Nutritional considerations in patients with cystic fibrosis

The overlooked factor: Sleep quality in assessing malnutrition risk and nutritional status in adolescents with cystic fibrosis

AIM

This study aimed to assess the relationship between sleep quality, malnutrition risk, and nutritional status in adolescents with cystic fibrosis(CF).

MATERIAL AND METHOD

This cross-sectional study was conducted with 55 adolescents (aged 10-18 years) diagnosed with CF. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), and malnutrition risk was evaluated based on disease-specific criteria. Nutritional status was assessed using body mass index (BMI), BMI percentiles, dietary energy intake, and food group consumption. Multiple linear regression analyses were used to determine the relationship between sleep quality, malnutrition risk, and nutritional status.

RESULTS

Among the participants, 50.9 % had poor sleep quality, and 29.1 % were classified as high-risk for malnutrition. Poor sleep quality was significantly associated with increased malnutrition risk (p < 0.05), independent of dietary energy intake and BMI percentiles. Lower BMI percentile was strongly associated with higher malnutrition risk (p < 0.001), identifying BMI as a critical predictor. Specifically, 27.3 % of participants had a BMI <10th percentile, which contributed to their classification as high-risk for malnutrition. However, dietary energy intake did not significantly predict malnutrition risk despite its relevance in dietary management.

CONCLUSION

This study emphasizes the crucial role of sleep quality in assessing malnutrition risk among adolescents with CF. Poor sleep quality was associated with higher malnutrition risk, suggesting that sleep disturbances may contribute to nutritional challenges. Sleep quality should be considered a key factor in assessing malnutrition risk among adolescents with CF and integrated into clinical practice to develop comprehensive management strategies addressing sleep disturbances and nutritional challenges, improving health outcomes.

Exocrine Pancreatic Insufficiency Dosing Guidelines for Pancreatic Enzyme Replacement Therapy Vary Widely Across Disease Types

BACKGROUND

Pancreatic enzyme replacement therapy (PERT) is the standard treatment for exocrine pancreatic insufficiency (EPI). However, many individuals are inadequately treated, with gaps in clinical dosing, guidelines, and tools to aid individual titration.

METHODS

A systematic review identified research and guidelines on PERT dosing recommendations across conditions, systematically reviewing and synthesizing total PERT intake, meal/snack guidelines, and changes over time to provide an up-to-date look at the most common doses used in studies and guidelines.

RESULTS

This review of 257 articles found wide variability in PERT dosing guidelines within and across conditions. Many patients with EPI are underdosed, with guidelines differing globally and by disease type, and clinician prescribing may also play a role. The most common dosing guidelines focus on starting doses at 40,000-50,000 units of lipase/meal with increases of up to two to three times this amount before pursuing additive therapies. Guidelines and studies typically focus only on fat digestion, and comparison by total daily dose shows underdosing is common. Most PERT studies are on safety and efficacy rather than optimal titration.

CONCLUSION

The current guidelines for PERT in EPI demonstrate substantial variability in dosing recommendations, both within and across disease types. This variation highlights the need for further research to optimize PERT dosing and improve patient outcomes. Healthcare providers should consider individualizing PERT dosing based on nutritional status and response to therapy, ensuring regular follow-up with patients for dose titrations with consideration that most guidelines are framed as initial doses rather than upper limits.

Nutrition in Cystic Fibrosis—Some Notes on the Fat Recommendations

Nutrition is important in cystic fibrosis (CF) because the disease is associated with a higher energy consumption, special nutritional deficiencies, and malabsorption mainly related to pancreatic insufficiency. The clinical course with deterioration of lung function has been shown to relate to nutrition. Despite general recommendation of high energy intake, the clinical deterioration is difficult to restrain suggesting that special needs have not been identified and specified. It is well-known that the CF phenotype is associated with lipid abnormalities, especially in the essential or conditionally essential fatty acids. This review will concentrate on the qualitative aspects of fat metabolism, which has mainly been neglected in dietary fat recommendations focusing on fat quantity. For more than 60 years it has been known and confirmed that the patients have a deficiency of linoleic acid, an n-6 essential fatty acid of importance for membrane structure and function. The ratio between arachidonic acid and docosahexaenoic acid, conditionally essential fatty acids of the n-6 and n-3 series, respectively, is often increased. The recently discovered relations between the CFTR modulators and lipid metabolism raise new interests in this field and together with new technology provide possibilities to specify further specify personalized therapy.

The determinants of survival among adults with cystic fibrosis-a cohort study

BACKGROUND

Cystic fibrosis (CF) is one of the most common autosomal recessive diseases. Factors contributing to disease exacerbations and survival rate of CF patients are type of mutation in the CFTR gene, poor nutritional status, lung failure, and infection development by Pseudomonas aeruginosa. The study aimed to evaluate the relationship between the severity of mutation, nutritional status, lung function, and Pseudomonas aeruginosa prevalence and survival rate in adult patients with cystic fibrosis.

