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Gao X, Chang R, Xu E, Ning Q, Du J. The Sage of Tea and the Inherited Metabolic Diseases. Altern Ther Health Med 2024; 30:167-169. [PMID: 37856821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Background Lu Yu (733-804 AD, Tang Dynasty) was an orphan raised and educated in a monastery. His profound knowledge of tea earned him the title "the Sage of Tea." This paper explores the possibility that Lu Yu may have been a patient of inherited metabolic diseases (IMDs), particularly phenylketonuria (PKU), considering historical records and unique aspects of his life. Case Presentation Examining Lu Yu's orphaned upbringing, clinical manifestations noted in his autobiography, dietary preferences, and the significance of his name, this study postulates that he may have had IMDs, notably PKU. His life choices, such as abstaining from meat and fish and favoring a low-protein diet during his time in a monastery, align with practices recommended for managing IMDs. The linguistic associations of his name further reinforce this hypothesis. Conclusions This investigation sheds light on the intriguing possibility that Lu Yu may have been affected by IMDs, notably PKU. By considering historical context, clinical correlations, dietary choices, and name symbolism, we offer a unique historical perspective on this celebrated figure's health. Further research could provide valuable insights into both his life and the broader medical practices of the Tang Dynasty.
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Delsoglio M, Capener R, MacDonald A, Daly A, Ashmore C, Donald S, Gaff L, VanDorp L, Skeath R, Ellerton C, Newby C, Dunning G, Dale C, Hunjan I, White L, Allen H, Hubbard GP, Stratton RJ. Evaluation of a New 'Mix-In' Style Glycomacropeptide-Based Protein Substitute for Food and Drinks in Patients with Phenylketonuria and Tyrosinemia. Nutrients 2023; 15:3598. [PMID: 37630788 PMCID: PMC10459832 DOI: 10.3390/nu15163598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Poor palatability, large volume, and lack of variety of some liquid and powdered protein substitutes (PSs) for patients with phenylketonuria (PKU) and tyrosinemia (TYR) can result in poor adherence. This study aimed to evaluate a new unflavoured, powdered GMP-based PS designed to be mixed into drinks, foods, or with other PSs, in patients with PKU and TYR. (2) Methods: Paediatric and adult community-based patients were recruited from eight metabolic centres and prescribed ≥1 sachet/day (10 g protein equivalent (PE)) of the Mix-In-style PS over 28 days. Adherence, palatability, GI tolerance, and metabolic control were recorded at baseline and follow-up. Patients who completed at least 7 days of intervention were included in the final analysis. (3) Results: Eighteen patients (3-45 years, nine males) with PKU (n = 12) and TYR (n = 6) used the Mix-In-style PS for ≥7 days (mean 26.4 days (SD 4.6), range 11-28 days) alongside their previous PS, with a mean intake of 16.7 g (SD 7.7) PE/day. Adherence was 86% (SD 25), and GI tolerance was stable, with n = 14 experiencing no/no new symptoms and n = 3 showing improved symptoms compared to baseline. Overall palatability was rated satisfactory by 78% of patients, who successfully used the Mix-In-style PS in various foods and drinks, including smoothies, squash, and milk alternatives, as a top-up to meet their protein needs. There was no concern regarding safety/metabolic control during the intervention. (4) Conclusions: The 'Mix-In'-style PS was well adhered to, accepted, and tolerated. Collectively, these data show that providing a flexible, convenient, and novel format of PS can help with adherence and meet patients' protein needs.
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Affiliation(s)
- Marta Delsoglio
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
| | - Rebecca Capener
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Sarah Donald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Louise VanDorp
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - Charlotte Ellerton
- University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK
| | - Camille Newby
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Georgina Dunning
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK
| | - Clare Dale
- Queen Elizabeth Hospital, Birmingham B15 2TH, UK
| | - Inderdip Hunjan
- Bradford Teaching Hospitals, NHS Foundation Trust, Bradford BD5 0NA, UK
| | - Lucy White
- Sheffield Children’s NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Heather Allen
- Sheffield Children’s NHS Foundation Trust, Sheffield S10 2TH, UK
| | - Gary P. Hubbard
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
| | - Rebecca J. Stratton
- Research and Innovation, Nutricia Ltd., White Horse Business Park, Trowbridge BA14 0XQ, UK
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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Rondanelli M, Porta F, Gasparri C, Barrile GC, Cavioni A, Mansueto F, Mazzola G, Patelli Z, Peroni G, Pirola M, Razza C, Tartara A, Perna S. A food pyramid for adult patients with phenylketonuria and a systematic review on the current evidences regarding the optimal dietary treatment of adult patients with PKU. Clin Nutr 2023; 42:732-763. [PMID: 37001196 DOI: 10.1016/j.clnu.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023]
Abstract
Early dietary treatment is mind-saving in patients with phenylketonuria. A "diet-for-life" is advocated, aimed to prevent effects of chronic exposure to hyperphenylalaninemia. While adherence to diet is significant during childhood as patients are followed-up at specialized metabolic centers, during adolescence and adulthood percentage of patients discontinuing diet and/or lost at follow-up is still high. The process of passing skills and responsibilities from pediatric team to adult team is defined "transition". The goal of transition clinics is to set up specific multidisciplinary care pathways and guarantee continuity of care and compliance of patients to care. In 2017, "The complete European guidelines on phenylketonuria" were published. These guidelines, however, do not provide an easy way to illustrate to adult patients how to follow correct dietary approach. The purpose of this review is to evaluate current evidence on optimum dietary treatment of adults with phenylketonuria and to provide food pyramid for this population. The pyramid built shows that carbohydrates should be consumed every day (3 portions), together with fruits and vegetables (5 portions), extra virgin olive oil, and calcium water (almost 1 L/day); weekly portions can include 150 g potatoes walnuts and hazelnuts (20 g). At top of pyramid, there are two pennants. The green means that, based on individual metabolic phenotype and daily phenylalanine tolerance, patients need personalized supplementation (specific phenylalanine free amino acid mixtures, vitamins and omega 3 fatty acids); the one red indicates foods that are banned from diet (aspartame and protein foods exceeding individual dietary phenylalanine tolerance).
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Affiliation(s)
- Mariangela Rondanelli
- IRCCS Mondino Foundation, 27100 Pavia, Italy; Unit of Human and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy.
| | - Francesco Porta
- Department of Pediatrics, Città Della Salute e Della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy.
| | - Clara Gasparri
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Gaetan Claude Barrile
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Alessandro Cavioni
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Francesca Mansueto
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Giuseppe Mazzola
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Zaira Patelli
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Gabriella Peroni
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Martina Pirola
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Claudia Razza
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Alice Tartara
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Simone Perna
- Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), Università Degli Studi di Milano, 20122 Milano, Italy.
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Ahring KK, Dagnæs-Hansen F, Brüel A, Christensen M, Jensen E, Jensen TG, Johannsen M, Johansen KS, Lund AM, Madsen JG, Brøndum-Nielsen K, Pedersen M, Sørensen LK, Kjolby M, Møller LB. The effect of casein glycomacropeptide versus free synthetic amino acids for early treatment of phenylketonuria in a mice model. PLoS One 2022; 17:e0261150. [PMID: 35015767 PMCID: PMC8751992 DOI: 10.1371/journal.pone.0261150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 11/24/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction Management of phenylketonuria (PKU) is mainly achieved through dietary control with limited intake of phenylalanine (Phe) from food, supplemented with low protein (LP) food and a mixture of free synthetic (FS) amino acids (AA) (FSAA). Casein glycomacropeptide (CGMP) is a natural peptide released in whey during cheese making by the action of the enzyme chymosin. Because CGMP in its pure form does not contain Phe, it is nutritionally suitable as a supplement in the diet for PKU when enriched with specific AAs. Lacprodan® CGMP-20 (= CGMP) used in this study contained only trace amounts of Phe due to minor presence of other proteins/peptides. Objective The aims were to address the following questions in a classical PKU mouse model: Study 1, off diet: Can pure CGMP or CGMP supplemented with Large Neutral Amino Acids (LNAA) as a supplement to normal diet significantly lower the content of Phe in the brain compared to a control group on normal diet, and does supplementation of selected LNAA results in significant lower brain Phe level?. Study 2, on diet: Does a combination of CGMP, essential (non-Phe) EAAs and LP diet, provide similar plasma and brain Phe levels, growth and behavioral skills as a formula which alone consist of FSAA, with a similar composition?. Material and methods 45 female mice homozygous for the Pahenu2 mutation were treated for 12 weeks in five different groups; G1(N-CGMP), fed on Normal (N) casein diet (75%) in combination with CGMP (25%); G2 (N-CGMP-LNAA), fed on Normal (N) casein diet (75%) in combination with CGMP (19,7%) and selected LNAA (5,3% Leu, Tyr and Trp); G3 (N), fed on normal casein diet (100%); G4 (CGMP-EAA-LP), fed on CGMP (70,4%) in combination with essential AA (19,6%) and LP diet; G5 (FSAA-LP), fed on FSAA (100%) and LP diet. The following parameters were measured during the treatment period: Plasma AA profiles including Phe and Tyr, growth, food and water intake and number of teeth cut. At the end of the treatment period, a body scan (fat and lean body mass) and a behavioral test (Barnes Maze) were performed. Finally, the brains were examined for content of Phe, Tyr, Trp, dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), serotonin (5-HT) and 5-hydroxyindole-acetic acid (5-HIAA), and the bone density and bone mineral content were determined by dual-energy x-ray absorptiometry. Results Study 1: Mice off diet supplemented with CGMP (G1 (N-CGMP)) or supplemented with CGMP in combination with LNAA (G2 (N-CGMP-LNAA)) had significantly lower Phe in plasma and in the brain compared to mice fed only casein (G3 (N)). Extra LNAA (Tyr, Trp and Leu) to CGMP did not have any significant impact on Phe levels in the plasma and brain, but an increase in serotonin was measured in the brain of G2 mice compared to G1. Study 2: PKU mice fed with mixture of CGMP and EAA as supplement to LP diet (G4 (CGMP-EAA-LP)) demonstrated lower plasma-Phe levels but similar brain- Phe levels and growth as mice fed on an almost identical combination of FSAA (G5 (FSAA-LP)). Conclusion CGMP can be a relevant supplement for the treatment of PKU.
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Affiliation(s)
- Kirsten K. Ahring
- Departments of Paediatrics and Clinical Genetics, PKU Clinic, Kennedy Center, Copenhagen University Hospital, Rigshospitalet, Denmark
- * E-mail:
| | | | - Annemarie Brüel
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Mette Christensen
- Departments of Paediatrics and Clinical Genetics, Centre for Inherited Metabolic Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Erik Jensen
- Arla Foods Ingredients Group P/S, Viby J, Denmark
| | - Thomas G. Jensen
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Mogens Johannsen
- Department of Forensic Medicine, Aarhus University, Skejby, Aarhus, Denmark
| | - Karen S. Johansen
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Allan M. Lund
- Departments of Paediatrics and Clinical Genetics, Centre for Inherited Metabolic Diseases, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Jesper G. Madsen
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Karen Brøndum-Nielsen
- Departments of Paediatrics and Clinical Genetics, PKU Clinic, Kennedy Center, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Michael Pedersen
- Comparative Medicine Lab, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mads Kjolby
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark
| | - Lisbeth B. Møller
- Department of Clinical Genetics, Kennedy Center, Copenhagen University Hospital, Rigshospitalet, Denmark
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Wood G, Pinto A, Evans S, Daly A, Adams S, Costelloe S, Gribben J, Ellerton C, Emm A, Firman S, Ford S, French M, Gaff L, Giuliano E, Hill M, Hunjan I, Newby C, Mackenzie A, Pereira R, Prescott C, Robertson L, Seabert H, Skeath R, Tapley S, Terry A, Tooke A, van Wyk K, White FJ, White L, Woodall A, Rocha JC, MacDonald A. Special Low Protein Foods Prescribed in England for PKU Patients: An Analysis of Prescribing Patterns and Cost. Nutrients 2021; 13:nu13113977. [PMID: 34836232 PMCID: PMC8620831 DOI: 10.3390/nu13113977] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 10/29/2021] [Accepted: 11/03/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with phenylketonuria (PKU) are reliant on special low protein foods (SLPFs) as part of their dietary treatment. In England, several issues regarding the accessibility of SLPFs through the national prescribing system have been highlighted. Therefore, prescribing patterns and expenditure on all SLPFs available on prescription in England (n = 142) were examined. Their costs in comparison to regular protein-containing (n = 182) and ‘free-from’ products (n = 135) were also analysed. Similar foods were grouped into subgroups (n = 40). The number of units and costs of SLPFs prescribed in total and per subgroup from January to December 2020 were calculated using National Health Service (NHS) Business Service Authority (NHSBSA) ePACT2 (electronic Prescribing Analysis and Cost Tool) for England. Monthly patient SLPF units prescribed were calculated using patient numbers with PKU and non-PKU inherited metabolic disorders (IMD) consuming SLPFs. This was compared to the National Society for PKU (NSPKU) prescribing guidance. Ninety-eight percent of SLPF subgroups (n = 39/40) were more expensive than regular and ‘free-from’ food subgroups. However, costs to prescribe SLPFs are significantly less than theoretical calculations. From January to December 2020, 208,932 units of SLPFs were prescribed (excluding milk replacers), costing the NHS £2,151,973 (including milk replacers). This equates to £962 per patient annually, and prescribed amounts are well below the upper limits suggested by the NSPKU, indicating under prescribing of SLPFs. It is recommended that a simpler and improved system should be implemented. Ideally, specialist metabolic dietitians should have responsibility for prescribing SLPFs. This would ensure that patients with PKU have the necessary access to their essential dietary treatment, which, in turn, should help promote dietary adherence and improve metabolic control.
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Affiliation(s)
- Georgina Wood
- Faculty of Health, Education & Life Sciences, Birmingham City University, City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK
- Correspondence:
| | - Alex Pinto
- Dietetic Department, Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (A.D.); (A.M.)
| | - Sharon Evans
- Dietetic Department, Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (A.D.); (A.M.)
| | - Anne Daly
- Dietetic Department, Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (A.D.); (A.M.)
| | - Sandra Adams
- Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK;
| | - Susie Costelloe
- Royal Devon & Exeter NHS Foundation Trust, Barrack Rd, Exeter EX2 5DW, UK;
| | - Joanna Gribben
- Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EU, UK; (J.G.); (S.F.)
| | - Charlotte Ellerton
- University College London Hospitals NHS Foundation Trust, National Hospital for Neurology & Neurosurgery, Queen Square, London WC1N 3BG, UK;
| | - Anita Emm
- University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, UK;
| | - Sarah Firman
- Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EU, UK; (J.G.); (S.F.)
| | - Suzanne Ford
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK;
| | - Moira French
- University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester LE1 5WW, UK;
| | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK; (L.G.); (C.P.)
| | - Emily Giuliano
- Northamptonshire Healthcare NHS Foundation Trust, St Mary’s Hospital, London Road, Kettering NN15 7PW, UK;
| | - Melanie Hill
- Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield S5 7AU, UK;
| | - Inderdip Hunjan
- Bradford Teaching Hospitals NHS Foundation Trust, Duckworth Lane, Bradford BD9 6RJ, UK;
| | - Camille Newby
- Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK;
| | | | - Rachel Pereira
- Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK;
| | - Celine Prescott
- Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK; (L.G.); (C.P.)
| | - Louise Robertson
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham B15 2TH, UK;
| | - Heidi Seabert
- Somerset NHS Foundation Trust, Parkfield Drive, Taunton TA1 5DA, UK;
| | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, UK;
| | - Simon Tapley
- University Hospitals Bristol & Weston NHS Foundation Trust, Marlborough St, Bristol BS1 3NU, UK;
| | - Allyson Terry
- Alder Hey Children’s NHS Foundation Trust, E Prescot Road, Liverpool L12 2AP, UK;
| | - Alison Tooke
- Nottingham University Hospitals NHS Trust, Queen’s Medical Centre Campus, Derby Road, Nottingham NG7 2UH, UK;
| | - Karen van Wyk
- Royal Manchester Children’s Hospital, Oxford Road, Manchester M13 9WL, UK; (K.v.W.); (F.J.W.)
| | - Fiona J. White
- Royal Manchester Children’s Hospital, Oxford Road, Manchester M13 9WL, UK; (K.v.W.); (F.J.W.)
| | - Lucy White
- Sheffield Children’s NHS Foundation Trust, Clarkson St, Broomhall, Sheffield S10 2TH, UK;
| | - Alison Woodall
- Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, UK;
| | - Júlio César Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal;
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo Mártires da Pátria 130, 1169-056 Lisbon, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisbon, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Women’s and Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (A.D.); (A.M.)
