Provision and Supervision of Food and Protein Substitute in School for Children with PKU: Parent Experiences

Children spend a substantial part of their childhood in school, so provision of dietary care and inclusion of children with phenylketonuria (PKU) in this setting is essential. There are no reports describing the dietary support children with PKU receive whilst at school. The aim of this cross-sectional study was to explore the experiences of the dietary management of children with PKU in schools across the UK. Data was collected using an online survey completed by parents/caregivers of children with PKU. Of 159 questionnaire responses, 92% (n = 146) of children attended state school, 6% (n = 10) private school and 2% (n = 3) other. Fourteen per cent (n = 21/154) were at nursery/preschool, 51% (n = 79/154) primary and 35% (n = 54/154) secondary school. Sixty-one per cent (n = 97/159) said their child did not have school meals, with some catering services refusing to provide suitable food and some parents distrusting the school meals service. Sixty-one per cent of children had an individual health care plan (IHCP) (n = 95/155). Children were commonly unsupervised at lunchtime (40%, n = 63/159), with snacks (46%, n = 71/155) and protein substitute (30%, n = 47/157), with significantly less supervision in secondary than primary school (p < 0.001). An IHCP was significantly associated with improved supervision of food and protein substitute administration (p < 0.01), and better communication between parents/caregivers and the school team (p < 0.05). Children commonly accessed non-permitted foods in school. Therefore, parents/caregivers described important issues concerning the school provision of low phenylalanine food and protein substitute. Every child should have an IHCP which details their dietary needs and how these will be met safely and discreetly. It is imperative that children with PKU are supported in school.

Adaptation and Validation of a Questionnaire to Evaluate Knowledge of the Low Phe Diet in PKU

Phenylketonuria (PKU) is an autosomal recessive disorder of phenylalanine (Phe) metabolism, causing a build-up of Phe in the body. Treatment consists of a Phe-restricted diet for life and regular determination of blood Phe levels to monitor the intake of Phe. Despite the fact that diet is the cornerstone of treatment, there are no studies examining common knowledge about food items and whether they are allowed as part of the PKU diet. Improving parents’ and patients’ knowledge and competence about the diet enables them to make appropriate food choices. This study validates a food-knowledge questionnaire first developed in Spanish and modified for English speaking populations. The questionnaire potentially helps parents to prepare appropriate meals and healthcare providers to create individualized educational programs about PKU for children and adolescents with this disorder.

Quality of Life in CKD Patients on Low-Protein Diets in a Multiple-Choice Diet System. Comparison between a French and an Italian Experience

Prescribing a low-protein diet (LPD) is part of the standard management of patients in advanced stages of chronic kidney disease (CKD). However, studies on the quality of life (QoL) of patients on LPDs are lacking, and the impact these diets have on their QoL is often given as a reason for not prescribing one. We, therefore, decided to assess the QoL in a cohort of CKD stage 3–5 patients followed up by a multiple-choice diet approach in an outpatient nephrology clinic in France. To do so, we used the short version of the World Health Organization’s quality of life questionnaire and compared the results with a historical cohort of Italian patients. We enrolled 153 patients, managed with tailored protein restriction in Le Mans, and compared them with 128 patients on similar diets who had been followed in Turin (Italy). We found there were no significant differences in terms of age (median 73 vs. 74 years, respectively), gender, CKD stage, and comorbidities (Charlson’s Comorbidity Index 7 vs. 6). French patients displayed a greater body mass index (29.0 vs. 25.4, p < 0.001) and prevalence of obesity (41.2 vs. 15.0%, p < 0.001). Baseline protein intake was over the target in France (1.2 g/kg of real body weight/day). In both cohorts, the burden of comorbidities was associated with poorer physical health perception while kidney function was inversely correlated to satisfaction with social life, independently of the type of diet. Our study suggests that the type of LPD they follow does not influence QoL in CKD patients and that a personalized approach towards protein restriction is feasible, even in elderly patients.

