Conclusions: Combined omega-3 and 4000 IU vitamin D supplementation for 6 weeks had a positive effect on bone health, as indicated by serum ICTP, with no effect on serum 25(OH)D levels over vitamin D supplementation alone.

Keywords: acute lymphoblastic leukemia; bone turnover markers; children; dietary supplements; n-3 polyunsaturated fatty acids; vitamin D.

Figure 1

Flow diagram of Consolidated Standards of Reporting Trials (CONSORT) for studying patients with acute lymphoblastic leukemia. ω-3: long-chain omega-3 polyunsaturated fatty acids; VD: vitamin D; Ca: calcium; PP: per protocol.

Figure 2

Changes in 25(OH)D concentrations and LCPUFA-ω3 incorporation into erythrocytes between baseline, 6 weeks, and 12 weeks. (A) Changes in 25(OH)D concentrations of the ω-3VDCa group; (B) changes in 25(OH)D concentrations of the VDCa group; (C) changes in the incorporation of EPA into erythrocytes; and (D) changes in the incorporation of DHA into erythrocytes. EPA: eicosapentaenoic acid; DHA: docosahexaenoic acid; ω-3VDCa group: omega-3 long-chain polyunsaturated fatty acids, vitamin D, and calcium; VDCa group: vitamin D and calcium. * EPA ω-3VDCa group, baseline vs. 6 weeks p = 0.001. * EPA ω-3VDCa group, baseline vs. 12 weeks p < 0.0001. ** EPA ω-3VDCa group 12 weeks vs. VDCa group 12 weeks p = 0.039. * DHA ω-3VDCa group, baseline vs. 6 weeks p < 0.0001. * DHA ω-3VDCa group, baseline vs. 12 weeks p < 0.0001. ** DHA ω-3VDCa group 6 weeks vs. VDCa group 6 weeks p < 0.0001. ** DHA ω-3VDCa group 12 weeks vs. VDCa group 12 weeks p < 0.0001. Red color: patients that did not change 25(OH)D nutritional status and black color: patients that changed 25(OH)D nutritional status.

Figure 3

Changes in vitamin D nutritional status and concentrations at baseline, 6 weeks, and 12 weeks. (A) Changes in vitamin D nutritional status of the ω-3VDCa group; (B) changes in vitamin D nutritional status of the VDCa group; (C) changes in 25(OH)D concentrations; and (D) ∆ of 25(OH)D. ω-3VDCa group: omega-3 long-chain polyunsaturated fatty acids, vitamin D, and calcium; VDCa group: vitamin D and calcium. Data was analyzed with Student’s t test for related samples or the Mann–Whitney U test. Here, * 25(OH)D, ω-3VDCa group, baseline vs. 6 weeks p < 0.0001, and ** 25(OH)D, ω-3VDCa group, 6 weeks vs. 12 weeks. ∆ 25(OH)D, VDCa group, 6 weeks vs. baseline p = 0.018. * ω-3VDCa group, Δ6 weeks–baseline vs. Δ12–6 weeks p = < 0.0001. * VDCa group, Δ6 weeks–baseline vs. Δ12–6 weeks p = 0.018.

Figure 4

Changes in PTH concentrations at baseline, 6 weeks, and 12 weeks. (A) Changes in PTH concentrations; (B) ∆ of PTH. ω-3VDCa group: omega-3 long-chain polyunsaturated fatty acids, vitamin D, and calcium; VDCa group: vitamin D and calcium; PTH: parathormone. Analysis performed using the Mann–Whitney U test and Wilcoxon signed-rank test.

Figure 5

Changes in concentrations and deltas of bone turnover markers at baseline, 6 weeks, and 12 weeks. (A) Changes in ICTP concentrations; (B) ∆ ICTP; (C) changes in TRAP-5b concentrations; (D) ∆ TRAP-5b; (E) changes in osteocalcin concentrations; (F) ∆ osteocalcin. ICTP: C-terminal telopeptide of type I collagen.; TRAP-5b: tartrate-resistant acid phosphatase 5b; ω-3VDCa group: omega-3 long-chain polyunsaturated fatty acids, vitamin D, and calcium; VDCa group: vitamin D and calcium. Analysis performed using the Mann–Whitney U test and Wilcoxon signed-rank test.