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Aitkenhead L, Krishna G, Ellerton C, Moinuddin M, Matcham J, Shiel L, Hossain S, Kiffin M, Foley J, Skeath R, Cleary M, Lachmann R, Murphy E. Long-term cognitive and psychosocial outcomes in adults with phenylketonuria. J Inherit Metab Dis 2021; 44:1353-1368. [PMID: 34145605 DOI: 10.1002/jimd.12413] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 12/22/2022]
Abstract
Previous studies have suggested that cognitive and psychosocial underfunctioning in early-treated adults with phenylketonuria (PKU) may be explained by suboptimal adherence to dietary treatments, however, these studies often employ small samples, with different outcome measures, definitions and cut-offs. Samples have also tended to comprise participants with a limited range of blood phenylalanine concentrations, and often individuals who may not have been treated early enough to avoid neurological damage. In this study, we explore the impact of lifetime dietary control, as indicated by blood phenylalanine concentrations in childhood, adolescence and adulthood, on long-term cognitive and psychosocial outcomes in a large sample of adults with PKU who were diagnosed by neonatal screening and commenced on dietary treatment within the first month of life. One hundred and fifty-four participants underwent cognitive testing, assessing attention, learning, working memory, language, executive functioning and processing speed. One hundred and forty-nine completed measures of psychosocial functioning, documenting educational, occupational, quality of life, emotional and social outcomes which were compared with a group of healthy controls. Many adults with PKU demonstrated cognitive impairments, most frequently affecting processing speed (23%), executive function (20%) and learning (12%). Cognitive outcomes were related to measures of historic metabolic control, but only processing speed was significantly related to phenylalanine concentration at the time of testing after controlling for historic levels. Adults with PKU did not, however, differ from controls in educational, occupational, quality of life or emotional outcomes, or on a measure of family functioning, and showed only minor differences in relationship style. These findings have implications for patient counselling and decisions regarding the management of PKU in adulthood.
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Affiliation(s)
- Lynne Aitkenhead
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
| | - Gauri Krishna
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Charlotte Ellerton
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Md Moinuddin
- UCL Institute of Child Health, London, UK
- Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk, UK
| | - Jessica Matcham
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Lisha Shiel
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Shasoty Hossain
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Marianne Kiffin
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Jennifer Foley
- UCL Institute of Neurology, London, UK
- Department of Neuropsychology, National Hospital of Neurology & Neurosurgery, London, UK
| | - Rachel Skeath
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
| | - Maureen Cleary
- Department of Metabolic Medicine, Great Ormond Street Hospital, London, UK
- Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Robin Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
| | - Elaine Murphy
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
- UCL Institute of Neurology, London, UK
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7
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Jones H, Pinto A, Evans S, Ford S, O’Driscoll M, Buckley S, Ashmore C, Daly A, MacDonald A. Provision and Supervision of Food and Protein Substitute in School for Children with PKU: Parent Experiences. Nutrients 2021; 13:3863. [PMID: 34836117 PMCID: PMC8621748 DOI: 10.3390/nu13113863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Hannah Jones
- Faculty of Health, Education & Life Sciences, Birmingham City University: City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK;
| | - Alex Pinto
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Sharon Evans
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Suzanne Ford
- National Society for Phenylketonuria, Sheffield S12 9ET, UK;
- North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - Mike O’Driscoll
- School of Health and Education, Middlesex University, Room WG41A (Williams Building), The Burroughs Hendon, London NW4 4BT, UK;
| | - Sharon Buckley
- Department of Psychology, Faculty of Health, Psychology and Social Care, Manchester Campus, Manchester Metropolitan University, 53 Bonsall Street, Manchester M15 6GX, UK;
| | - Catherine Ashmore
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Anne Daly
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Anita MacDonald
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
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8
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Rodrigues C, Pinto A, Faria A, Teixeira D, van Wegberg AMJ, Ahring K, Feillet F, Calhau C, MacDonald A, Moreira-Rosário A, Rocha JC. Is the Phenylalanine-Restricted Diet a Risk Factor for Overweight or Obesity in Patients with Phenylketonuria (PKU)? A Systematic Review and Meta-Analysis. Nutrients 2021; 13:nu13103443. [PMID: 34684443 PMCID: PMC8538431 DOI: 10.3390/nu13103443] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/16/2021] [Accepted: 09/22/2021] [Indexed: 01/25/2023] Open
Abstract
Although there is a general assumption that a phenylalanine (Phe)-restricted diet promotes overweight in patients with phenylketonuria (PKU), it is unclear if this presumption is supported by scientific evidence. This systematic review aimed to determine if patients with PKU are at a higher risk of overweight compared to healthy individuals. A literature search was carried out on PubMed, Cochrane Library, and Embase databases. Risk of bias of individual studies was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, and the quality of the evidence for each outcome was assessed using the NutriGrade scoring system. From 829 articles identified, 15 were included in the systematic review and 12 in the meta-analysis. Body mass index (BMI) was similar between patients with PKU and healthy controls, providing no evidence to support the idea that a Phe-restricted diet is a risk factor for the development of overweight. However, a subgroup of patients with classical PKU had a significantly higher BMI than healthy controls. Given the increasing prevalence of overweight in the general population, patients with PKU require lifelong follow-up, receiving personalised nutritional counselling, with methodical nutritional status monitoring from a multidisciplinary team in inherited metabolic disorders.
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Affiliation(s)
- Catarina Rodrigues
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal; (C.R.); (A.F.); (D.T.); (C.C.)
- Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
| | - Alex Pinto
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (A.M.)
| | - Ana Faria
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal; (C.R.); (A.F.); (D.T.); (C.C.)
- Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Diana Teixeira
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal; (C.R.); (A.F.); (D.T.); (C.C.)
- Comprehensive Health Research Centre, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Annemiek M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Centre Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands;
| | - Kirsten Ahring
- Department of PKU, Copenhagen University Hospital, DK-2600 Glostrup, Denmark;
| | - François Feillet
- Department of Paediatrics, Reference Center for Inborn Errors of Metabolism, Hôpital d’Enfants Brabois, CHU Nancy, 54500 Vandoeuvre les Nancy, France;
| | - Conceição Calhau
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal; (C.R.); (A.F.); (D.T.); (C.C.)
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (A.M.)
| | - André Moreira-Rosário
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal; (C.R.); (A.F.); (D.T.); (C.C.)
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
- Correspondence: (A.M.-R.); (J.C.R.); Tel.: +351-21-880-3000 (A.M.-R. & J.C.R.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal; (C.R.); (A.F.); (D.T.); (C.C.)
- CINTESIS—Center for Health Technology and Services Research, NOVA Medical School, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisboa, Portugal
- Correspondence: (A.M.-R.); (J.C.R.); Tel.: +351-21-880-3000 (A.M.-R. & J.C.R.)
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Ramos-Álvarez R, Kapp M, Rodríguez-Ruiz MM, Fausor R, Bueno-Delgado MA, Ahring K, Waisbren SE. Adaptation and Validation of a Questionnaire to Evaluate Knowledge of the Low Phe Diet in PKU. Nutrients 2021; 13:nu13082719. [PMID: 34444879 PMCID: PMC8400675 DOI: 10.3390/nu13082719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/21/2021] [Accepted: 07/30/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Rodolfo Ramos-Álvarez
- Department of Social Psychology, Melilla Campus, Granada University, 52005 Melilla, Spain
- Correspondence: (R.R.-Á.); (S.E.W.)
| | - Maili Kapp
- Teaching Innovation Project (Code: 14–82), Melilla Campus, Granada University, 52005 Melilla, Spain;
| | | | - Rocío Fausor
- Department of Personality, Assessment and Clinical Psychology, Complutense University of Madrid, 28223 Madrid, Spain;
| | | | - Kirsten Ahring
- Center for PKU, Copenhagen University Hospital, 2600 Copenhagen, Denmark;
| | - Susan E. Waisbren
- Genetics and Metabolism Programs, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, MA 02115, USA
- Correspondence: (R.R.-Á.); (S.E.W.)
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Poloni S, dos Santos BB, Chiesa A, Specola N, Pereyra M, Saborío-Rocafort M, Salazar MF, Leal-Witt MJ, Castro G, Peñaloza F, Wong SP, Porras RB, Paranza LO, Sanabria MC, Amieva MV, Morales M, Naranjo ARC, Mahfoud A, Colmenares AR, Lemes A, Sotillo-Lindo JF, Perez C, Rey LM, Torriente GMZ, Refosco LF, Schwartz IVD, Cornejo V. Current Practices and Challenges in the Diagnosis and Management of PKU in Latin America: A Multicenter Survey. Nutrients 2021; 13:2566. [PMID: 34444728 PMCID: PMC8399454 DOI: 10.3390/nu13082566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/08/2021] [Indexed: 01/09/2023] Open
Abstract
This study aimed to describe the current practices in the diagnosis and dietary management of phenylketonuria (PKU) in Latin America, as well as the main barriers to treatment. We developed a 44-item online survey aimed at health professionals. After a pilot test, the final version was sent to 25 practitioners working with inborn errors of metabolism (IEM) in 14 countries. Our results include 22 centers in 13 countries. Most countries (12/13) screened newborns for PKU. Phenylalanine (Phe) targets at different ages were very heterogeneous among centers, with greater consistency at the 0-1 year age group (14/22 sought 120-240 µmol/L) and the lowest at >12 years (10 targets reported). Most countries had only unflavored powdered amino acid substitutes (10/13) and did not have low-protein foods (8/13). Only 3/13 countries had regional databases of the Phe content of foods, and only 4/22 centers had nutrient analysis software. The perceived obstacles to treatment were: low purchasing power (62%), limited/insufficient availability of low-protein foods (60%), poor adherence, and lack of technical resources to manage the diet (50% each). We observed a heterogeneous scenario in the dietary management of PKU, and most countries experienced a lack of dietary resources for both patients and health professionals.
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Affiliation(s)
- Soraia Poloni
- Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil; (B.B.d.S.); (L.F.R.); (I.V.D.S.)
| | - Bruna Bento dos Santos
- Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil; (B.B.d.S.); (L.F.R.); (I.V.D.S.)
- Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre 91501-970, Brazil
| | - Ana Chiesa
- Centro de Investigaciones Endocrinologicas DR Cesar Bergadá, CEDIE-CONICET-Fundación de Endocrinologia Infantil-Division de Endocrinologia Hospital de Niños R Gutierrez, Gallo 1330, Buenos Aires C1425EFD, Argentina;
| | - Norma Specola
- Unidad de Metabolismo, Hospital de Niños de La Plata, La Plata B1904, Argentina;
| | - Marcela Pereyra
- Servicio de Crecimiento y Desarrollo del Hospital Pediátrico Dr. H. Notti, 2603, Mendoza M5519, Argentina;
| | - Manuel Saborío-Rocafort
- Hospital Nacional de Niños, Caja Costarricense de Seguro Social & Sistema de Estudios de Posgrado, Universidad de Costa Rica, San José 11501, Costa Rica;
| | - María Florencia Salazar
- Instituto de Nutrición y Tecnología de los Alimentos (INTA) Universidad de Chile, Santiago de Chile 1058, Chile; (M.F.S.); (M.J.L.-W.); (G.C.); (F.P.); (V.C.)
| | - María Jesús Leal-Witt
- Instituto de Nutrición y Tecnología de los Alimentos (INTA) Universidad de Chile, Santiago de Chile 1058, Chile; (M.F.S.); (M.J.L.-W.); (G.C.); (F.P.); (V.C.)
| | - Gabriela Castro
- Instituto de Nutrición y Tecnología de los Alimentos (INTA) Universidad de Chile, Santiago de Chile 1058, Chile; (M.F.S.); (M.J.L.-W.); (G.C.); (F.P.); (V.C.)
| | - Felipe Peñaloza
- Instituto de Nutrición y Tecnología de los Alimentos (INTA) Universidad de Chile, Santiago de Chile 1058, Chile; (M.F.S.); (M.J.L.-W.); (G.C.); (F.P.); (V.C.)
| | - Sunling Palma Wong
- Programa Nacional de Tamizaje, Hospital Nacional de Niños, San José 267-1005, Costa Rica;
| | - Ramsés Badilla Porras
- FCCMG Servicio de Genética Médica y Metabolismo, Hospital Nacional de Niños, San José 267-1005, Costa Rica;
| | | | - Marta Cristina Sanabria
- Pediatric Department and Department of the Hospital de Clínicas, Universidad Nacional de Asunciòn, Asunción 1102, Paraguay;
| | - Marcela Vela Amieva
- Laboratorio de Errores Innatos del Metabolismo y Tamiz-Instituto Nacional de Pediatría, Ciudad de México 04530, Mexico;
| | | | - Amanda Rocío Caro Naranjo
- Instituto de Errores Innatos del Metabolismo de la Pontificia Universidad Javeriana, Bogota 110231, Colombia;
| | | | - Ana Rosa Colmenares
- Hospital Clinica Caracas-Materno Infantil de Caricuao, Caracas 1000, Venezuela;
| | - Aida Lemes
- Instituto de la Seguridad Social, Montevideo 11000, Uruguay;
| | | | - Ceila Perez
- Robert Reid Cabral Children’s Hospital, Santo Domingo 10101, Dominican Republic;
| | | | - Georgina María Zayas Torriente
- Centro de Nutrición e Higiene de los Alimentos del Instituto Nacional de Higiene, Epidemiología y Microbiología (INHEM), La Habana 10300, Cuba;
| | - Lilia Farret Refosco
- Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil; (B.B.d.S.); (L.F.R.); (I.V.D.S.)
| | - Ida Vanessa Doederlein Schwartz
- Hospital de Clínicas de Porto Alegre, Porto Alegre 90035-903, Brazil; (B.B.d.S.); (L.F.R.); (I.V.D.S.)
- Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul, Porto Alegre 91501-970, Brazil
| | - Veronica Cornejo
- Instituto de Nutrición y Tecnología de los Alimentos (INTA) Universidad de Chile, Santiago de Chile 1058, Chile; (M.F.S.); (M.J.L.-W.); (G.C.); (F.P.); (V.C.)
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Daly A, Högler W, Crabtree N, Shaw N, Evans S, Pinto A, Jackson R, Ashmore C, Rocha JC, Strauss BJ, Wilcox G, Fraser WD, Tang JCY, MacDonald A. A Three-Year Longitudinal Study Comparing Bone Mass, Density, and Geometry Measured by DXA, pQCT, and Bone Turnover Markers in Children with PKU Taking L-Amino Acid or Glycomacropeptide Protein Substitutes. Nutrients 2021; 13:nu13062075. [PMID: 34204378 PMCID: PMC8233747 DOI: 10.3390/nu13062075] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/09/2021] [Indexed: 12/20/2022] Open
Abstract
In patients with phenylketonuria (PKU), treated by diet therapy only, evidence suggests that areal bone mineral density (BMDa) is within the normal clinical reference range but is below the population norm. Aims: To study longitudinal bone density, mass, and geometry over 36 months in children with PKU taking either amino acid (L-AA) or casein glycomacropeptide substitutes (CGMP-AA) as their main protein source. Methodology: A total of 48 subjects completed the study, 19 subjects in the L-AA group (median age 11.1, range 5–16 years) and 29 subjects in the CGMP-AA group (median age 8.3, range 5–16 years). The CGMP-AA was further divided into two groups, CGMP100 (median age 9.2, range 5–16 years) (n = 13), children taking CGMP-AA only and CGMP50 (median age 7.3, range 5–15 years) (n = 16), children taking a combination of CGMP-AA and L-AA. Dual X-ray absorptiometry (DXA) was measured at enrolment and 36 months, peripheral quantitative computer tomography (pQCT) at 36 months only, and serum blood and urine bone turnover markers (BTM) and blood bone biochemistry at enrolment, 6, 12, and 36 months. Results: No statistically significant differences were found between the three groups for DXA outcome parameters, i.e., BMDa (L2–L4 BMDa g/cm2), bone mineral apparent density (L2–L4 BMAD g/cm3) and total body less head BMDa (TBLH g/cm2). All blood biochemistry markers were within the reference ranges, and BTM showed active bone turnover with a trend for BTM to decrease with increasing age. Conclusions: Bone density was clinically normal, although the median z scores were below the population mean. BTM showed active bone turnover and blood biochemistry was within the reference ranges. There appeared to be no advantage to bone density, mass, or geometry from taking a macropeptide-based protein substitute as compared with L-AAs.