Improved Eating Behaviour and Nutrient Intake in Noncompliant Patients with Phenylketonuria after Reintroducing a Protein Substitute: Observations from a Multicentre Study

Noncompliance is widespread in adults with PKU and is associated with adverse metabolic, nutritional and cognitive abnormalities. Returning to the PKU diet is important for this at-risk population, yet for many this is challenging to achieve. Strategies that ease the return to the PKU diet, while offering nutritional and cognitive advantages, are needed. Twelve PKU adults (33.7 ± 2.6 years), who had been noncompliant for 4.5 years (range: 1 to 11 years), took 33 g of a low-volume, nutrient-enriched, protein substitute daily for 28 days. Outcomes of eating behaviour, nutrient intake and mood were assessed at entry (baseline, days 1-3) and after the intervention period (days 29-31). At baseline, intakes of natural protein and estimated phenylalanine were high (66.4 g and 3318.5 mg, respectively) and intakes of calcium, magnesium, iron, zinc, iodine and vitamin D were below country-specific recommendations. With use of the experimental protein substitute, natural protein and estimated phenylalanine intake declined (p = 0.043 for both). Fat and saturated fat intakes also decreased (p = 0.019 and p = 0.041, respectively), while energy and carbohydrate intake remained unchanged. Micronutrient intake increased (p ≤ 0.05 for all aforementioned) to levels well within reference nutrient intake recommendations. Blood vitamin B₁₂ and vitamin D increased by 19.8% and 10.4%, respectively. Reductions in anxiety and confusion were also observed during the course of the study yet should be handled as preliminary data. This study demonstrates that reintroducing a low-volume, nutrient-enriched protein substitute delivers favourable nutritional and possible mood benefits in noncompliant PKU patients, yet longer-term studies are needed to further confirm this. This preliminary knowledge should be used in the design of new strategies to better facilitate patients' return to the PKU diet, with the approach described here as a foundation.

[Nutritional knowledge and perception on dialysis: influence on adhesion and transgression; initial study]

BACKGROUND

The dialysis patients have problems in maintaining proper conduct and adherence to the diet prescribed in liquid nephrology consultation. Indicate the interdialytic weight gain, serum potassium and phosphorus along with self-report instruments, markers that have been used as indicators of non-adherence to the diet. Most of the time is not counted in dialysis units with dietitians-nutritionists. Nephrologists and nurses lack the time and / or sufficient to establish and monitor adherence to an individualized diet knowledge.

OBJECTIVES

The main objective is to determine adherence to dietary guidelines and hemodialysis fluids by DDFQ questionnaire and establish its relationship with the dietary habits of the patients, assessed by test dietary habits and cooking procedures. Secondary objectives are to measure adherence by DDFQ and relate the results to biochemical markers of intake and interdialytic weight gain (GID). Linking monitoring liquid diet and reported by the patient, biochemical markers of intake, interdialytic weight gain and the outcome of DDFQ. Determine membership based on sex, time on hemodialysis, have diabetes or have been transplanted once. And linking dietary habits reported by patients in the test of dietary habits and cooking procedures with patients' knowledge of the guidelines prescribed by nephrologists in consultation.

METHODOLOGY

Cross-sectional pilot study. Sociodemographic variables: age and sex. Clinical variables: diabetic transplant patient ever, time on dialysis, dry weight and GID. Biochemical markers: serum potassium and phosphorus. Variables adherence to diet questionnaire measures DDFQ.

STATISTICAL ANALYSIS

SPSS 20 Descriptive, Spearman correlation test, Student t test, Mann-Whitney U test and contingency table.

RESULTS

42 patients; 59.5% male, 40.5% female. Age 63.64 ± 16.17 years. Diabetics 11.9%. GID 1.96 ± 0.70 kg. Potassium 5.08 ± 0.86 meq / l phosphorus 4.71 ± 1.63 mg / dl. DDFQ Measured with 50% of patients not adhering to the diet in 2 days 14 days and 50% have no adherence to liquid in 1 day 14 days. There are correlations between adherence to diet and phosphorus (ρ= 0.304) and adherence to fluid and GID (ρ= 0.413).