METHODS

A study of 124 (68 ♀ and 56 ♂) adults with CF aged 18-51 years were evaluated for (a) type of mutation in the CFTR gene, (b) nutritional status (BMI), (c) lung function (FEV₁%), and (d) Pseudomonas aeruginosa prevalence. For statistical calculations, Kaplan-Meier analysis of survival, chi-squared test for multiple samples, and logistic regression were used.

RESULTS

The type of mutation (χ² = 12.73, df = 3, p = 0.005), FEV₁% (χ² = 15.20, df = 2, p = 0.0005), Pseudomonas aeruginosa prevalence (χ² = 11.48, df = 3, p = 0.009), and BMI (χ² = 31.08, df = 4, p < 0.000) significantly differentiated the probability of survival of patients with CF. The shortest life expectancy was observed in patients with a severe type of mutation on both alleles, FEV₁% < 40, subjects in whom Pseudomonas culture was extensively drug-resistant or pandrug-resistant, and patients whose BMI was lower than 18.5 kg/m². The period from 30 to 40 years of age was the most critical in CF adults' lifespan. The risk of adults with CF death doubled with Pseudomonas aeruginosa prevalence (OR = 2.06, 95% CI 1.29; 2.28) and eightfold when the bacteria acquired antibiotic resistance (OR = 8.11, 95% CI 1.67; 38.15).

CONCLUSIONS

All factors included in the study were significantly related to the survival rate of patients with cystic fibrosis.

Challenges with optimizing nutrition in cystic fibrosis

Introduction. Optimizing nutrition remains the cornerstone of therapy for patients with cystic fibrosis (CF) since it is associated with better pulmonary function and survival. However, a significant proportion of patients still fail to achieve normal growth and nutritional status. Areas covered. This review describes the current challenges in providing effective nutritional therapy in CF with a focus on the current issues related to energy imbalance, dietary composition, adherence to nutritional recommendations, pancreatic enzyme replacement therapy, and the effects of modulators of the CF transmembrane conductance regulator. Expert opinion. CF is a multisystemic disease that requires a personalized nutritional approach with accurate evaluation of energy balance. There is an urgent need for evidence-based recommendations on the dietary composition, in consideration of the increasing prevalence of overweight, diabetes and the potential effects of fatty acids on inflammation and immune response. More research into new pancreatic enzyme formulations is also required.

[Liver disease, gastrointestinal complications, nutritional management and feeding disorders in pediatric cystic fibrosis]

In cystic fibrosis (CF), approximately 5-8% of the patients develop multilobular cirrhosis during the first decade of life. Annual screening (clinical examination, liver biochemistry, ultrasonography) is recommended in order to identify early signs of liver involvement, initiate ursodeoxycholic acid therapy and detect complications (portal hypertension and liver failure). Management should focus on nutrition and prevention of variceal bleeding. The gut may also be involved in children with CF. Gastroesophageal reflux is frequent, although often neglected and should be investigated by pH monitoring and impedancemetry, if available. Acute pancreatitis occurs in patients with persistent exocrine pancreatic activity. Intussusception, appendicular mucocele, distal intestinal occlusion syndrome, small bowel bacterial overgrowth and Clostridium difficile colitis should be considered in case of abdominal pain. Preventive nutritional support should be started as soon as possible after diagnosis of CF. Attainment of normal growth is one of the main goals and can be achieved with hypercaloric and salt supplemented food. Pancreatic enzyme replacement therapy should be started as soon as exocrine pancreatic insufficiency is confirmed and ingested immediately prior to meals with intake of fat-soluble vitamins. Curative nutritional interventions are more likely to be effective in the early stages of pulmonary disease. Feeding disorders, related to the physiopathology and the psychologic aspects of the disease are frequent. Repeated corporeal aggressions, associated with inappropriate medical and parental pressure, may increase the child's refusal of food. The multidisciplinary team should guide parents in order to avoid all intrusive feeding practices and promote pleasant mealtimes.

Current and future treatment options for cystic fibrosis lung disease: latest evidence and clinical implications

Treatment for cystic fibrosis (CF) has conventionally targeted downstream consequences of the defect such as mucus plugging and infection. More recently, significant advances have been made in treating the root cause of the disease, namely a defective CF transmembrane conductance regulator (CFTR) gene. This review summarizes current pulmonary treatment options and highlights advances in research and development of new therapies.

Improving nutritional status in a pediatric cystic fibrosis center

BACKGROUND

The nutritional status of patients with cystic fibrosis (CF) is strongly associated with pulmonary function, respiratory status and survival. Malnutrition could result from a discrepancy between energy needs and food intake while malabsorption results from pancreatic insufficiency which occurs in 85% of people with CF.