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Affiliation(s)
- Anne Daly
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
- Correspondence:
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University, Kepler University Hospital, Krankenhausstraße 26-30, 4020 Linz, Austria;
| | - Nicola Crabtree
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Nick Shaw
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Richard Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Brownlow Hill, Liverpool L69 3GL, UK;
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio C. Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health and Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Boyd J. Strauss
- School of Medical Sciences, Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester M13 9PL, UK; (B.J.S.); (G.W.)
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne 3800, Australia
| | - Gisela Wilcox
- School of Medical Sciences, Faculty of Biology, Medicine and Health Sciences, University of Manchester, Manchester M13 9PL, UK; (B.J.S.); (G.W.)
- The Mark Holland Metabolic Unit, Salford Royal Foundation NHS Trust, Ladywell NW2, Salford, Manchester M6 8HD, UK
| | - William D. Fraser
- BioAnalytical Facility, BCRE Builiding University or East Anglia, Norwich NR4 7TJ, UK; (W.D.F.); (J.C.Y.T.)
| | - Jonathan C. Y. Tang
- BioAnalytical Facility, BCRE Builiding University or East Anglia, Norwich NR4 7TJ, UK; (W.D.F.); (J.C.Y.T.)
- Departments of Clinical Biochemistry and Endocrinology, Norfolk and Norwich University Hospitals Trust, Norwich NR4 7UY, UK
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (N.C.); (N.S.); (S.E.); (A.P.); (C.A.); (A.M.)
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12
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Bortoluzzi VT, Dutra Filho CS, Wannmacher CMD. Oxidative stress in phenylketonuria-evidence from human studies and animal models, and possible implications for redox signaling. Metab Brain Dis 2021; 36:523-543. [PMID: 33580861 DOI: 10.1007/s11011-021-00676-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/24/2021] [Indexed: 01/11/2023]
Abstract
Phenylketonuria (PKU) is one of the commonest inborn error of amino acid metabolism. Before mass neonatal screening was possible, and the success of introducing diet therapy right after birth, the typical clinical finds in patients ranged from intellectual disability, epilepsy, motor deficits to behavioral disturbances and other neurological and psychiatric symptoms. Since early diagnosis and treatment became widespread, usually only those patients who do not strictly follow the diet present psychiatric, less severe symptoms such as anxiety, depression, sleep pattern disturbance, and concentration and memory problems. Despite the success of low protein intake in preventing otherwise severe outcomes, PKU's underlying neuropathophysiology remains to be better elucidated. Oxidative stress has gained acceptance as a disturbance implicated in the pathogenesis of PKU. The conception of oxidative stress has evolved to comprehend how it could interfere and ultimately modulate metabolic pathways regulating cell function. We summarize the evidence of oxidative damage, as well as compromised antioxidant defenses, from patients, animal models of PKU, and in vitro experiments, discussing the possible clinical significance of these findings. There are many studies on oxidative stress and PKU, but only a few went further than showing macromolecular damage and disturbance of antioxidant defenses. In this review, we argue that these few studies may point that oxidative stress may also disturb redox signaling in PKU, an aspect few authors have explored so far. The reported effect of phenylalanine on the expression or activity of enzymes participating in metabolic pathways known to be responsive to redox signaling might be mediated through oxidative stress.
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Affiliation(s)
- Vanessa Trindade Bortoluzzi
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2600-Anexo, Porto Alegre, RS, CEP 90.035-003, Brazil.
| | - Carlos Severo Dutra Filho
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2600-Anexo, Porto Alegre, RS, CEP 90.035-003, Brazil
| | - Clovis Milton Duval Wannmacher
- Departamento de Bioquímica, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2600-Anexo, Porto Alegre, RS, CEP 90.035-003, Brazil
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13
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Ilgaz F, Marsaux C, Pinto A, Singh R, Rohde C, Karabulut E, Gökmen-Özel H, Kuhn M, MacDonald A. Protein Substitute Requirements of Patients with Phenylketonuria on BH4 Treatment: A Systematic Review and Meta-Analysis. Nutrients 2021; 13:1040. [PMID: 33807079 PMCID: PMC8004763 DOI: 10.3390/nu13031040] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
The traditional treatment for phenylketonuria (PKU) is a phenylalanine (Phe)-restricted diet, supplemented with a Phe-free/low-Phe protein substitute. Pharmaceutical treatment with synthetic tetrahydrobiopterin (BH4), an enzyme cofactor, allows a patient subgroup to relax their diet. However, dietary protocols guiding the adjustments of protein equivalent intake from protein substitute with BH4 treatment are lacking. We systematically reviewed protein substitute usage with long-term BH4 therapy. Electronic databases were searched for articles published between January 2000 and March 2020. Eighteen studies (306 PKU patients) were eligible. Meta-analyses demonstrated a significant increase in Phe and natural protein intakes and a significant decrease in protein equivalent intake from protein substitute with cofactor therapy. Protein substitute could be discontinued in 51% of responsive patients, but was still required in 49%, despite improvement in Phe tolerance. Normal growth was maintained, but micronutrient deficiency was observed with BH4 treatment. A systematic protocol to increase natural protein intake while reducing protein substitute dose should be followed to ensure protein and micronutrient requirements are met and sustained. We propose recommendations to guide healthcare professionals when adjusting dietary prescriptions of PKU patients on BH4. Studies investigating new therapeutic options in PKU should systematically collect data on protein substitute and natural protein intakes, as well as other nutritional factors.
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Affiliation(s)
- Fatma Ilgaz
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey; (F.I.); (H.G.-Ö.)
| | - Cyril Marsaux
- Danone Nutricia Research, 3584CT Utrecht, The Netherlands;
| | - Alex Pinto
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.M.)
| | - Rani Singh
- Metabolic Genetics Nutrition Program, Department of Human Genetics, Emory University, Atlanta, GA 30322, USA;
| | - Carmen Rohde
- Department of Paediatrics of the University Clinics Leipzig, University of Leipzig, 04103 Leipzig, Germany;
| | - Erdem Karabulut
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey;
| | - Hülya Gökmen-Özel
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Hacettepe University, 06100 Ankara, Turkey; (F.I.); (H.G.-Ö.)
| | - Mirjam Kuhn
- Danone Nutricia Research, 3584CT Utrecht, The Netherlands;
| | - Anita MacDonald
- Department of Dietetics, Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (A.P.); (A.M.)
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Newbould E, Pinto A, Evans S, Ford S, O’Driscoll M, Ashmore C, Daly A, MacDonald A. Accidental Consumption of Aspartame in Phenylketonuria: Patient Experiences. Nutrients 2021; 13:nu13020707. [PMID: 33672234 PMCID: PMC7926728 DOI: 10.3390/nu13020707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/04/2022] Open
Abstract
Aspartame is a phenylalanine containing sweetener, added to foods and drinks, which is avoided in phenylketonuria (PKU). However, the amount of phenylalanine provided by aspartame is unidentifiable from food and drinks labels. We performed a cross-sectional online survey aiming to examine the accidental aspartame consumption in PKU. 206 questionnaires (58% female) were completed. 55% of respondents (n = 114) were adults with PKU or their parent/carers and 45% (n = 92) were parents/carers of children with PKU. 74% (n = 152/206) had consumed food/drinks containing aspartame. Repeated accidental aspartame consumption was common and more frequent in children (p < 0.0001). The aspartame containing food/drinks accidentally consumed were fizzy drinks (68%, n = 103/152), fruit squash (40%, n = 61/152), chewing gum (30%, n = 46/152), flavoured water (25%, n = 38/152), ready to drink fruit squash cartons (23%, n = 35/152) and sports drinks (21%, n = 32/152). The main reasons described for accidental consumption, were manufacturers’ changing recipes (81%, n = 123/152), inability to check the ingredients in pubs/restaurants/vending machines (59%, n = 89/152) or forgetting to check the label (32%, n = 49/152). 23% (n= 48/206) had been prescribed medicines containing aspartame and 75% (n = 36/48) said that medicines were not checked by medics when prescribed. 85% (n = 164/192) considered the sugar tax made accidental aspartame consumption more likely. Some of the difficulties for patients were aspartame identification in drinks consumed in restaurants, pubs, vending machines (77%, n = 158/206); similarities in appearance of aspartame and non-aspartame products (62%, n = 127/206); time consuming shopping/checking labels (56%, n = 115/206); and unclear labelling (55%, n = 114/206). These issues caused anxiety for the person with PKU (52%, n = 106/206), anxiety for parent/caregivers (46%, n = 95/206), guilt for parent/carers (42%, n = 87/206) and social isolation (42%, n = 87/206). It is important to understand the impact of aspartame and legislation such as the sugar tax on people with PKU. Policy makers and industry should ensure that the quality of life of people with rare conditions such as PKU is not compromised through their action.
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Affiliation(s)
- Ella Newbould
- Faculty of Health, Education & Life Sciences, Birmingham City University: City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK;
| | - Alex Pinto
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Sharon Evans
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Suzanne Ford
- National Society for Phenylketonuria, Purley CR8 9DD, UK;
| | - Mike O’Driscoll
- School of Health and Education, Middlesex University, Room WG41A (Williams Building), The Burroughs Hendon, London NW4 4BT, UK;
| | - Catherine Ashmore
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Anne Daly
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Anita MacDonald
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
- Correspondence:
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15
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Daly A, Evans S, Pinto A, Ashmore C, MacDonald A. Protein Substitutes in PKU; Their Historical Evolution. Nutrients 2021; 13:484. [PMID: 33540516 PMCID: PMC7912909 DOI: 10.3390/nu13020484] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 12/29/2022] Open
Abstract
Protein substitutes developed for phenylketonuria (PKU) are a synthetic source of protein commonly based on L-amino acids. They are essential in the treatment of phenylketonuria (PKU) and other amino acid disorders, allowing the antagonistic amino acid to be removed but with the safe provision of all other amino acids necessary for maintaining normal physiological function. They were first formulated by a chemist and used experimentally on a 2-year-old girl with PKU and their nutritional formulations and design have improved over time. Since 2008, a bioactive macropeptide has been used as a base for protein substitutes in PKU, with potential benefits of improved bone and gut health, nitrogen retention, and blood phenylalanine control. In 2018, animal studies showed that physiomimic technology coating the amino acids with a polymer allows a slow release of amino acids with an improved physiological profile. History has shown that in PKU, the protein substitute's efficacy is determined by its nutritional profile, amino acid composition, dose, timing, distribution, and an adequate energy intake. Protein substitutes are often given little importance, yet their pharmacological actions and clinical benefit are pivotal when managing PKU.
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Affiliation(s)
- Anne Daly
- Birmingham Women’s and Children’s Hospital, NHS Foundation Trust, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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16
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Abstract
BACKGROUND Phenylketonuria is an inherited disease for which the main treatment is the dietary restriction of the amino acid phenylalanine. The diet has to be initiated in the neonatal period to prevent or reduce mental handicap. However, the diet is very restrictive and unpalatable and can be difficult to follow. A deficiency of the amino acid tyrosine has been suggested as a cause of some of the neuropsychological problems exhibited in phenylketonuria. Therefore, this review aims to assess the efficacy of tyrosine supplementation for phenylketonuria. This is an update of previously published versions of this review. OBJECTIVES To assess the effects of tyrosine supplementation alongside or instead of a phenylalanine-restricted diet for people with phenylketonuria, who commenced on diet at diagnosis and either continued on the diet or relaxed the diet later in life. To assess the evidence that tyrosine supplementation alongside, or instead of a phenylalanine-restricted diet improves intelligence, neuropsychological performance, growth and nutritional status, mortality rate and quality of life. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Trials Register which is comprised of references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. Additional studies were identified from handsearches of the Journal of Inherited Metabolic Disease (from inception in 1978 to 1998). The manufacturers of prescribable dietary products used in the treatment of phenylketonuria were also contacted for further references. Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 07 December 2020. SELECTION CRITERIA All randomised or quasi-randomised trials investigating the use of tyrosine supplementation versus placebo in people with phenylketonuria in addition to, or instead of, a phenylalanine-restricted diet. People treated for maternal phenylketonuria were excluded. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trial eligibility, methodological quality and extracted the data. MAIN RESULTS Six trials were found, of which three trials reporting the results of a total of 56 participants, were suitable for inclusion in the review. The blood tyrosine concentrations were significantly higher in the participants receiving tyrosine supplements than those in the placebo group, mean difference 23.46 (95% confidence interval 12.87 to 34.05). No significant differences were found between any of the other outcomes measured. The trials were assessed as having a low to moderate risk of bias across several domains. AUTHORS' CONCLUSIONS From the available evidence no recommendations can be made about whether tyrosine supplementation should be introduced into routine clinical practice. Further randomised controlled studies are required to provide more evidence. However, given this is not an active area of research, we have no plans to update this review in the future.
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Affiliation(s)
- Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Sherie Smith
- Division of Child Health, Obstetrics & Gynaecology (COG), School of Medicine, University of Nottingham, Nottingham, UK
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Kraleva D, Evans S, Pinto A, Daly A, Ashmore C, Pointon-Bell K, Rocha JC, MacDonald A. Protein Labelling Accuracy for UK Patients with PKU Following a Low Protein Diet. Nutrients 2020; 12:nu12113440. [PMID: 33182603 PMCID: PMC7696494 DOI: 10.3390/nu12113440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 01/02/2023] Open
Abstract
A phenylalanine (protein)-restricted diet is the primary treatment for phenylketonuria (PKU). Patients are dependent on food protein labelling to successfully manage their condition. We evaluated the accuracy of protein labelling on packaged manufactured foods from supermarket websites for foods that may be eaten as part of a phenylalanine-restricted diet. Protein labelling information was evaluated for 462 food items (“free from”, n = 159, regular, n = 303), divided into 16 food groups using supermarket website data. Data collection included protein content per portion/100 g when food was “as sold”, “cooked” or “prepared”; cooking methods, and preparation instructions. Labelling errors affecting protein content were observed in every food group, with overall protein labelling unclear in 55% (n = 255/462) of foods. There was misleading, omitted, or erroneous (MOE) information in 43% (n = 68/159) of “free from” foods compared with 62% (n = 187/303) of regular foods, with fewer inaccuracies in “free from” food labelling (p = 0.007). Protein analysis was available for uncooked weight only but not cooked weight for 58% (n = 85/146) of foods; 4% (n = 17/462) had misleading protein content. There was a high rate of incomplete, misleading, or inaccurate data affecting the interpretation of the protein content of food items on supermarket websites. This could adversely affect metabolic control of patients with PKU and warrants serious consideration.
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Affiliation(s)
- Dilyana Kraleva
- Faculty of Health, Education & Life Sciences, Birmingham City University City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK; (D.K.); (K.P.-B.)
| | - Sharon Evans
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (A.D.); (C.A.)
| | - Alex Pinto
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (A.D.); (C.A.)
| | - Anne Daly
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (A.D.); (C.A.)
| | - Catherine Ashmore
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (A.D.); (C.A.)
| | - Kiri Pointon-Bell
- Faculty of Health, Education & Life Sciences, Birmingham City University City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK; (D.K.); (K.P.-B.)
| | - Júlio César Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056 Lisbon, Portugal;
- Center for Health Technology and Services Research (CINTESIS), R. Dr. Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Anita MacDonald
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (A.D.); (C.A.)