CONCLUSIONS

There is a lack of adherence to dietary guidelines in dialysis patients, in contrast to the accession referred by them. The review of dietary and fluid patterns is necessary in patients with CKD on dialysis. Hence the importance of training and support for nurses using simple tools to detect breaches and act with greater dietary education.

Psychological benefits of a high-protein, low-carbohydrate diet in obese women with polycystic ovary syndrome—A pilot study

This study compared the psychological effects of a low-protein high-carbohydrate (LPHC) diet and a high-protein low-carbohydrate (HPLC) diet in women with polycystic ovary syndrome (PCOS). Twenty-five overweight women with PCOS were matched for age, weight, and whether they were trying to conceive. They were randomly allocated to the LPHC or HPLC diet for 16 weeks. All participants attended a weekly exercise, group support and educational program. The Hospital Anxiety and Depression Scale and the Rosenberg Self Esteem Scale were administered at the beginning and end of the study. The HPLC diet was associated with significant reduction in depression and improvement in self-esteem. There was no change in any psychological measures for the LPHC group. There was no difference in weight loss between the groups. Due to enhanced feelings of well-being, it is possible that HPLC diets may be associated with better compliance and hence be more successful in the long term treatment of obesity.

Association of socio-psychological factors with the effects of low protein diet for the prevention of the progression of chronic renal failure

OBJECTIVE

Our objectives were to investigate the therapeutic effects of low protein diet (LPD) for chronic renal failure (CRF) in compliant patients with the diet, and to clarify the relationships to the sociopsychological factors.

PATIENTS AND METHODS

Sixty-five patients (47 men and 18 women) with CRF who followed LPD (0.69 g/kg/day) for more than 3 months were recruited in this study. Compliance with the diet therapy was strictly assessed by the patients' dietary records, subsequent interviews regarding the status of daily dietary intake and estimated protein intakes calculated from urinary nitrogen excretion by 24-hour urine collections. The changes of glomerular filtration rate (GFR), serum creatinine (Cr), blood urea nitrogen (BUN), the reciprocal of serum creatinine (1/Cr), scores of Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), scales of Profile of Mood States (POMS), scores of self-efficacy and social support were investigated.

RESULTS

Decline rate of GFR, elevation of Cr and BUN and reduction in 1/Cr were significantly lower in compliant patients than in noncompliant patients (p<0.05). There were no differences in SF36 scores between compliant and noncompliant patients. The POMS scales of depression/dejection were high in female noncompliant patients compared to other groups of patients (p<0.05). Self-efficacy score was higher in compliant patients than in noncompliant patients (p<0.05). Social support scores were significantly higher in male compliant patients than in others (p<0.05), and both emotional support and behavioral support showed interaction with both gender and compliance with diet therapy (p<0.05).

CONCLUSION

LPD therapy is effective in suppressing the progression of CRF when it is well-adhered to. There are no correlations of this diet therapy to health-related QOL. Social support and high self-efficacy for men and high self-efficacy for women are associated with improvement of the compliance with LPD therapy, leading to good therapeutic effects.

Situational analysis of dietary challenges of the treatment regimen for children and adolescents with phenylketonuria and their primary caregivers

A situational analysis was conducted to evaluate challenges with the treatment regimen (a low protein diet and special supplemental formula) for children and adolescents with phenylketonuria (PKU) and their caregivers. A semistructured interview was administered to 19 caregivers and 11 children with PKU to describe formula and dietary problems and their frequency, difficulty, and affective intensity. Information was also gathered on attempted solutions to problems and their perceived effectiveness. Caregivers who rated dietary problems as less frequent, difficult, and emotionally upsetting and strategies as more effective for solving problems had children with significantly lower phenylalanine (Phe) levels, a biological indicator of adherence (i.e., better adherence; all p values <.05). Caregivers who reported using strategies coded as representing an authoritarian parenting style to solve dietary problems were significantly more likely to have lower household incomes and older children with higher Phe levels than were those who did not report such strategies (all p values <.05).