METHODS

A quality improvement (QI) project was designed to improve the nutritional status of patients with CF with low Body Mass Index (BMI) between 3 and 19 years of age. An algorithm was developed which included clinic-based assessments of patients' nutritional status and periodic assessment by a dietitian, social worker and/or psychologist during the project. Gastrostomy tube placement and feeding was offered as a last resort to improve caloric intake.

RESULTS

173 patients seen during January-June, 2010, were included in this project. They were classified into four BMI groups and data were collected quarterly through June, 2012. The project target population (BMI percentile ≤ 24) had a median BMI percentile at the start of the project of 11.8. At the end of the project median BMI percentile was 22 (46% improvement).

CONCLUSION

Improving nutrition and BMI for patients with CF is achievable. There must be a motivated, multi-disciplinary team that includes patients and families. A patient-specific combination of interventions must be used. These interventions could be quite basic for patients with BMI percentile ≥ 25, yet more elaborate for patients with BMI percentile <25. Clinic-based algorithms such as ours can successfully improve the BMI percentile in patients with CF.

Pathophysiology of cystic fibrosis and drugs used in associated digestive tract diseases

Cystic fibrosis (CF) causes chronic infections in the respiratory tract and alters the digestive tract. This paper reviews the most important aspects of drug treatment and changes in the digestive tract of patients with CF. This is a review of the literature, emphasizing the discoveries made within the last 15 years by analyzing scientific papers published in journals indexed in the Scientific Electronic Library Online, Sciences Information, United States National Library of Medicine and Medical Literature Analysis and Retrieval System Online databases, both in English and Portuguese, using the key words: cystic fibrosis, medication, therapeutic, absorption, digestion. Randomized, observational, experimental, and epidemiological clinical studies were selected, among others, with statistical significance of 5%. This review evaluates the changes found in the digestive tract of CF patients including pancreatic insufficiency, constipation and liver diseases. Changes in nutritional status are also described. Clinical treatment, nutritional supplementation and drug management were classified in this review as essential to the quality of life of CF patients, and became available through public policies for monitoring and treating CF. The information gathered on CF and a multi professional approach to the disease is essential in the treatment of these patients.

High serum retinol and lung function in young patients with cystic fibrosis

OBJECTIVE

The aim of the present study was to explore the relation between lung function and serum retinol (SR) in cystic fibrosis (CF) patients.

METHODS

This was a cross-sectional study conducted in a group of 98 young patients with CF (6.8-22.3 years), after the exclusion of those with pulmonary exacerbation, vitamin A deficiency, or other risks, from an initial group of 124 cases.

RESULTS

Data of forced expiratory volume in 1 second (FEV₁) were widely scattered (87.7% ± 16.9%). These were similar in the 78 pancreatic insufficient and 11 pancreatic sufficient patients. SR (56.6 ± 18.4 μg/dL) was >2.5th percentile of healthy people in the whole group, although 31 patients were situated above the 97.5th percentile (higher value: 110 μg/dL). The FEV₁ was noticeably higher in these than in those within the normal range (93.6 ± 14.0 vs 85.0 ± 17.6 μg/dL; P < 0.05). The z score of SR correlated positively with FEV₁ (r = 0.364; P = 0.000), after adjusting data for sex, age, body mass index, and pancreatic function. The odds ratio for a FEV₁ >80% is 3.78 in patients with SR above the 97.5th percentile, versus only 0.26 in those within the normal range. There were no cases with retinol toxicity.

CONCLUSIONS

FEV₁ of young patients with CF correlates positively with SR, regardless of age, pancreatic function, or nutritional condition. Those with a moderately high retinol (up to 110 μg/dL) maintain the best respiratory function (FEV₁ ≥80% in >90% of them) without any signs of toxicity.

Measuring energy expenditure in clinical populations: rewards and challenges

The measurement of energy expenditure (EE) is recommended as an important component of comprehensive clinical nutrition assessments in patients with altered metabolic states, who failed to respond to nutrition support and with critical illness that require individualized nutrition support. There is evidence that EE is variable in patients with metabolic diseases, such as chronic renal disease, cirrhosis, HIV, cancer cachexia, cystic fibrosis and patients under intensive care. By using appropriate techniques and interpretations of basal or resting EE, clinicians can facilitate the adequate nutrition support with minimum negative impacts from under- or overfeeding in these patients. This review is based on our current understanding of the different components of EE and the techniques to measure them, and to re-examine advances and challenges to determine energy needs in clinical populations with more focuses on the obese, pediatric and elderly patients. In addition, technological advances have expanded the choices of market-available equipments for assessing EE, which also bring specific challenges and rewards in selecting the right equipment with specific performance criteria. Lastly, analytical considerations of interpreting the results of EE in the context of changing body composition are presented and discussed.