- Correspondence:
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18
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Verduci E, Carbone MT, Borghi E, Ottaviano E, Burlina A, Biasucci G. Nutrition, Microbiota and Role of Gut-Brain Axis in Subjects with Phenylketonuria (PKU): A Review. Nutrients 2020; 12:E3319. [PMID: 33138040 PMCID: PMC7692600 DOI: 10.3390/nu12113319] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/27/2020] [Indexed: 12/12/2022] Open
Abstract
The composition and functioning of the gut microbiota, the complex population of microorganisms residing in the intestine, is strongly affected by endogenous and exogenous factors, among which diet is key. Important perturbations of the microbiota have been observed to contribute to disease risk, as in the case of neurological disorders, inflammatory bowel disease, obesity, diabetes, cardiovascular disease, among others. Although mechanisms are not fully clarified, nutrients interacting with the microbiota are thought to affect host metabolism, immune response or disrupt the protective functions of the intestinal barrier. Similarly, key intermediaries, whose presence may be strongly influenced by dietary habits, sustain the communication along the gut-brain-axis, influencing brain functions in the same way as the brain influences gut activity. Due to the role of diet in the modulation of the microbiota, its composition is of high interest in inherited errors of metabolism (IEMs) and may reveal an appealing therapeutic target. In IEMs, for example in phenylketonuria (PKU), since part of the therapeutic intervention is based on chronic or life-long tailored dietetic regimens, important variations of the microbial diversity or relative abundance have been observed. A holistic approach, including a healthy composition of the microbiota, is recommended to modulate host metabolism and affected neurological functions.
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Affiliation(s)
- Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children’s Hospital-University of Milan, Via Lodovico Castelvetro, 32, 20154 Milan, Italy
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Maria Teresa Carbone
- UOS Metabolic and Rare Diseases, AORN Santobono, Via Mario Fiore 6, 80122 Naples, Italy;
| | - Elisa Borghi
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Emerenziana Ottaviano
- Department of Health Science, University of Milan, via di Rudinì 8, 20142 Milan, Italy; (E.B.); (E.O.)
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Diagnostic Services, University Hospital of Padua, Via Orus 2B, 35129 Padua, Italy;
| | - Giacomo Biasucci
- Department of Paediatrics & Neonatology, Guglielmo da Saliceto Hospital, Via Taverna Giuseppe, 49, 29121 Piacenza, Italy;
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19
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Daly A, Evans S, Pinto A, Ashmore C, Rocha JC, MacDonald A. A 3 Year Longitudinal Prospective Review Examining the Dietary Profile and Contribution Made by Special Low Protein Foods to Energy and Macronutrient Intake in Children with Phenylketonuria. Nutrients 2020; 12:E3153. [PMID: 33076399 PMCID: PMC7602523 DOI: 10.3390/nu12103153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 12/18/2022] Open
Abstract
The nutritional composition of special low protein foods (SLPFs) is controlled under EU legislation for 'Foods for Special Medical Purposes (FSMP)'. They are designed to meet the energy needs of patients unable to eat a normal protein containing diet. In phenylketonuria (PKU), the macronutrient contribution of SLPFs has been inadequately examined. AIM A 3-year longitudinal prospective study investigating the contribution of SLPFs to the macronutrient intake of children with early treated PKU. METHODS 48 children (27 boys) with a mean recruitment age of 9.3 y were studied. Semi-quantitative dietary assessments and food frequency questionnaires (FFQ) were collected three to four times/year for 3 years. RESULTS The mean energy intake provided by SLPFs was 33% (SD ± 8), and this figure was 42% (SD ± 13) for normal food and 21% (SD ± 5) for protein substitutes (PS). SLPFs supplied a mean intake of 40% carbohydrate (SD ± 10), 51% starch (SD ± 18), 21% sugar (SD ± 8), and 38% fat (SD ± 13). Fibre intake met 83% of the Scientific Advisory Committee on Nutrition (SACN) reference value, with 50% coming from SLPFs with added gums and hydrocolloids. Low protein bread, pasta and milk provided the highest energy contribution, and the intake of sweet SLPFs (e.g., biscuits, cakes, and chocolate) was minimal. Children averaged three portions fruit/vegetable daily, and children aged ≥ 12 y had irregular meal patterns. CONCLUSION SLPFs provide essential energy in phenylalanine restricted diets. Optimising the nutritional quality of SLPFs deserves more attention.
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Affiliation(s)
- Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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20
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Daly A, Evans S, Pinto A, Jackson R, Ashmore C, Rocha JC, MacDonald A. Preliminary Investigation to Review If a Glycomacropeptide Compared to L-Amino Acid Protein Substitute Alters the Pre- and Postprandial Amino Acid Profile in Children with Phenylketonuria. Nutrients 2020; 12:E2443. [PMID: 32823853 PMCID: PMC7468934 DOI: 10.3390/nu12082443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 12/24/2022] Open
Abstract
In Phenylketonuria (PKU), the peptide structure of the protein substitute (PS), casein glycomacropeptide (CGMP), is supplemented with amino acids (CGMP-AA). CGMP may slow the rate of amino acid (AA) absorption compared with traditional phenylalanine-free amino acids (Phe-free AA), which may improve nitrogen utilization, decrease urea production, and alter insulin response. AIM In children with PKU, to compare pre and postprandial AA concentrations when taking one of three PS's: Phe-free AA, CGMP-AA 1 or 2. METHODS 43 children (24 boys, 19 girls), median age 9 years (range 5-16 years) were studied; 11 took CGMP-AA1, 18 CGMP-AA2, and 14 Phe-free AA. Early morning fasting pre and 2 h postprandial blood samples were collected for quantitative AA on one occasion. A breakfast with allocated 20 g protein equivalent from PS was given post fasting blood sample. RESULTS There was a significant increase in postprandial AA for all individual AAs with all three PS. Postprandial AA histidine (p < 0.001), leucine (p < 0.001), and tyrosine (p < 0.001) were higher in CGMP-AA2 than CGMP-AA1, and leucine (p < 0.001), threonine (p < 0.001), and tyrosine (p = 0.003) higher in GCMP-AA2 than Phe-free AA. This was reflective of the AA composition of the three different PS's. CONCLUSIONS In PKU, the AA composition of CGMP-AA influences 2 h postprandial AA composition, suggesting that a PS derived from CGMP-AA may be absorbed similarly to Phe-free AA, but this requires further investigation.
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Affiliation(s)
- Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Richard Jackson
- Liverpool Clinical Trials Centre, University of Liverpool, Brownlow Hill, Liverpool L69 3GL, UK;
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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21
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Abstract
The prognosis for phenylketonuria (PKU) has been improved by neonatal screening and dietary management via a low-phenylalanine diet. This treatment must be followed throughout life, which induces severe compliance problems. Drug treatment with sapropterin (or BH4) has come to help a reduced percentage of patients who respond to this drug. A subcutaneous enzyme therapy is available in the USA and has obtained European marketing authorization, but generates significant side effects, which limits its effectiveness. New therapeutic options for PKU are currently being developed, in particular gene therapy. The purpose of this article is to take stock of the pathophysiology and the various new therapeutic modalities currently in development.
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Affiliation(s)
- Arnaud Wiedemann
- Centre de référence des maladies métaboliques, Service de pédiatrie, CHRU de Nancy, 54000 Nancy, France - Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France
| | - Abderrahim Oussalah
- Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 France
| | - Élise Jeannesson
- Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 France
| | - Jean-Louis Guéant
- Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France - Département de médecine moléculaire, Laboratoire de biochimie et de biologie moléculaire nutrition, CHRU de Nancy, 54000 France
| | - François Feillet
- Centre de référence des maladies métaboliques, Service de pédiatrie, CHRU de Nancy, 54000 Nancy, France - Inserm UMR_S 1256 (NGERE, Nutrition Génétique et Exposition aux Risques Environnementaux), Faculté de médecine de Nancy, Université de Lorraine, 54000 Nancy, France
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22
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Abstract
Phenylalanine hydroxylase (PAH) deficiency, commonly named phenylketonuria (PKU) is a disorder of phenylalanine (Phe) metabolism inherited with an autosomal recessive trait. It is characterized by high blood and cerebral Phe levels, resulting in intellectual disabilities, seizures, etc. Early diagnosis and treatment of the patients prevent major neuro-cognitive deficits. Treatment consists of a lifelong restriction of Phe intake, combined with the supplementation of special medical foods, such as Amino Acid medical food (AA-mf), enriched in tyrosine (Tyr) and other amino acids and nutrients to avoid nutritional deficits. Developmental and neurocognitive outcomes for patients, however, remain suboptimal, especially when adherence to the demanding diet is poor. Additions to treatment include new, more palatable foods, based on Glycomacropeptide that contains limited amounts of Phe, the administration of large neutral amino acids to prevent phenylalanine entry into the brain and tetrahydrobiopterin cofactor capable of increasing residual PAH activity. Moreover, further efforts are underway to develop an oral therapy containing phenylalanine ammonia-lyase. Nutritional support of PKU future mothers (maternal PKU) is also discussed. This review aims to summarize the current literature on new PKU treatment strategies.
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Affiliation(s)
- Penelope D Manta-Vogli
- Department of Clinical Nutrition & Dietetics Agia Sofia Children's Hospital, Athens, Greece
| | - Yannis Dotsikas
- Department of Pharmacy, Laboratory of Pharm. Analysis, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR 157 71, Athens, Greece
| | - Yannis L Loukas
- Department of Pharmacy, Laboratory of Pharm. Analysis, National and Kapodestrian University of Athens, Panepistimiopolis Zographou, GR 157 71, Athens, Greece
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Abstract
BACKGROUND Phenylketonuria is an inherited disease treated with dietary restriction of the amino acid phenylalanine. The diet is initiated in the neonatal period to prevent learning disability; however, it is restrictive and can be difficult to follow. Whether the diet can be relaxed or discontinued during adolescence or should be continued for life remains a controversial issue, which we aim to address in this review. This is an updated version of a previously published review. OBJECTIVES To assess the effects of a low-phenylalanine diet commenced early in life for people with phenylketonuria. To assess the possible effects of relaxation or termination of the diet on intelligence, neuropsychological outcomes and mortality, growth, nutritional status, eating behaviour and quality of life. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register comprising references identified from comprehensive electronic database searches, handsearches of relevant journals and abstract books of conference proceedings. Most recent search of the Inborn Errors of Metabolism Trials Register: 30 April 2020. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing a low-phenylalanine diet to relaxation or termination of dietary restrictions in people with phenylketonuria. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility and methodological quality, and subsequently extracted the data. MAIN RESULTS We included four studies in this review (251 participants), and found few significant differences between treatment and comparison groups for the outcomes of interest. Blood phenylalanine levels were significantly lower in participants with phenylketonuria following a low-phenylalanine diet compared to those on a less restricted diet, mean difference (MD) at three months -698.67 (95% confidence interval (CI) -869.44 to -527.89). Intelligence quotient was significantly higher in participants who continued the diet than in those who stopped the diet, MD after 12 months 5.00 (95% CI 0.40 to 9.60). However, these results came from a single study. AUTHORS' CONCLUSIONS The results of non-randomised studies have concluded that a low-phenylalanine diet is effective in reducing blood phenylalanine levels and improving intelligence quotient and neuropsychological outcomes. We were unable to find any randomised controlled studies that have assessed the effect of a low-phenylalanine diet versus no diet from diagnosis. In view of evidence from non-randomised studies, such a study would be unethical and it is recommended that low-phenylalanine diet should be commenced at the time of diagnosis. There is uncertainty about the precise level of phenylalanine restriction and when, if ever, the diet should be relaxed. This should be addressed by randomised controlled studies; however, no new studies are expected in this area so we do not plan to update this review.
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Affiliation(s)
- Elisabeth Jameson
- Willink Biochemical Genetics Unit, Manchester Centre for Genomic Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Tracey Remmington
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
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Burlina AP, Cazzorla C, Massa P, Loro C, Gueraldi D, Burlina AB. The Impact of a Slow-Release Large Neutral Amino Acids Supplement on Treatment Adherence in Adult Patients with Phenylketonuria. Nutrients 2020; 12:nu12072078. [PMID: 32674279 PMCID: PMC7400920 DOI: 10.3390/nu12072078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023] Open
Abstract
The gold standard treatment for phenylketonuria (PKU) is a lifelong low-phenylalanine (Phe) diet supplemented with Phe-free protein substitutes. Adherence to therapy becomes difficult after childhood. Supplementing with large neutral amino acids (LNAAs) has been proposed as an alternative medication to Phe-free protein substitutes (i.e., amino acid mixtures). The aim of this study was to evaluate adherence to therapy and quality of life (QoL) in a cohort of sub-optimally controlled adult PKU patients treated with a new LNAA formulation. Twelve patients were enrolled in a 12-month-trial of slow-release LNAAs (1g/kg/day) plus a Phe-restricted diet. Medication adherence was measured with the Morisky Green Levine Medication Adherence Scale; the QoL was measured using the phenylketonuria-quality of life (PKU-QoL) questionnaire. Phe, tyrosine (Tyr) levels, and Phe/Tyr ratios were measured fortnightly. Before treatment, 3/12 patients self-reported a ‘medium’ adherence to medication and 9/12 reported a low adherence; 60% of patients reported a full adherence over the past four weeks. After 12 months of LNAA treatment, all patients self-reported a high adherence to medication, with 96% reporting a full adherence. Phe levels remained unchanged, while Tyr levels increased in most patients. The Phy/Tyr ratio decreased. All patients had a significant improvement in the QoL. LNAAs may give patients a further opportunity to improve medication adherence and, consequently, their QoL.
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Affiliation(s)
- Alessandro P. Burlina
- Neurological Unit, St. Bassiano Hospital, Via dei Lotti 40, 36061 Bassano del Grappa, Italy;
| | - Chiara Cazzorla
- Division of Inherited Metabolic Diseases, Department of Women and Children’s Health, University Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.C.); (P.M.); (C.L.); (D.G.)
| | - Pamela Massa
- Division of Inherited Metabolic Diseases, Department of Women and Children’s Health, University Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.C.); (P.M.); (C.L.); (D.G.)
| | - Christian Loro
- Division of Inherited Metabolic Diseases, Department of Women and Children’s Health, University Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.C.); (P.M.); (C.L.); (D.G.)
| | - Daniela Gueraldi
- Division of Inherited Metabolic Diseases, Department of Women and Children’s Health, University Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.C.); (P.M.); (C.L.); (D.G.)
| | - Alberto B. Burlina
- Division of Inherited Metabolic Diseases, Department of Women and Children’s Health, University Hospital of Padova, Via Giustiniani 3, 35128 Padova, Italy; (C.C.); (P.M.); (C.L.); (D.G.)
- Correspondence: ; Tel.: +39-049 8213569
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Wood G, Evans S, Pointon-Bell K, Rocha JC, MacDonald A. Special Low Protein Foods in the UK: An Examination of Their Macronutrient Composition in Comparison to Regular Foods. Nutrients 2020; 12:E1893. [PMID: 32630585 PMCID: PMC7353443 DOI: 10.3390/nu12061893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/21/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022] Open
Abstract
Special low protein foods (SLPFs) are essential in a low phenylalanine diet for treating phenylketonuria (PKU). With little known about their nutritional composition, all SLPFs on UK prescription were studied (n = 146) and compared to equivalent protein-containing foods (n = 190). SLPF nutritional analysis was obtained from suppliers/manufacturers. Comparable information about regular protein-containing foods was obtained from online UK supermarkets. Similar foods were grouped together, with mean nutritional values calculated for each subgroup (n = 40) and percentage differences determined between SLPFs and regular food subgroups. All SLPF subgroups contained 43-100% less protein than regular foods. Sixty-three percent (n = 25/40) of SLPF subgroups contained less total fat with palm oil (25%, n = 36/146) and hydrogenated vegetable oil (23%, n = 33/146) key fat sources. Sixty-eight percent (n = 27/40) of SLPF subgroups contained more carbohydrate, with 72% (n = 105/146) containing added sugar. Key SLPF starch sources were maize/corn (72%; n = 105/146). Seventy-seven percent (n = 113/146) of SLPFs versus 18% (n = 34/190) of regular foods contained added fibre, predominantly hydrocolloids. Nine percent of SLPFs contained phenylalanine > 25 mg/100 g and sources of phenylalanine/protein in their ingredient lists. Stricter nutritional composition regulations for SLPFs are required, identifying maximum upper limits for macronutrients and phenylalanine, and fat and carbohydrate sources that are associated with healthy outcomes.