Nonadherence With Diet and Fluid Restrictions Among Adults Having Hemodialysis

PURPOSE

To describe the prevalence of nonadherence with the prescribed diet and fluid restrictions among patients receiving hemodialysis.

METHODS

A multicenter cross-sectional design with 916 patients recruited from 18 dialysis centers in Germany and Belgium. The Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) was used to measure patients' nonadherence.

FINDINGS

The results showed that many patients had difficulty following diet (81.4%) and fluid (74.6%) restrictions. Younger male patients and smokers were at highest risk for non-adherence. Higher levels of interdialysis weight gain were associated with nonadherence.

CONCLUSIONS

The findings indicate the need to continue to monitor and study hemodialysis patients' adherence behavior longitudinally and to design interventions to enhance adherence.

Haemodialysis patients' beliefs about renal failure and its treatment

Patients' beliefs about illness are important because they influence adherence and adjustment, but they are often surprising and idiosyncratic. Qualitative research can identify them in ways that are not shaped by psychological theory, but quantification is necessary if clinicians are to be informed about the beliefs that are likely to be prevalent in their patients. Qualitative analysis of interviews with 16 haemodialysis (HD) patients identified beliefs about end-stage renal failure (ESRF) and its treatment that were formed into a questionnaire, completed by 156 similar patients. Patients attributed ESRF to diverse factors including lack of self-care and inadequate medical care. Patients lacked a clear belief in the mechanism of action of dietary control, and its necessity was not readily acknowledged. The common view of haemodialysis as 'cleansing' extended to the reassuring belief that it would purge the body of disallowed food or drink. Many patients regarded haemodialysis and dietary control as externally imposed challenges that dominated life. The findings identify potential targets for educational intervention to improve adherence and adjustment and predictions about effects of patients' beliefs that can be tested in future prospective studies.

Mid-morning tryptophan depletion delays REM sleep onset in healthy subjects

Because serotonin is involved in the diachronic regulation of sleep, we tested the effect of a midmorning rapid deficiency in the serotonin precursor tryptophan on the next night's sleep. After a 48-h low-protein diet, 17 healthy volunteers received either a tryptophan-free mixture of amino acids or a placebo at 10:30 A.M., in a randomized double-blind cross-over design, resulting in a 77% decrease and 41% decrease of serum tryptophan at 3:30 P.M. and 9:30 P.M., respectively. Urinary sulfatoxy-melatonin excretion and mood were unaffected by the rapid tryptophan depletion (RTD), but rapid eye movement (REM) sleep latency increased by 21 min (from 91.5 +/- 4.5 min to 112.2 +/- 6.9 min), sleep fragmentation 58%, and REM density of the first REM sleep period doubled. The results show that midmorning RTD delays REM sleep latency during following night-time sleep, whereas evening RTD shortens REM sleep latency in previous studies, and suggest that the serotonin control of REM sleep latency is upregulated.

Vegetarian diet alternated with conventional low-protein diet for patients with chronic renal failure

OBJECTIVES

A dietary management program, consisting of the alternation between a vegetarian low-protein diet (VD) and an animal-based conventional low-protein diet (CLPD), aims to increase foods choices and to improve compliance with dietary prescriptions, psychologic aspects, and the quality of life of renal patients. The present study investigates the subjective effects and the practical consequences of this dietary approach in patients with chronic renal failure.

METHODS

Twenty patients (13 men, 7 women, 53 +/- 10 years) with chronic renal failure (creatinine clearance, <45 mL/min) were given the possibility to alternate (at their own convenience) the CLPD with the VD. After a follow-up period of 9 +/- 8 months, biochemistries were drawn and a questionnaire was mailed to asses the patients' subjective remarks about the proposed dietary management.

RESULTS

Most of the patients (90%) favorably accepted this dietary schedule because it provided more variety, it was less repetitive, and it was more suitable for those leading an active life. In many cases, patients reported that their quality of life and some psychologic problems were improved, as well as the palatability of the diet. On this dietary regimen, monthly demands of starch-made foods can be reduced and, hence, the social and/or individual costs. These features contributed to better compliance with dietary prescriptions. Nutritional parameters did not change significantly, and a decrease in total and low-density lipoprotein cholesterol levels were observed.

