Food insecurity, diet quality, and the oral microbiome: implications for chemotherapy-induced oral mucositis in pediatric b-cell acute lymphoblastic leukemia patients

The National Institute of Nursing Research awarded Emory University $106,228 on December 4, 2026, under the Nursing Research program (CFDA 93.361) to conduct a prospective observational study examining food insecurity, diet quality, and the oral microbiome as factors influencing chemotherapy-induced oral mucositis in pediatric B-cell acute lymphoblastic leukemia patients. The research addresses a gap in pediatric oncology: while children with B-ALL experience oral mucositis at higher rates than adults following high-dose methotrexate treatment, clinical practice guidelines have been developed primarily from adult oncology data. The study will investigate how food insecurity—more prevalent in oncology populations and households with children—may contribute to adverse mucositis outcomes through its effects on diet quality and the oral microbiome, and will include environmental and contextual covariates and patient-reported outcomes to strengthen findings beyond prior preliminary research limited by sociodemographic homogeneity. Work is performed in Atlanta, Georgia, with a period of performance through July 31, 2028.

Abstract

Despite improving survival rates due to recent medical advancements, pediatric b-cell acute lymphoblastic leukemia (b-all) patients continue to experience treatment-related toxicities, particularly those associated with high-dose methotrexate (HD-MTX). Chemotherapy-induced oral mucositis (ciom) is one such toxicity that can cause excoriated mouth sores and debilitating pain, thus decreasing quality of life and increasing healthcare costs. Children with b-all experience ciom at higher rates than adults, yet mucositis clinical practice guidelines have primarily been developed using data from adult oncology patients. Food insecurity, which is observed more frequently in oncology populations and households with children, may contribute to these adverse ciom outcomes by influencing diet quality and the oral microbiome (i.e., a collection of microbes within the oral cavity that serve as a protective mechanism when balanced and symbiotic). Food insecurity has been linked to poor diet quality in children and suboptimal health outcomes in adult cancer patients. In turn, poor diet quality has been associated with a dysbiotic oral microbiome and increased ciom incidence and severity in adult cancer patients. Preliminary research has demonstrated a relationship between the oral microbiome and ciom in pediatric oncology populations. However, the sociodemographic homogeneity of the participants, the omission of environmental and contextual covariates, and the exclusion of patient-reported outcomes limit the strength of the findings. Furthermore, research examining the influence of food insecurity and diet quality on ciom is rarely conducted in pediatric oncology populations. The goal of this prospective observational study is to examine the interplay between food insecurity, diet quality, the oral microbiome, and patient-reported ciom in 45 pediatric b-all patients before (T1) and two weeks after (T2) the first HD-MTX dose. The specific aims are: (1) to assess the association of food insecurity (area-, household-, and child- level) and diet quality with ciom incidence and severity; (2) to investigate the association between the diversity and composition of the oral microbiome (16S rrna sequencing of saliva) and ciom incidence and severity; and (3) (exploratory aim) to explore whether food insecurity and diet quality alter the diversity and composition of the oral microbiome and subsequently impact ciom incidence and severity. Participants will be recruited from children's healthcare of atlanta using a non-probability quota sampling method designed to reflect the sociodemographic distribution of pediatric leukemia cases as reported by the national cancer institute. Findings will help identify potential pathways that influence ciom in the pediatric b-all population, supporting the development of future screening tools and interventional research that targets environmental, dietary, and biological factors to mitigate adverse outcomes. This project involves a team of expert researchers from emory university and a comprehensive two-year training plan to prepare an independent researcher in pediatric oncology with expertise in environmental health, diet quality, microbiomics, and symptom science.