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Affiliation(s)
- Georgina Wood
- Faculty of Health, Education & Life Sciences, Birmingham City University, City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK;
| | - Sharon Evans
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.M.)
| | - Kiri Pointon-Bell
- Faculty of Health, Education & Life Sciences, Birmingham City University, City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK;
| | - Júlio César Rocha
- Nutrition & Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria, 130, 1169-056 Lisbon, Portugal;
- Center for Health Technology and Services Research (CINTESIS), R. Dr. Plácido da Costa, s/n, 4200-450 Porto, Portugal
| | - Anita MacDonald
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.M.)
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Mozrzymas R, Walkowiak D, Drzymała-Czyż S, Krzyżanowska-Jankowska P, Duś-Żuchowska M, Kałużny Ł, Walkowiak J. Vitamin K Status in Adherent and Non-Adherent Patients with Phenylketonuria: A Cross-Sectional Study. Nutrients 2020; 12:nu12061772. [PMID: 32545860 PMCID: PMC7353192 DOI: 10.3390/nu12061772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/04/2020] [Accepted: 06/12/2020] [Indexed: 01/09/2023] Open
Abstract
This is the first study to evaluate vitamin K status in relation to dietary intake and phenylalanine dietary compliance in patients with phenylketonuria (PKU). The dietary and PKU formula intake of vitamin K was calculated in 34 PKU patients, with vitamin K status determined by the measurement of prothrombin induced by vitamin K absence (PIVKA-II). Blood phenylalanine concentrations in the preceding 12 months were considered. There were significantly more phenylalanine results exceeding 6 mg/dL in patients with normal PIVKA-II concentrations than in those with abnormal PIVKA-II levels (p = 0.035). Similarly, a higher total intake of vitamin K and dietary vitamin intake expressed as μg/day (p = 0.033 for both) and %RDA (p = 0.0002 and p = 0.003, respectively) was observed in patients with normal PIVKA-II levels. Abnormal PIVKA-II concentrations were associated with a lower OR (0.1607; 95%CI: 0.0273–0.9445, p = 0.043) of having a median phenylalanine concentration higher than 6 mg/dL. In conclusion, vitamin K deficiency is not uncommon in phenylketonuria and may also occur in patients with adequate vitamin K intake. PKU patients with better dietary compliance have a higher risk of vitamin K deficiency. The present findings highlight the need for further studies to re-evaluate dietary recommendations regarding vitamin K intake, both concerning formula-based and dietary consumption of natural products.
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Affiliation(s)
- Renata Mozrzymas
- Research and Development Center, Regional Specialist Hospital in Wrocław, H. M. Kamieńskiego Street 73a, 51-124 Wrocław, Poland;
| | - Dariusz Walkowiak
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Przybyszewskiego Street 39, 60-356 Poznan, Poland;
| | - Sławomira Drzymała-Czyż
- Department of Bromatology, Poznan University of Medical Sciences, Marcelinska Street 42, 60-354 Poznan, Poland;
| | - Patrycja Krzyżanowska-Jankowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (P.K.-J.); (M.D.-Ż.); (Ł.K.)
| | - Monika Duś-Żuchowska
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (P.K.-J.); (M.D.-Ż.); (Ł.K.)
| | - Łukasz Kałużny
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (P.K.-J.); (M.D.-Ż.); (Ł.K.)
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572 Poznan, Poland; (P.K.-J.); (M.D.-Ż.); (Ł.K.)
- Correspondence: ; Tel.: +48-61-849-1432
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Levy H, Lamppu D, Anastosoaie V, Baker JL, DiBona K, Hawthorne S, Lindenberger J, Kinch D, Seymour A, McIlduff M, Watling S, Vockley J. 5-year retrospective analysis of patients with phenylketonuria (PKU) and hyperphenylalaninemia treated at two specialized clinics. Mol Genet Metab 2020; 129:177-185. [PMID: 31883647 DOI: 10.1016/j.ymgme.2019.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/05/2019] [Accepted: 12/08/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is an autosomal recessive disease caused by mutations in the PAH gene, resulting in deficiency of phenylalanine hydroxylase (PAH), an enzyme that converts phenylalanine (Phe) to tyrosine (Tyr). The purpose of this study was to capture real-world data associated with managing PKU under current standard of care and to characterize a representative population for a planned gene therapy trial. METHODS A retrospective chart review was conducted at two U.S. clinics for individuals 10-40 years old diagnosed with PKU-related hyperphenylalaninemia (HPA). Demographics, medical history, treatments and blood Phe data were collected from electronic medical records spanning a five-year period ending in November 2017. RESULTS 152 patients were enrolled (65.8% had classical PKU). Although >95% of patients were prescribed a Phe-restricted diet, blood Phe concentrations remained substantially elevated, particularly in patients diagnosed with classical PKU. As the Phe threshold was lowered (Phe < 600, 360, 120 or 30 μmol/L), the number of patients with consecutive lab values below the threshold decreased, suggesting that many patients' Phe levels are inadequately controlled. 62.5% of patients were reported as having a history of at least one neuropsychiatric comorbidity, and adults were more likely than adolescents (69.5% vs. 54.3%). 92 of 98 PAH genotypes collected were distinct mutations; the 6 null-null genotypes were associated with classical PKU. Overall the demographics and clinical data were consistent across both sites. CONCLUSION Despite dietary restrictions, mean Phe concentrations were > 360 μmol/L (a level considered well-controlled based on current U.S. treatment guidelines) for mild, moderate, and classical PKU patients. There remains an unmet need for therapies to control Phe concentrations.
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Affiliation(s)
- Harvey Levy
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | | | - Vera Anastosoaie
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Jennifer L Baker
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin DiBona
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Sarah Hawthorne
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA
| | - Jessica Lindenberger
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | | | | | - Mark McIlduff
- Boston Biomedical Associates, LLC, Marlborough, MA, USA
| | | | - Jerry Vockley
- Division Medical Genetics, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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Luu S, Breunig T, Drilias N, Kuhl A, Scott Schwoerer J, Cody P. A Survey of Eating Attitudes and Behaviors in Adolescents and Adults With Phenylalanine Hydroxylase Deficiency. WMJ 2020; 119:37-43. [PMID: 32348070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Phenylalanine hydroxylase deficiency, commonly known as phenylketonuria (PKU), is an inborn error of metabolism that manifests in severe neurological damage when left untreated. Routine newborn screening has made early identification and treatment of affected individuals possible, changing the prognosis of PKU from devastating to excellent. The most effective treatment for PKU involves lifelong dietary restriction of protein, nutrition supplementation via medical foods, and frequent monitoring of amino acid levels in the blood. However, it has been observed that imposing strict medical control over daily dietary habits can lead to destructive attitudes towards eating and body image. This study investigated whether people with PKU are at increased risk of disordered eating behaviors and attitudes. METHODS Fifteen patients with PKU between the ages of 12 and 35 from the University of Wisconsin (UW) Biochemical Genetics Clinic were surveyed about their metabolic management and eating attitudes and behaviors. RESULTS While this study was too small to make conclusions of clinical significance, our findings did suggest that patients with poor metabolic control exhibited symptoms of disordered eating at a higher frequency than those with good metabolic control. CONCLUSIONS There is currently no validated screening tool to evaluate for disordered eating behaviors in individuals with PKU, which makes identifying and treating disordered eating and related conditions difficult. The development of this project emphasized the importance of tailored screening and provider awareness for disordered eating for populations with chronic illnesses.
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Affiliation(s)
- Sharon Luu
- Master of Genetic Counselor Studies Training Program, University of Wisconsin-Madison, Madison, Wisconsin,
| | - Therese Breunig
- UW Biochemical Genetics Clinic, University of Wisconsin-Madison, Madison, Wisconsin
| | - Nicoletta Drilias
- UW Biochemical Genetics Clinic, University of Wisconsin-Madison, Madison, Wisconsin
| | - Ashley Kuhl
- UW Biochemical Genetics Clinic, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Paula Cody
- Division of General Pediatrics and Adolescent Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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29
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van Wegberg AMJ, Evers RAF, van Dam E, de Vries MC, Janssen MCH, Heiner-Fokkema MR, van Spronsen FJ. Does the 48-hour BH4 loading test miss responsive PKU patients? Mol Genet Metab 2020; 129:186-192. [PMID: 31924462 DOI: 10.1016/j.ymgme.2019.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is an inborn error of phenylalanine (Phe) metabolism. Besides dietary treatment, some patients are responsive to and treated with tetrahydrobiopterin (BH4). Our primary objective was to examine whether the 48-hour BH4 loading test misses BH4-responsive PKU patients. Secondary, we assessed if it would be beneficial to 1) use a cut-off value of 20% Phe reduction instead of commonly used 30%, and 2) extend the loading test to 7 days. METHODS 24 patients with a 20-30% decrease of blood Phe levels during their initial 48-hour BH4 loading test or at least one mutation associated with long-term BH4 responsiveness, were invited to participate. 22 of them underwent the 7-day BH4 loading test. During the BH4 loading test, BH4 was administered orally once daily for 7 days (20 mg/kg/day). Blood samples on filter paper were collected at 13 time points. Potential BH4 responders (≥20% decrease in blood Phe concentrations at ≥1 moment within the first 48 h or ≥30% at ≥1 moment during the entire test) underwent a treatment trial to assess true long-term responsiveness (≥30% decrease of Phe levels compared to baseline and/or ≥50% increase in natural protein tolerance in accordance with the Dutch guidelines before 2017). The duration of the treatment trial varied from 2 to 18 months. RESULTS Of the 22 patients who completed the 7-day BH4 loading test, 2 were excluded, 8 had negative tests and 12 were considered to be potential BH4 responders. Of these 12 potential BH4-responsive PKU patients, 5 turned out to be false positive, 6 true-responder and 1 was withdrawn. CONCLUSION Even though the 48-hour BH4 loading test has proven its efficacy in the past, a full week may be necessary to detect all responders. So, if blood Phe concentrations during the 48-hour BH4 test shows a clear tendency, but not sufficient decrease, a full week (with only measurements each 24 h) could be offered. A threshold of ≥20% decrease within 48 h is not useful for predicting true BH4 responsiveness.
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Affiliation(s)
- Annemiek M J van Wegberg
- Department of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Roeland A F Evers
- Department of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Esther van Dam
- Department of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Maaike C de Vries
- Department of Paediatrics, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, Laboratory of Metabolic Diseases, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - Francjan J van Spronsen
- Department of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Centre Groningen, the Netherlands.
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Abstract
Phenylketonuria is a rare inborn error of metabolism. The build-up of phenylalanine in the blood and body tissues can have significant impact on the brain's development. High phenylalanine levels have been shown to be associated with an increase in neuropsychiatric symptoms, including mood, anxiety, and attention problems; decreased social competence; and low self-esteem. This case report highlights such a presentation in an adolescent with phenylketonuria.
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Green B, Browne R, Firman S, Hill M, Rahman Y, Kaalund Hansen K, Adam S, Skeath R, Hallam P, Herlihy I, Jenkinson F, Nicol C, Adams S, Gaff L, Donald S, Dawson C, Robertson L, Fitzachary C, Chan H, Slabbert A, Dunlop C, Cozens A, Newby C, Bittle V, Hubbard G, Stratton R. Nutritional and Metabolic Characteristics of UK Adult Phenylketonuria Patients with Varying Dietary Adherence. Nutrients 2019; 11:nu11102459. [PMID: 31615158 PMCID: PMC6835765 DOI: 10.3390/nu11102459] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 09/30/2019] [Accepted: 10/11/2019] [Indexed: 01/20/2023] Open
Abstract
The nutritional and metabolic characteristics of adult phenylketonuria (PKU) patients in the UK with varying dietary adherence is unknown. In other countries, nutritional and metabolic abnormalities have been reported in nonadherent patients compared to adherent counterparts. A pooled analysis of primary baseline data from two UK multi-centre studies was therefore performed to establish whether this is true from a UK perspective. Adult PKU patients who had provided 3-day food records and amino acid blood samples were included and grouped according to dietary adherence (adherent; n = 16 vs. nonadherent; n = 14). Nonadherent patients consumed greater amounts of natural protein compared to adherent patients (61.6 ± 30.7 vs. 18.3 ± 7.7 g/day; q < 0.001). In contrast, the contribution of protein substitutes to total protein intake was lower in nonadherent compared to adherent patients (3.9 ± 9.2 g/day vs. 58.6 ± 10.2 g/day; q < 0.001). Intakes of iron, zinc, vitamin D3, magnesium, calcium, selenium, iodine, vitamin C, vitamin A and copper were significantly lower in nonadherent compared to adherent patients and were below UK Reference Nutrient Intakes. Similarly, intakes of thiamin, riboflavin, niacin, vitamin B6 and phosphorus were significantly lower in nonadherent compared to adherent patients but met the UK Reference Nutrient Intakes. Phenylalanine concentrations in nonadherent patients were significantly higher than adherent patients (861 ± 348 vs. 464 ± 196 µmol/L; q=0.040) and fell outside of European treatment target ranges. This study shows the nutritional and metabolic consequences of deviation from phenylalanine restriction and intake of PKU protein substitutes in nonadherent adult PKU patients. Collectively, these data further underlie the importance of life-long adherence to the PKU diet.
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Affiliation(s)
- Benjamin Green
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
| | - Robert Browne
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
| | - Sarah Firman
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Melanie Hill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK.
| | - Yusof Rahman
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Kit Kaalund Hansen
- University College London Hospitals NHS Foundation Trust, London WC1N 3BG, UK.
| | - Sarah Adam
- Royal Hospital for Children, Glasgow, Glasgow G51 4TF, UK.
| | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Paula Hallam
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Ide Herlihy
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK.
| | - Fiona Jenkinson
- Royal Victoria Infirmary, Newcastle, Newcastle upon Tyne NE1 4LP, UK.
| | - Claire Nicol
- Royal Victoria Infirmary, Newcastle, Newcastle upon Tyne NE1 4LP, UK.
| | - Sandra Adams
- Royal Victoria Infirmary, Newcastle, Newcastle upon Tyne NE1 4LP, UK.
| | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK.
| | - Sarah Donald
- Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK.
| | | | | | | | - Heidi Chan
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Arlene Slabbert
- Guy's and St Thomas' NHS Foundation Trust, London SE1 9RT, UK.
| | - Carolyn Dunlop
- Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK.
| | - Alison Cozens
- Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK.
| | - Camille Newby
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK.
| | - Victoria Bittle
- Bristol University Hospitals NHS Foundation Trust, Bristol BS1 3NU, UK.
| | - Gary Hubbard
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
| | - Rebecca Stratton
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire BA14 0XQ, UK.
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK.
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Walkowiak D, Bukowska-Posadzy A, Kałużny Ł, Ołtarzewski M, Staszewski R, Musielak M, Walkowiak J. Therapy compliance in children with phenylketonuria younger than 5 years: A cohort study. ADV CLIN EXP MED 2019; 28:1385-1391. [PMID: 31469949 DOI: 10.17219/acem/104536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Phenylketonuria (PKU) is a metabolic disease. It is manifested by a complete or partial inability to convert phenylalanine (Phe) to tyrosine and leads to increased concentrations of Phe in the blood and in other tissues, including the brain, causing irreversible neurological damage if left untreated. Low-phenylalanine diet is a key component of classical PKU therapy. OBJECTIVES The objective of this study was to assess the effectiveness of classical phenylketonuria therapy and compliance with doctors' recommendations in the first 5 years of life. MATERIAL AND METHODS Data was collected from all diagnosed and treated patients (n = 57) born 1999-2010. Phenylalanine blood levels, the number of visits to a specialist outpatients' center, the number of blood tests, as well as socioeconomic status (SES) and parents' education level have been analyzed, and potential relationships have been assessed. RESULTS In the 1st year of life patients visited their doctors (odds ratio (OR) = 6.8267; 95% confidence interval (95% CI) = 2.827-16.5163; p < 0.0001) and had their blood collected (OR = 2.7875; 95% CI = 1.0467-7.4234; p < 0.0402) significantly more frequently than in the 2nd year. This tendency persisted into subsequent years. Similarly, in infancy they had statistically significantly lower odds of exceeding more than 40% of their Phe levels over therapeutic range than 1 year later (OR = 3.6078; 95% CI = 1.4859-8.7599; p < 0.0046). No PKU child had more than 70% of Phe levels over the therapeutic range in the 1st year of life, whereas 4 years later there were 18 such children. Phe levels were correlated with the number of visits to a specialist (ρ = 0.39) and the number of Phe blood tests with index of dietary control (ρ = -0.33). The effectiveness of therapy and compliance with the doctor's recommendations seem to depend neither on the level of education of the patient's parents nor on their SES. CONCLUSIONS Therapy effectiveness and patients' compliance in PKU is very good in infancy. However, both deteriorate in subsequent years. Moreover, they do not seem to depend on the family background.