CONCLUSIONS

Our observations suggest that alternating between an animal-based CLPD and a vegetable-based VD can provide a useful dietary management for renal patients, giving them more chances for long-lasting dietary compliance.

Effects of caloric, protein, and sodium deprivation on the affiliative behavior of Norway rats (Rattus norvegicus)

The tendency of food-deprived, protein-deprived, and sodium-deprived Norway rats (Rattus norvegicus) and their respective controls to affiliate with conspecifics deprived of either food, protein, or sodium was examined. The authors found that (a) independent of internal state, focal rats offered a forced choice between protein-deprived and protein-replete target rats spent more time near replete than deprived target rats; and (b) both food-deprived and sodium-deprived focal rats offered a forced choice between food-deprived and replete target rats spent less time near fasted rats than did well-fed and sodium-replete focal rats. The data indicate that (a) rats can distinguish both food-deprived and protein-deprived rats from replete rats and (b) the deprivation states of rats can affect their willingness to affiliate with deprived conspecifics.

Dietary behaviors and sources of support in hemodialysis patients

Individuals with chronic renal failure generally have strict dietary guidelines. This descriptive study was designed to identify the relationship between sources of social support and dietary management by Japanese hemodialysis patients. A self-administered questionnaire was completed by a convenience sample of 325 adults receiving dialysis. Subjects 65 years and older received more support from family members, doctors, nurses, and technicians than younger subjects. Subjects who had been on dialysis for less than 3 years received more support from nurses and doctors than those who had been on dialysis for longer periods of time. Multiple regression analysis identified that support from family members and nurses were significantly related to dietary behaviors. Nurses working with dialysis patients should remember to use their influence to positively support their patients and to bear in mind that long-term dialysis patients, especially those who are young and unmarried, may benefit from ongoing nursing support and encouragement.

Role of learning in the selection of dietary protein in the golden hamster (Mesocricetus auratus)

Hamsters (Mesocricetus auratus) were kept for several weeks on maintenance diets (MDs) that were either nutritionally complete or protein deficient, and had periodic access to protein-free and high-protein conditioning diets (CDs) with marker flavors (anise and clove). In Experiment 1, protein-restricted hamsters came to prefer the flavor of high-protein CDs but did not prefer unflavored high-protein CD. Thus, hamsters learned to select dietary protein by attending to the flavor of the CD. In Experiment 2, a within-subjects design was used, and MDs also had marker flavors (garlic and sage). Hamsters came to prefer the flavor of high-protein CD when protein restricted, and they showed this preference even in the absence of protein restriction if reexposed for only 90 min to merely the flavor of a protein-deficient MD. Thus, learned associations between the flavor and the usual postingestional consequences of a recently ingested MD can affect short-term dietary protein selection.

Dietary protein restriction and selective preference for a protein-containing diet in the golden hamster (Mesocricetus auratus)

Two experiments were performed to examine protein appetite in golden hamsters (Mesocricetus auratus). In Experiment 1, hamsters were maintained for 10 days on either a protein-free or a nutritionally complete maintenance diet, and they were also given access to protein-rich and carbohydrate-rich test diets for 6 h/day. Hamsters maintained on the protein-free diet strongly preferred the protein test diet, but hamsters on the complete diet showed no such preference even when their caloric intake was matched to that of hamsters on the protein-free diet. In Experiment 2, hamsters that had developed a preference for the protein test diet while maintained on the protein-free diet were given Purina Chow for 25 days to permit them to recover from their protein deficiency. When later maintained on the complete diet, these hamsters did not demonstrate a preference for the protein test diet when maintained on the complete diet, but did so when returned to the protein-free maintenance diet. These findings indicate that dietary protein restriction causes hamsters to develop a strong preference for a protein-rich diet and that this preference may be manifested only in response to a physiological need for protein.