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Affiliation(s)
- Dariusz Walkowiak
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Poland
| | - Anna Bukowska-Posadzy
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poland
- Department of Clinical Psychology, Poznan University of Medical Sciences, Poland
| | - Łukasz Kałużny
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poland
| | - Mariusz Ołtarzewski
- Department of Screening Tests, Institute of Mother and Child, Warszawa, Poland
| | - Rafał Staszewski
- Department of Organization and Management in Health Care, Poznan University of Medical Sciences, Poland
| | - Michał Musielak
- Department of Social Sciences, Poznan University of Medical Sciences, Poland
| | - Jarosław Walkowiak
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Poland
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van Vliet D, van der Goot E, van Ginkel WG, van Faassen MHJR, de Blaauw P, Kema IP, Martinez A, Heiner-Fokkema MR, van der Zee EA, van Spronsen FJ. The Benefit of Large Neutral Amino Acid Supplementation to a Liberalized Phenylalanine-Restricted Diet in Adult Phenylketonuria Patients: Evidence from Adult Pah-Enu2 Mice. Nutrients 2019; 11:E2252. [PMID: 31546852 PMCID: PMC6770592 DOI: 10.3390/nu11092252] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/13/2019] [Accepted: 09/17/2019] [Indexed: 11/16/2022] Open
Abstract
Many phenylketonuria (PKU) patients cannot adhere to the severe dietary restrictions as advised by the European PKU guidelines, which can be accompanied by aggravated neuropsychological impairments that, at least in part, have been attributed to brain monoaminergic neurotransmitter deficiencies. Supplementation of large neutral amino acids (LNAA) to an unrestricted diet has previously been shown to effectively improve brain monoamines in PKU mice of various ages. To determine the additive value of LNAA supplementation to a liberalized phenylalanine-restricted diet, brain and plasma monoamine and amino acid concentrations in 10 to 16-month-old adult C57Bl/6 PKU mice on a less severe phenylalanine-restricted diet with LNAA supplementation were compared to those on a non-supplemented severe or less severe phenylalanine-restricted diet. LNAA supplementation to a less severe phenylalanine-restricted diet was found to improve both brain monoamine and phenylalanine concentrations. Compared to a severe phenylalanine-restricted diet, it was equally effective to restore brain norepinephrine and serotonin even though being less effective to reduce brain phenylalanine concentrations. These results in adult PKU mice support the idea that LNAA supplementation may enhance the effect of a less severe phenylalanine-restricted diet and suggest that cerebral outcome of PKU patients treated with a less severe phenylalanine-restricted diet may be helped by additional LNAA treatment.
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Affiliation(s)
- Danique van Vliet
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Els van der Goot
- Department of Molecular Neurobiology, Groningen Institute for Evolutionary Life Sciences (GELIFES), University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Wiggert G van Ginkel
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Martijn H J R van Faassen
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Pim de Blaauw
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Ido P Kema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Aurora Martinez
- Department of Biomedicine and K.G. Jebsen Centre for Neuropsychiatric Disorders, University of Bergen, 5009 Bergen, Norway.
| | - M Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Eddy A van der Zee
- Department of Molecular Neurobiology, Groningen Institute for Evolutionary Life Sciences (GELIFES), University of Groningen, 9700 RB Groningen, The Netherlands.
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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Zori R, Ahring K, Burton B, Pastores GM, Rutsch F, Jha A, Jurecki E, Rowell R, Harding C. Long-term comparative effectiveness of pegvaliase versus standard of care comparators in adults with phenylketonuria. Mol Genet Metab 2019; 128:92-101. [PMID: 31439512 PMCID: PMC9013411 DOI: 10.1016/j.ymgme.2019.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 12/20/2022]
Abstract
Phenylketonuria (PKU) is caused by phenylalanine hydroxylase (PAH) deficiency, resulting in high blood and brain Phenylalanine (Phe) concentrations that can lead to impaired brain development and function. Standard treatment involves a Phe-restricted diet alone or in conjunction with sapropterin dihydrochloride in responsive patients. The Food and Drug Administration approved pegvaliase enzyme substitution therapy for adults with blood Phe >600 μmol/L in the US. Recently, the European Commission also approved pegvaliase for treatment of PKU patients aged 16 years or older with blood Phe >600 μmol/L. The analyses presented below were conducted to provide comparative evidence on long-term treatment effectiveness of pegvaliase versus standard of care in adults with PKU. Adult patients (≥18 years) with baseline blood Phe >600 μmol/L who had enrolled in the pegvaliase phase 2 and phase 3 clinical trials were propensity score-matched to historical cohorts of patients treated with "sapropterin + diet" or with "diet alone". These cohorts were derived from the PKU Demographics, Outcome and Safety (PKUDOS) registry and compared for clinical outcomes including blood Phe concentration and natural intact protein intake after 1 and 2 years. Propensity scores were estimated using logistic regression with probability of treatment as outcome (i.e. pegvaliase, "sapropterin + diet", or "diet alone") and patient demographic and disease severity covariates as predictors. An additional analysis in adult PKU patients with baseline blood Phe ≤600 μmol/L comparing non-matched patient groups "sapropterin + diet" to "diet alone" using PKUDOS registry data only was also conducted. The analyses in patients with baseline blood Phe >600 μmol comparing pegvaliase with "sapropterin + diet" (N = 64 matched pairs) showed lower mean blood Phe concentrations after 1 and 2 years with pegvaliase (505 and 427 μmol/L) versus "sapropterin + diet" (807 and 891 μmol/L); mean natural intact protein intake after 1 and 2 years was 49 and 57 g/day respectively with pegvaliase versus 23 and 28 g/day with "sapropterin + diet". The analysis comparing pegvaliase with "diet alone" (N = 120 matched pairs) showed lower mean blood Phe at 1 and 2 years with pegvaliase (473 and 302 μmol/L) versus "diet alone" (1022 and 965 μmol/L); mean natural intact protein intake after 1 and 2 years was 47 and 57 g/day with pegvaliase and 27 and 22 g/day with "diet alone". Considerably more patients achieved blood Phe ≤600, ≤360, and ≤120 μmol/L and reductions from baseline of ≥20%, ≥30%, and ≥50% in blood Phe after 1 and 2 years of pegvaliase versus standard treatments. The analysis in patients with baseline blood Phe ≤600 μmol/L showed lower blood Phe after 1 and 2 years with "sapropterin + diet" (240 and 324 μmol/L) versus "diet alone" (580 and 549 μmol/L) and greater percentages of patients achieving blood Phe targets ≤600, ≤360, and ≤120 μmol/L and reductions from baseline of ≥20%, ≥30%, and ≥50% in blood Phe. These results support pegvaliase as the more effective treatment option to lower Phe levels in adults with PKU who have difficulty keeping blood Phe ≤600 μmol/L with "diet alone". For patients with blood Phe ≤600 μmol/L, adding sapropterin to dietary management is an appropriate treatment option, for those responsive to the treatment.
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Affiliation(s)
- Roberto Zori
- University of Florida Health, Gainesville, FL, USA.
| | - Kirsten Ahring
- Copenhagen University Hospital, Department of Paediatrics, PKU Clinic, Copenhagen, Denmark.
| | | | - Gregory M Pastores
- Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland.
| | - Frank Rutsch
- Münster University Children's Hospital, Department of General Pediatrics, Münster, Germany.
| | | | | | | | - Cary Harding
- Oregon Health & Science University, Portland, OR, USA.
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Green B, Rahman Y, Firman S, Adam S, Jenkinson F, Nicol C, Adams S, Dawson C, Robertson L, Dunlop C, Cozens A, Hubbard G, Stratton R. Improved Eating Behaviour and Nutrient Intake in Noncompliant Patients with Phenylketonuria after Reintroducing a Protein Substitute: Observations from a Multicentre Study. Nutrients 2019; 11:nu11092035. [PMID: 31480383 PMCID: PMC6770397 DOI: 10.3390/nu11092035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/21/2019] [Accepted: 08/28/2019] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Benjamin Green
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK.
| | - Yusof Rahman
- Guy's and St Thomas' Hospital, London, SE1 9RT, UK
| | - Sarah Firman
- Guy's and St Thomas' Hospital, London, SE1 9RT, UK
| | - Sarah Adam
- Royal Hospital for Children, Glasgow, G51 4TF, UK
| | | | - Claire Nicol
- Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | - Sandra Adams
- Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
| | | | | | - Carolyn Dunlop
- Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK
| | - Alison Cozens
- Royal Hospital for Sick Children, Edinburgh, EH9 1LF, UK
| | - Gary Hubbard
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK
| | - Rebecca Stratton
- Medical Affairs, Nutricia Advanced Medical Nutrition, Wiltshire, BA14 0XQ, UK
- Faculty of Medicine, University of Southampton, Southampton, SO14 0DA, UK
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36
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van Vliet K, Rodenburg IL, van Ginkel WG, Lubout CMA, Wolffenbuttel BHR, van der Klauw MM, Heiner-Fokkema MR, van Spronsen FJ. Biomarkers of Micronutrients in Regular Follow-Up for Tyrosinemia Type 1 and Phenylketonuria Patients. Nutrients 2019; 11:E2011. [PMID: 31461828 PMCID: PMC6769775 DOI: 10.3390/nu11092011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/16/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022] Open
Abstract
Phenylketonuria (PKU) is treated with dietary restrictions and sometimes tetrahydrobiopterin (BH4). PKU patients are at risk for developing micronutrient deficiencies, such as vitamin B12 and folic acid, likely due to their diet. Tyrosinemia type 1 (TT1) is similar to PKU in both pathogenesis and treatment. TT1 patients follow a similar diet, but nutritional deficiencies have not been investigated yet. In this retrospective study, biomarkers of micronutrients in TT1 and PKU patients were investigated and outcomes were correlated to dietary intake and anthropometric measurements from regular follow-up measurements from patients attending the outpatient clinic. Data was analyzed using Kruskal-Wallis, Fisher's exact and Spearman correlation tests. Furthermore, descriptive data were used. Overall, similar results for TT1 and PKU patients (with and without BH4) were observed. In all groups high vitamin B12 concentrations were seen rather than B12 deficiencies. Furthermore, all groups showed biochemical evidence of vitamin D deficiency. This study shows that micronutrients in TT1 and PKU patients are similar and often within the normal ranges and that vitamin D concentrations could be optimized.
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Affiliation(s)
- Kimber van Vliet
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Iris L Rodenburg
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Willem G van Ginkel
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Charlotte M A Lubout
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Melanie M van der Klauw
- Department of Endocrinology, Groningen, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - M Rebecca Heiner-Fokkema
- Laboratory of Metabolic Diseases, Groningen, Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Groningen, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands.
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37
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Schulpis K, Iakovou KK. Replacement of breastfeeding with medical food for the treatment of galactosemia and phenylketonuria: maternal stress. J Pediatr Endocrinol Metab 2019; 32:791-795. [PMID: 31194686 DOI: 10.1515/jpem-2019-0109] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/16/2019] [Indexed: 11/15/2022]
Abstract
Breastfeeding replacement is the only treatment for galactosemia (GAL) and phenylketonuria (PKU) during infancy. We aimed to evaluate the stress degree in mothers who were obliged to replace breastfeeding with special formulas as the only treatment for the diseased newborns. Thirty-two mothers with GAL newborns, 19 on breastfeeding only and 13 on breastfeeding plus formula, participated in this study. Additionally, 54 mothers with PKU infants, 32 offered breastfeeding only and 22 breastfeeding plus formula, participated in the study. Stress degree was evaluated in both groups: GAL and PKU. Mothers on breastfeeding only experienced the highest degree of stress than those who were on breastfeeding plus formula. After 1 month of psychological support, most mothers were ameliorated: mothers on breastfeeding only felt better as compared to those on breastfeeding plus formula. Conversely, in mothers on breastfeeding plus formulas, symptoms and signs of stress almost disappeared. In conclusion, GAL or PKU mothers with breastfeeding only experienced the highest degree of stress when asked for breastfeeding replacement. Psychological support made all the studied groups to feel better or free of symptoms and signs of stress.
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Affiliation(s)
- Kleopatra Schulpis
- Department of Inborn Errors of Metabolism, Institute of Child Health, Athens, Greece
| | - Kostas Konstantinos Iakovou
- Department of Inborn Errors of Metabolism, Institute of Child Health, Thivon & Levadias 1 Goudi, Athens, Greece
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Couce ML, de Castro MJ, de Lamas C, Leis R. Effects of LC-PUFA Supplementation in Patients with Phenylketonuria: A Systematic Review of Controlled Trials. Nutrients 2019; 11:nu11071537. [PMID: 31284588 PMCID: PMC6682937 DOI: 10.3390/nu11071537] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/01/2019] [Accepted: 07/02/2019] [Indexed: 01/13/2023] Open
Abstract
Evidence suggests a role of long chain polyunsaturated fatty acids (LC-PUFA), in which animal foods are especially rich, in optimal neural development. The LC-PUFAs docosahexaenoic acid (DHA) and arachidonic acid, found in high concentrations in the brain and retina, have potential beneficial effects on cognition, and motor and visual functions. Phenylketonuria (PKU) is the most common inborn error of amino acid metabolism. The treatment of PKU consists of a phenylalanine-free diet, which limits the intake of natural proteins of high biological value. In this systematic review, we summarize the available evidence supporting a role for LC-PUFA supplementation as an effective means of increasing LC-PUFA levels and improving visual and neurocognitive functions in PKU patients. Data from controlled trials of children and adults (up to 47 years of age) were obtained by searching the MEDLINE and SCOPUS databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For each selected study, the risk of bias was assessed applying the methodology of the Cochrane Collaboration. The findings indicate that DHA supplementation in PKU patients from 2 weeks to 47 years of age improves DHA status and decreases visual evoked potential P100 wave latency in PKU children from 1 to 11 years old. Neurocognitive data are inconclusive.
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Affiliation(s)
- María Luz Couce
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain.
- IDIS-Health Research Institute of Santiago de Compostela, 15706 Santiago de Compostela, Spain.
- CIBERER, Pabellón 11, 28029 Madrid, Spain.
- Universidade de Santiago de Compostela, 15704 Santiago de Compostela, Spain.
| | - María José de Castro
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- IDIS-Health Research Institute of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- CIBERER, Pabellón 11, 28029 Madrid, Spain
| | - Carmela de Lamas
- CIBERER, Pabellón 11, 28029 Madrid, Spain
- Universidade de Santiago de Compostela, 15704 Santiago de Compostela, Spain
- Department of Pediatrics, Pediatric Metabolism and Research Unit, Reina Sofia University Hospital, IMIBIC, 14004 Cordoba, Spain
| | - Rosaura Leis
- Department of Pediatrics, University Clinical Hospital of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- IDIS-Health Research Institute of Santiago de Compostela, 15706 Santiago de Compostela, Spain
- CIBERER, Pabellón 11, 28029 Madrid, Spain
- Universidade de Santiago de Compostela, 15704 Santiago de Compostela, Spain
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Krüger CCH, Azevedo TD, Piltz MT, Silva ÁT, Cândido LMB. Casein-derived peptides as an alternative ingredient for low-phenylalanine diets. NUTR HOSP 2019; 36:718-722. [PMID: 30958685 DOI: 10.20960/nh.2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Abstract
Introduction: casein-derived peptides can be liberated both in vivo via normal digestion of casein, as well as in vitro via enzymatic hydrolysis. These peptides were suggested to have biological activity. Objectives: the aim of this study was to describe the production and characterization of casein peptides and to explore the potential of these peptides as an option for low-phenylalanine diets. Methods: peptides were produced by tryptic hydrolysis of sodium caseinate and acid precipitation with HCl, followed by precipitation with ethanol or aggregation of CaCl2 or ZnSO4. Results: the amino acid analysis revealed a significant reduction in the amount of phenylalanine from the original protein. Conclusion: casein-derived peptides could be a future alternative of short chain peptides to low-phenylalanine formulations.
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Affiliation(s)
| | - Thaise D Azevedo
- Food and Nutrition Post Graduate Program. Federal University of Paraná
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Muntau AC, Adams DJ, Bélanger-Quintana A, Bushueva TV, Cerone R, Chien YH, Chiesa A, Coşkun T, de Las Heras J, Feillet F, Katz R, Lagler F, Piazzon F, Rohr F, van Spronsen FJ, Vargas P, Wilcox G, Bhattacharya K. International best practice for the evaluation of responsiveness to sapropterin dihydrochloride in patients with phenylketonuria. Mol Genet Metab 2019; 127:1-11. [PMID: 31103398 DOI: 10.1016/j.ymgme.2019.04.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/14/2019] [Accepted: 04/13/2019] [Indexed: 12/26/2022]
Abstract
Phenylketonuria (PKU) is an inherited metabolic disease caused by phenylalanine hydroxylase (PAH) deficiency. As the resulting high blood phenylalanine (Phe) concentration can have detrimental effects on brain development and function, international guidelines recommend lifelong control of blood Phe concentration with dietary and/or medical therapy. Sapropterin dihydrochloride is a synthetic preparation of tetrahydrobiopterin (6R-BH4), the naturally occurring cofactor of PAH. It acts as a pharmacological chaperone, reducing blood Phe concentration and increasing dietary Phe tolerance in BH4-responsive patients with PAH deficiency. Protocols to establish responsiveness to sapropterin dihydrochloride vary widely. Two meetings were held with an international panel of clinical experts in PKU management to develop recommendations for sapropterin dihydrochloride response testing. At the first meeting, regional differences and similarities in testing practices were discussed based on guidelines, a literature review, outcomes of a global physician survey, and case reports. Statements developed based on the discussions were sent to all participants for consensus (>70% of participants) evaluation using a 7-level rating system, and further discussed during the second meeting. The experts recommend sapropterin dihydrochloride response testing in patients with untreated blood Phe concentrations of 360-2000 μmol/L, except in those with two null mutations. For neonates, a 24-h sapropterin dihydrochloride loading test is recommended; responsiveness is defined as a decrease in blood Phe ≥30%. For older infants, children, adolescents, and adults, a test duration of ≥48 h or a 4-week trial is recommended. The main endpoint for a 48-h to 7-day trial is a decrease in blood Phe, while improved Phe tolerance is the endpoint to be assessed during a longer trial. Longer trials may not be feasible in some locations due to lack of reimbursement for hospitalization, while a 4-week trial may not be possible due to limited access to sapropterin dihydrochloride or public health regulation. A 48-h response test should be considered in pregnant patients who cannot achieve blood Phe ≤360 μmol/L with a Phe-restricted diet. Durability of response and clinical benefits of sapropterin dihydrochloride should be assessed over the long term. Harmonization of protocols is expected to improve identification of responders and comparability of test results worldwide.
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Affiliation(s)
- Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
| | - Darius J Adams
- Atlantic Health System, Morristown Medical Center, Morristown, NJ, USA.
| | | | - Tatiana V Bushueva
- National Medical Research Center of Children's Health of the Ministry of Health of the Russian Federation, Moscow, Russia.
| | - Roberto Cerone
- G. Gaslini Institute, University of Genova, Genova, Italy.
| | | | - Ana Chiesa
- Centro de Investigaciones Endocrinologicas "Dr Cesar Bergadá" CEDIE, CONICET, Hospital de Niños Ricardo Gutierrez, Fundacion de Endocrinologia Infantil, Buenos Aires, Argentina.
| | - Turgay Coşkun
- Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Javier de Las Heras
- Hospital Universitario de Cruces, Biocruces Health Research Institute and University of the Basque Country UPV/EHU, Vizcaya, Spain.
| | - François Feillet
- Children's University Hospital, CHU Brabois, Vandoeuvre les Nancy, France.
| | - Rachel Katz
- Ann and Robert Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | | | - Flavia Piazzon
- Associação de Pais e Amigos dos Excepcionais de São Paulo (APAE DE SÃO PAULO), São Paulo, SP, Brazil.
| | - Fran Rohr
- Boston Children's Hospital, Boston, MA, USA.
| | - Francjan J van Spronsen
- Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands.
| | - Paula Vargas
- Hospital Materno Infantil Presidente Vargas, Porto Alegre, RS, Brazil.
| | - Gisela Wilcox
- University of Manchester & Salford Royal NHS Foundation Trust, Salford, UK.
| | - Kaustuv Bhattacharya
- Genetic Metabolic Disorders Service, University of Sydney, Children's Hospital Westmead Clinical School, Sydney, NSW, Australia.
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Bruinenberg VM, van Vliet D, van der Goot E, Counotte DS, Kuhn M, van Spronsen FJ, van der Zee EA. Long-term dietary intervention with low Phe and/or a specific nutrient combination improve certain aspects of brain functioning in phenylketonuria (PKU). PLoS One 2019; 14:e0213391. [PMID: 30875376 PMCID: PMC6420157 DOI: 10.1371/journal.pone.0213391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/19/2019] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION In phenylketonuria (PKU), a gene mutation in the phenylalanine metabolic pathway causes accumulation of phenylalanine (Phe) in blood and brain. Although early introduction of a Phe-restricted diet can prevent severe symptoms from developing, patients who are diagnosed and treated early still experience deficits in cognitive functioning indicating shortcomings of current treatment. In the search for new and/or additional treatment strategies, a specific nutrient combination (SNC) was postulated to improve brain function in PKU. In this study, a long-term dietary intervention with a low-Phe diet, a specific combination of nutrients designed to improve brain function, or both concepts together was investigated in male and female BTBR PKU and WT mice. MATERIAL & METHODS 48 homozygous wild-types (WT, +/+) and 96 PKU BTBRPah2 (-/-) male and female mice received dietary interventions from postnatal day 31 till 10 months of age and were distributed in the following six groups: high Phe diet (WT C-HP, PKU C-HP), high Phe plus specific nutrient combination (WT SNC-HP, PKU SNC-HP), PKU low-Phe diet (PKU C-LP), and PKU low-Phe diet plus specific nutrient combination (PKU SNC- LP). Memory and motor function were tested at time points 3, 6, and 9 months after treatment initiation in the open field (OF), novel object recognition test (NOR), spatial object recognition test (SOR), and the balance beam (BB). At the end of the experiments, brain neurotransmitter concentrations were determined. RESULTS In the NOR, we found that PKU mice, despite being subjected to high Phe conditions, could master the task on all three time points when supplemented with SNC. Under low Phe conditions, PKU mice on control diet could master the NOR at all three time points, while PKU mice on the SNC supplemented diet could master the task at time points 6 and 9 months. SNC supplementation did not consistently influence the performance in the OF, SOR or BB in PKU mice. The low Phe diet was able to normalize concentrations of norepinephrine and serotonin; however, these neurotransmitters were not influenced by SNC supplementation. CONCLUSION This study demonstrates that both a long-lasting low Phe diet, the diet enriched with SNC, as well as the combined diet was able to ameliorate some, but not all of these PKU-induced abnormalities. Specifically, this study is the first long-term intervention study in BTBR PKU mice that shows that SNC supplementation can specifically improve novel object recognition.
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Affiliation(s)
- Vibeke M. Bruinenberg
- Molecular Neurobiology, GELIFES, University of Groningen, Groningen, The Netherlands
| | - Danique van Vliet
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Els van der Goot
- Molecular Neurobiology, GELIFES, University of Groningen, Groningen, The Netherlands
| | | | | | - Francjan J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Eddy A. van der Zee
- Molecular Neurobiology, GELIFES, University of Groningen, Groningen, The Netherlands
- * E-mail:
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Evans S, Daly A, Wildgoose J, Cochrane B, Chahal S, Ashmore C, Loveridge N, MacDonald A. Growth, Protein and Energy Intake in Children with PKU Taking a Weaning Protein Substitute in the First Two Years of Life: A Case-Control Study. Nutrients 2019; 11:nu11030552. [PMID: 30841589 PMCID: PMC6471165 DOI: 10.3390/nu11030552] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 01/10/2023] Open
Abstract
Growth issues have been observed in young children with phenylketonuria (PKU), but studies are conflicting. In infancy, there is an increasing trend to introduce a second-stage semi-solid weaning protein substitute (WPS) but there is concern that this may not meet energy requirements. In this longitudinal, prospective study, 20 children with PKU transitioning to a WPS, and 20 non-PKU controls were observed monthly from weaning commencement (4–6 months) to 12 m and at 15, 18 and 24 months of age for: weight, length, head circumference, body mass index (BMI), energy and macronutrient intake. Growth parameters were within normal range at all ages in both groups with no significant difference in mean z-scores except for accelerated length in the PKU group. No child with PKU had z-scores < −2 for any growth parameter at age 2 years. Total protein and energy intake in both groups were similar at all ages; however, from 12–24 months in the PKU group, the percentage of energy intake from carbohydrate increased (60%) but from fat decreased (25%) and inversely for controls (48% and 36%). In PKU, use of low volume WPS meets Phe-free protein requirements, facilitates transition to solid foods and supports normal growth. Further longitudinal study of growth, body composition and energy/nutrient intakes in early childhood are required to identify any changing trends.
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Affiliation(s)
- Sharon Evans
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Anne Daly
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Jo Wildgoose
- Bradford Teaching Hospitals NHS Trust, Bradford BD9 6RJ, UK.
| | | | - Satnam Chahal
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Catherine Ashmore
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
| | - Nik Loveridge
- Danone Early Life Nutrition, Macquarie Park, New South Wales, Australia.
| | - Anita MacDonald
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK.
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Hozyasz KK, Żółkowska J. Diversity of phenylalanine tolerance in pregnant phenylketonuria patients homozygous for the p.R408W mutation: the need for improved understanding of phenylalanine homeostasis. J BIOL REG HOMEOS AG 2019; 33:491-497. [PMID: 30907078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Dietetic treatment of phenylketonuria (PKU) includes a low-phenylalanine (phe) diet that provides sufficient phe for maintenance and growth plus special phe-free formulas with amino acids to meet requirements for protein, energy and micronutrients.
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Affiliation(s)
- K K Hozyasz
- Institute of Health Sciences, State School of Higher Education, Biała Podlaska, Poland, e-mail:
| | - J Żółkowska
- PKU Polyclinic, Institute of Mother and Child, Warsaw, Poland
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Burlina AP, Lachmann RH, Manara R, Cazzorla C, Celato A, van Spronsen FJ, Burlina A. The neurological and psychological phenotype of adult patients with early-treated phenylketonuria: A systematic review. J Inherit Metab Dis 2019; 42:209-219. [PMID: 30690773 DOI: 10.1002/jimd.12065] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/21/2019] [Indexed: 11/11/2022]
Abstract
Newborn screening for phenylketonuria (PKU) and early introduction of dietary therapy has been remarkably successful in preventing the severe neurological features of PKU, including mental retardation and epilepsy. However, concerns remain that long-term outcome is still suboptimal, particularly in adult patients who are no longer on strict phenylalanine-restricted diets. With our systematic literature review we aimed to describe the neurological phenotype of adults with early-treated phenylketonuria (ETPKU). The literature search covered the period from 1 January 1990 up to 16 April 2018, using the NLM MEDLINE controlled vocabulary. Of the 643 records initially identified, 83 were included in the analysis. The most commonly reported neurological signs were tremor and hyperreflexia. The overall quality of life (QoL) of ETPKU adults was good or comparable to control populations, and there was no evidence for a significant incidence of psychiatric disease or social difficulties. Neuroimaging revealed that brain abnormalities are present in ETPKU adults, but their clinical significance remains unclear. Generally, intelligence quotient (IQ) appears normal but specific deficits in neuropsychological and social functioning were reported in early-treated adults compared with healthy individuals. However, accurately defining the prevalence of these deficits is complicated by the lack of standardized neuropsychological tests. Future research should employ standardized neurological, neuropsychological, and neuroimaging protocols, and consider other techniques such as advanced imaging analyses and the recently validated PKU-specific QoL questionnaire, to precisely define the nature of the impairments within the adult ETPKU population and how these relate to metabolic control throughout life.
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Affiliation(s)
| | - Robin H Lachmann
- Charles Dent Metabolic Unit, National Hospital for Neurology and Neurosurgery, London, UK
| | - Renzo Manara
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Chiara Cazzorla
- Division of Inborn Metabolic Diseases, Department of Paediatrics, University Hospital, Padua, Italy
| | - Andrea Celato
- Division of Inborn Metabolic Diseases, Department of Paediatrics, University Hospital, Padua, Italy
| | - Francjan J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center of Groningen, University of Groningen, Groningen, The Netherlands
| | - Alberto Burlina
- Division of Inborn Metabolic Diseases, Department of Paediatrics, University Hospital, Padua, Italy
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Evans S, Ford S, Adam S, Adams S, Ash J, Ashmore C, Caine G, Carruthers R, Cawtherley S, Chahal S, Clark A, Cochrane B, Daly A, Dines K, Dixon M, Dunlop C, Ellerton C, French M, Gaff L, Gingell C, Green D, Gribben J, Grimsley A, Hallam P, Hendroff U, Hill M, Hoban R, Howe S, Hunjan I, Kaalund K, Kelleher E, Khan F, Kitchen S, Lang K, Lowry S, Males J, Martin G, McStravick N, Micciche A, Newby C, Nicol C, Pereira R, Robertson L, Ross K, Simpson E, Singleton K, Skeath R, Stafford J, Terry A, Thom R, Tooke A, vanWyk K, White F, White L, MacDonald A. Development of national consensus statements on food labelling interpretation and protein allocation in a low phenylalanine diet for PKU. Orphanet J Rare Dis 2019; 14:2. [PMID: 30606267 PMCID: PMC6318866 DOI: 10.1186/s13023-018-0950-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 11/02/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the treatment of phenylketonuria (PKU), there was disparity between UK dietitians regarding interpretation of how different foods should be allocated in a low phenylalanine diet (allowed without measurement, not allowed, or allowed as part of phenylalanine exchanges). This led to variable advice being given to patients. METHODOLOGY In 2015, British Inherited Metabolic Disease Group (BIMDG) dietitians (n = 70) were sent a multiple-choice questionnaire on the interpretation of protein from food-labels and the allocation of different foods. Based on majority responses, 16 statements were developed. Over 18-months, using Delphi methodology, these statements were systematically reviewed and refined with a facilitator recording discussion until a clear majority was attained for each statement. In Phase 2 and 3 a further 7 statements were added. RESULTS The statements incorporated controversial dietary topics including: a practical 'scale' for guiding calculation of protein from food-labels; a general definition for exchange-free foods; and guidance for specific foods. Responses were divided into paediatric and adult groups. Initially, there was majority consensus (≥86%) by paediatric dietitians (n = 29) for 14 of 16 statements; a further 2 structured discussions were required for 2 statements, with a final majority consensus of 72% (n = 26/36) and 64% (n = 16/25). In adult practice, 75% of dietitians agreed with all initial statements for adult patients and 40% advocated separate maternal-PKU guidelines. In Phase 2, 5 of 6 statements were agreed by ≥76% of respondents with one statement requiring a further round of discussion resulting in 2 agreed statements with a consensus of ≥71% by dietitians in both paediatric and adult practice. In Phase 3 one statement was added to elaborate further on an initial statement, and this received 94% acceptance by respondents. Statements were endorsed by the UK National Society for PKU. CONCLUSIONS The BIMDG dietitians group have developed consensus dietetic statements that aim to harmonise dietary advice given to patients with PKU across the UK, but monitoring of statement adherence by health professionals and patients is required.
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Affiliation(s)
- British Inherited Metabolic Diseases Group (BIMDG) Dietitians Group
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
- The National Society for Phenylketonuria, London, UK
- Queen Elizabeth University Hospital, Glasgow, UK
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
- University Hospital of Wales, Cardiff, UK
- Mid Yorkshire Hospitals NHS Trust, Yorkshire, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Children’s University Hospital Dublin, Dublin, Republic of Ireland
- Belfast Health & Social Care Trust, Belfast, UK
- Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
- Leicester Royal Infirmary, Leicester, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Salford Royal NHS Foundation Trust, Salford, UK
- Evelina London Children’s Healthcare, London, UK
- Mater Misericordiae University Hospital Dublin, Dublin, Ireland
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
- Ninewells Hospital Dundee, Dundee, Scotland
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
- Aneurin Bevan University Health Board Wales, Newport, UK
- Bristol Royal Hospital for Children, Bristol, UK
- Norfolk and Norwich University Hospital, Norfolk, UK
- Royal Aberdeen Children’s Hospital, Aberdeen, UK
- Royal Manchester Children’s Hospital, Manchester, UK
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Sharon Evans
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Suzanne Ford
- The National Society for Phenylketonuria, London, UK
| | - Sarah Adam
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Sandra Adams
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Jane Ash
- University Hospital of Wales, Cardiff, UK
| | - Catherine Ashmore
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | | | - Rachel Carruthers
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Sarah Cawtherley
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Satnam Chahal
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Anne Clark
- Children’s University Hospital Dublin, Dublin, Republic of Ireland
| | | | - Anne Daly
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Karen Dines
- Belfast Health & Social Care Trust, Belfast, UK
| | - Marjorie Dixon
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Carolyn Dunlop
- Royal Hospital for Sick Children Edinburgh, Edinburgh, UK
| | | | | | - Lisa Gaff
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Cerys Gingell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Diane Green
- Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | - Paula Hallam
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Una Hendroff
- Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Melanie Hill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel Hoban
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Sarah Howe
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Inderdip Hunjan
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kit Kaalund
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Eimear Kelleher
- Mater Misericordiae University Hospital Dublin, Dublin, Ireland
| | - Farzana Khan
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Steve Kitchen
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
| | - Karen Lang
- Ninewells Hospital Dundee, Dundee, Scotland
| | - Sharan Lowry
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Jo Males
- Aneurin Bevan University Health Board Wales, Newport, UK
| | - Georgina Martin
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | | | | | - Claire Nicol
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Louise Robertson
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Emma Simpson
- Royal Manchester Children’s Hospital, Manchester, UK
| | | | - Rachel Skeath
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Allyson Terry
- Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Ruth Thom
- Belfast Health & Social Care Trust, Belfast, UK
| | - Alison Tooke
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Karen vanWyk
- Royal Manchester Children’s Hospital, Manchester, UK
| | - Fiona White
- Royal Manchester Children’s Hospital, Manchester, UK
| | - Lucy White
- Sheffield Children’s NHS Foundation Trust, Sheffield, UK
| | - Anita MacDonald
- Dietetic Department, Birmingham Women’s & Children’s NHS Foundation Trust, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham, B4 6NH UK
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Brantley KD, Douglas TD, Singh RH. One-year follow-up of B vitamin and Iron status in patients with phenylketonuria provided tetrahydrobiopterin (BH4). Orphanet J Rare Dis 2018; 13:192. [PMID: 30373601 PMCID: PMC6206913 DOI: 10.1186/s13023-018-0923-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 10/02/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND People with Phenylketonuria (PKU) who respond to tetrahydrobiopterin (BH4) often decrease dependence on medical food (MF) following increased phenylalanine (phe) tolerance. Responders to BH4 may experience a reduction in certain nutrients if not compensated through intact foods or supplements. This study investigated B6, B12, folate, and iron status based on blood levels and dietary intake in patients with PKU responsive to BH4 over 1 year. METHODS Fifty-eight patients with PKU, ages 4-50 years were recruited and initiated on BH4 therapy. Patients were monitored for BH4 response, and nutritional status was recorded at regular intervals over 12 months. The analysis included 33 patients with known BH4 response status and complete nutritional data. Nutrient intake was determined by National Data System for Research (NDSR) analysis of self reported 3 day diet records and compared to Dietary Reference Intakes (DRIs). Blood biomarkers were analyzed by Quest Diagnostics and compared to laboratory reference ranges. Patient laboratory values were compared to controls from the National Health and Examination Survey (NHANES). Differences in nutrient intakes across time points were examined, stratified by age, using nonparametric methods. Statistical analyses were completed with SAS 9.4, with significance set at α = 0.05. RESULTS Medical food intake declined among pediatric (p < 0.01) and adult (p = 0.06) BH4 responders over 1 year. Among those < 18 years of age, mean percent of calories obtained from MF declined from 21.3 to 4.7%. In adults, percent calories from MF dropped from 19.5 to 4.0%. Though maintaining laboratory and dietary values within reference ranges, responders < 18 years experienced a significant decline in serum B12 (p = 0.01), dietary folate (p = 0.006), and dietary iron (p = 0.004) over the study. CONCLUSION Although mean dietary and laboratory values for B12, B6, folate, and iron in BH4 responders and non-responders were adequate at baseline and 12-month follow-up, responders experienced a significant decline in serum B12 over 1 year, which may be explained by decreased intake of fortified MF. Both response groups had lower serum B12 than NHANES controls at baseline and 12 months. Results indicate a need to monitor B12 concentrations and consider micronutrient supplementation, with special attention to pediatric patients with PKU.
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Affiliation(s)
| | - Teresa D Douglas
- Department of Human Genetics, Metabolic Nutrition Program, Emory University School of Medicine, Atlanta, GA USA
| | - Rani H Singh
- Department of Human Genetics, Metabolic Nutrition Program, Emory University School of Medicine, Atlanta, GA USA
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González MJ, Polo MR, Ripollés P, Gassió R, Ormazabal A, Sierra C, Roura RC, Artuch R, Campistol J. White matter microstructural damage in early treated phenylketonuric patients. Orphanet J Rare Dis 2018; 13:188. [PMID: 30367646 PMCID: PMC6203973 DOI: 10.1186/s13023-018-0912-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 09/12/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite dietary intervention, individuals with early treated phenylketonuria (ETPKU) could present neurocognitive deficits and white matter (WM) abnormalities. The aim of the present study was to evaluate the microstructural integrity of WM pathways across the whole brain in a cohort of paediatric ETPKU patients compared with healthy controls (HCs), by collecting DTI-MRI (diffusion tensor magnetic resonance imaging) data and diffusion values (mean diffusivity (MD), radial diffusivity (RD) and fractional anisotropy (FA)). METHODS DTI-MRI data and diffusion values (MD, RD, FA) from WM tracts across the whole brain were analized using Tract Based Spatial Statistics (TBSS), in 15 paediatrics TPKU patients (median age: 12 years) and compared with 11 HCs. Areas showing abnormal values in the patient group were correlated (Pearson) with age, lifetime Phe values, last year median and mean Phe, concurrent Phe values in plasma, urine neurotransmitters status biomarkers, and with a processing speed task. RESULTS ETPKU showed bilaterally decreased MD values compared with HCs in the body and splenium of the corpus callosum, superior longitudinal fasciculus, corona radiata and in the posterior limb of the internal capsule. RD values followed a similar pattern, although decreased RD values in PKU patients were also found in the anterior limb of the internal capsule and in the cerebral peduncle. Decreased MD and RD values within the aforementioned regions had significant negative correlations with age, last year median and mean Phe and concurrent Phe values. No correlations were found with monoamines in urine or processing speed task. CONCLUSIONS ETPKU patients showed MD and RD values significantly decreased across the whole brain when compared with HCs, and this damage was associated with high Phe values and the age of patients. Despite this microstructural damage, no affectation in processing speed was observed in patients with good metabolic control. DTI-MRI sequences could be used as a technique to quantify WM damage that is difficult to be detect in T1 or T2-weighted images, but also to quantify damage of WM through the follow up of patients with poor metabolic control in prospective studies.
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Affiliation(s)
- María Julieta González
- Neuropediatric Department, PKU Follow Up Unit, Hospital Sant Joan de Déu (HSJD), Institut de Recerca Sant Joan de Deu (IRSJD), Passeig Sant Joan de Deu 2, Postal code, 08950 Barcelona, Spain
| | - Mónica Rebollo Polo
- Neuroimaging Section, HSJD, IRSJD, Passeig Sant Joan de Deu 2, Postal code, 08950 Barcelona, Spain
| | - Pablo Ripollés
- Neuroimaging Section, HSJD, IRSJD, Passeig Sant Joan de Deu 2, Postal code, 08950 Barcelona, Spain
- Department of Psychology, New York University, 6 Washington Place, 10003 New York, USA
| | - Rosa Gassió
- Neuropediatric Department, PKU Follow Up Unit, Hospital Sant Joan de Déu (HSJD), Institut de Recerca Sant Joan de Deu (IRSJD), Passeig Sant Joan de Deu 2, Postal code, 08950 Barcelona, Spain
| | - Aída Ormazabal
- Clinical Biochemistry Department, HSJD, IRSJD, UB, (CIBERER-ISCIII), Passeig Sant Joan de Deu 2, 08950 Barcelona, Spain
| | - Cristina Sierra
- Clinical Biochemistry Department, HSJD, IRSJD, UB, (CIBERER-ISCIII), Passeig Sant Joan de Deu 2, 08950 Barcelona, Spain
| | - Roser Colomé Roura
- Neuropediatric Department, PKU Follow Up Unit, Hospital Sant Joan de Déu (HSJD), Institut de Recerca Sant Joan de Deu (IRSJD), Passeig Sant Joan de Deu 2, Postal code, 08950 Barcelona, Spain
| | - Rafael Artuch
- Clinical Biochemistry Department, HSJD, IRSJD, UB, (CIBERER-ISCIII), Passeig Sant Joan de Deu 2, 08950 Barcelona, Spain
| | - Jaume Campistol
- Neuropediatric Department, PKU Follow Up Unit, Hospital Sant Joan de Déu (HSJD), Institut de Recerca Sant Joan de Deu (IRSJD), Passeig Sant Joan de Deu 2, Postal code, 08950 Barcelona, Spain
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48
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Evers RAF, van Wegberg AMJ, van Dam E, de Vries MC, Janssen MCH, van Spronsen FJ. Anthropomorphic measurements and nutritional biomarkers after 5 years of BH 4 treatment in phenylketonuria patients. Mol Genet Metab 2018; 124:238-242. [PMID: 30078395 DOI: 10.1016/j.ymgme.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/17/2018] [Accepted: 06/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Roeland A F Evers
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Annemiek M J van Wegberg
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands; Radboud University Medical Center Nijmegen, Department of Gastroenterology and Hepatology-Dietetics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Esther van Dam
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Maaike C de Vries
- Radboud University Medical Center Nijmegen, Department of Pediatrics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Mirian C H Janssen
- Radboud University Medical Center, Department of Internal Medicine, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands.
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Verduci E, Moretti F, Bassanini G, Banderali G, Rovelli V, Casiraghi MC, Morace G, Borgo F, Borghi E. Phenylketonuric diet negatively impacts on butyrate production. Nutr Metab Cardiovasc Dis 2018; 28:385-392. [PMID: 29502926 DOI: 10.1016/j.numecd.2018.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/12/2018] [Accepted: 01/15/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Phenylalanine (Phe) restricted diet, combined with Phe-free l-amino acid supplementation, is the mainstay of treatment for phenylketonuria (PKU). Being the diet a key factor modulating gut microbiota composition, the aim of the present paper was to compare dietary intakes, gut microbiota biodiversity and short chain fatty acids (SCFAs) production in children with PKU, on low-Phe diet, and in children with mild hyperphenylalaninemia (MHP), on unrestricted diet. METHODS AND RESULTS We enrolled 21 PKU and 21 MHP children matched for gender, age and body mass index z-score. Dietary intakes, including glycemic index (GI) and glycemic load (GL), and fecal microbiota analyses, by means of denaturing gradient gel electrophoresis (DGGE) and Real-time PCR were assessed. Fecal SCFAs were quantified by gas chromatographic analysis. RESULTS We observed an increased carbohydrate (% of total energy), fiber and vegetables intakes (g/day) in PKU compared with MHP children (p = 0.047), as well a higher daily GI and GL (maximum p < 0.001). Compared with MHP, PKU showed a lower degree of microbial diversity and a decrease in fecal butyrate content (p = 0.02). Accordingly, two of the most abundant butyrate-producing genera, Faecalibacterium spp. and Roseburia spp., were found significantly depleted in PKU children (p = 0.02 and p = 0.03, respectively). CONCLUSION The low-Phe diet, characterized by a higher carbohydrate intake, increases GI and GL, resulting in a different quality of substrates for microbial fermentation. Further analyses, thoroughly evaluating microbial species altered by PKU diet are needed to better investigate gut microbiota in PKU children and to eventually pave the way for pre/probiotic supplementations.
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Affiliation(s)
- E Verduci
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy.
| | - F Moretti
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - G Bassanini
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - G Banderali
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - V Rovelli
- Department of Pediatrics, San Paolo Hospital, Università degli Studi di Milano, Milan, Italy
| | - M C Casiraghi
- Department of Food, Environmental and Nutritional Sciences, Università degli Studi di Milano, Milan, Italy
| | - G Morace
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - F Borgo
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - E Borghi
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
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Stroup BM, Nair N, Murali SG, Broniowska K, Rohr F, Levy HL, Ney DM. Metabolomic Markers of Essential Fatty Acids, Carnitine, and Cholesterol Metabolism in Adults and Adolescents with Phenylketonuria. J Nutr 2018; 148:194-201. [PMID: 29490096 PMCID: PMC6251508 DOI: 10.1093/jn/nxx039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 09/05/2017] [Accepted: 11/08/2017] [Indexed: 12/12/2022] Open
Abstract
Background Individuals with phenylketonuria (PKU) have a risk of cognitive impairment and inflammation. Many follow a low-phenylalanine (low-Phe) diet devoid of animal protein in combination with medical foods (MFs). Objective To assess lipid metabolism in participants with PKU consuming amino acid MFs (AA-MFs) or glycomacropeptide MFs (GMP-MFs), we conducted fatty acid and metabolomics analyses. Methods We used subsets of fasting plasma and urine samples from our randomized crossover trial in which participants with early-treated classical and variant (milder) PKU consumed a low-Phe diet combined with AA-MFs or GMP-MFs for 3 wk each. Fatty acid profiles of red blood cell (RBC) membranes were determined for 25 adults (aged 18-49 y) with PKU and 143 control participants. Metabolomics analyses of plasma and urine samples were conducted by Metabolon for 9-10 adolescent and adult participants with PKU and for 15 control participants. Results RBC fatty acid profiles were not significantly different with AA-MFs or GMP-MFs. PKU participants showed higher total n-6:n-3 (ω-6:ω-3) fatty acids (mean ± SD percentages of total fatty acids: AA-MF = 5.45% ± 1.07%; controls = 4.33%; P < 0.001) and lower docosahexaenoic acid (DHA; AA-MF = 3.21% ± 0.98%; controls = 3.70% ± 1.01%; P = 0.02) and eicosapentaenoic acid (AA-MF = 0.33% ± 0.12%; controls = 0.60% ± 0.43%; P < 0.001) in RBCs than did control participants. Despite higher carnitine intake from AA-MFs than GMP-MFs (mean ± SE intake: AA-MFs = 58.6 ± 5.3 mg/d; GMP-MFs = 0.3 ± 0.01 mg/d; P < 0.001), plasma concentrations of carnitine were similar and not different from those in the control group (AA-MF compared with GMP-MF, P = 0.73). AA-MFs resulted in higher urinary excretion of trimethylamine N-oxide (TMAO), which is synthesized by bacteria from carnitine, compared with GMP-MFs (mean ± SE scaled intensity-TMAO: AA-MFs = 1.2 ± 0.1, GMP-MFs = 0.9 ± 0.1; P = 0.005). Plasma deoxycarnitine was lower in PKU participants than in control participants, suggesting reduced carnitine biosynthesis in PKU (AA-MF = 0.9 ± 0.1; GMP-MF = 1.0 ± 0.1; controls = 1.3 ± 0.1; AA-MF compared with controls, P = 0.01; GMP-MF compared with controls, P = 0.04). Conclusions Supplementation with DHA is needed in PKU. Carnitine supplementation of AA-MFs shows reduced bioavailability due, in part, to bacterial degradation to TMAO, whereas the bioavailability of carnitine is greater with prebiotic GMP-MFs. This trial was registered at www.clinicaltrials.gov as NCT01428258.
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Affiliation(s)
- Bridget M Stroup
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
| | - Nivedita Nair
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
| | - Sangita G Murali
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
| | | | - Fran Rohr
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Harvey L Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Denise M Ney
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, WI
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