Markers for the Validation of Reported Dietary Intake in Adults with Cystic Fibrosis

Dietary intake and quality among adults with cystic fibrosis: A systematic review

AIMS

This systematic review aims to describe the dietary quality, dietary intake and related behaviours of adults diagnosed with cystic fibrosis.

METHODS

A comprehensive literature search was conducted in four databases (Medline, CINAHL, EMBASE, CENTRAL); studies were included if they addressed dietary intake, diet quality or eating behaviours among adults (≥15 years) living with cystic fibrosis and were published from January 2000 to November 2022. The Mixed Methods Appraisal Tool was used to assess the risk of bias and quality of included studies. Findings were synthesised narratively.

RESULTS

Nineteen observational studies (n = 2236) were included and considered high to moderate quality. Most (13/19) studies reported that individuals with cystic fibrosis were consuming high-energy diets; where studies reported energy intake as a proportion of requirements met, energy intake was high, even when using individualised or cystic fibrosis-specific referents. In addition, fat intakes as a proportion of energy appeared high (29%-39% of total energy), particularly as current guidelines recommend macronutrient profile similar to the general population (<30% of total energy). There was considerable variation in the reporting of fatty acid profiles and other nutrients. Five studies reported on concerns regarding diet and eating in this population.

CONCLUSION

Findings from the current review suggest dietary intakes of adults with cystic fibrosis appear to be less than optimal and concerns about diet, weight and food may be emerging in this population. Future research utilising consistent measures of dietary assessment and reporting, reporting of medical therapies, and exploring potential concerns about diet and eating is warranted.

Development and validation of a food frequency questionnaire in adult Saudi subjects in Jeddah city

BACKGROUND AND AIMS

In Saudi Arabia, very limited studies have been conducted to evaluate the validity of culturally appropriate food frequency questionnaire (FFQ). The aim of this study was to validate a newly designed FFQ against two reference methods in Saudi adults.

METHODS

A new FFQ adapted from the Block FFQ was completed via interview and validated against three-day food records (3DFRs; n = 126) and 24-hour urinary urea nitrogen (UUN)-based protein intake estimates (n = 118) in adult Saudis living in Jeddah. FFQ-estimated nutrient intake was compared to the 3DFR and UUN methods using Pearson's correlations (r), Bland-Altman plots, and weighted kappa (κw) statistics.

RESULTS

This study included 126 participants (80 females and 46 males). The FFQ generally overreported nutrient intakes compared to the reference methods. The FFQ was strongly correlated with 3DFRs for energy, protein, carbohydrate, and total fat (r > 0.7); moderately correlated with cholesterol (r = 0.55) and iron (r = 0.44); and weakly correlated with the other micronutrients (r = 0.1-0.3). A moderate positive correlation for protein intake was found (r = 0.62) between the FFQ and 24-hour UUN method. The Bland-Altman analysis indicated the FFQ had an acceptable level of agreement with no significant proportional bias (P > 0.05) with the 3DFRs for energy, protein, total fat, and iron and with protein intake. Similarly, an acceptable level of agreement was found between the FFQ and the 24-hour UUN method for estimating protein intake. Cross-classification analysis showed that ≥ 50% of participants were ranked within the same quartile for energy, protein, and total fat. The FFQ showed good agreement with the 3DFRs for energy and protein (κw ≥ 0.61) and acceptable agreement with protein intake. An acceptable agreement was reported between the FFQ and 24-hour UUN method (κw = 0.56). Separate analyses of females and males showed stronger correlations and agreements between the FFQ and the two reference methods only in females.

CONCLUSION

The developed FFQ is an effective and valid tool for assessing dietary intake in Saudi adults. However, it still requires future optimization to improve its validity.

Handgrip Strength: Associations with Clinical Variables, Body Composition, and Bone Mineral Density in Adults with Cystic Fibrosis

Background: Loss of fat-free mass (FFM) is associated with an increase in morbidity and mortality in cystic fibrosis (CF) patients. Handgrip strength (HGS) measures muscle function and may be associated with clinical parameters with prognostic value. Our objectives were to evaluate muscle strength through HGS in CF patients and to determine if there are any associations with respiratory clinical variables, FFM, and bone mineral density (BMD). Methods: A cross-sectional study conducted in clinically stable patients. We evaluated muscle function through HGS, respiratory function—forced expiratory volume in 1 s (FEV1) (%), forced vital capacity (FVC) (%), bronchorrhea, annual exacerbations, and body composition (FFM and FFM index, FFMI: fat-free mass in kg/height in m²) and Bone Mineral Density (BMD) through densitometry (DXA). Results: The study included 53 CF patients (58.5% females, mean age 28.3 ± 8.1, body mass index (BMI) 21.7 ± 3.4). The mean values for dynamometry were 40.2 ± 8.1 kg in males and 23.1 ± 7.0 kg in women, being 20.8% below the 10th percentile. Patients with lower muscle strength showed significantly more exacerbations and lower FEV1% and FVC%, as well as lower BMI, worse BMD (g/cm²), T-score, and Z-score. A significant and positive correlation was found between the mean and maximum dynamometry values and age, FVC%, BMI, FFMI, FFM (kg), and BMD. Conclusions: For adults with CF, HGS is a practical tool for assessment of health status. Low values reflect poor nutritional status and are associated with poor respiratory function, low fat-free mass and low bone mineral density.

Oral Nutritional Supplements in Adults with Cystic Fibrosis: Effects on Intake, Levels of Fat-Soluble Vitamins, and Bone Remodeling Biomarkers

Background: The use of oral nutritional supplements (ONS) is common practice in patients suffering from cystic fibrosis (CF). We aimed to describe the rate of ONS use to assess their contribution to dietary intake and to determine if they are associated with respiratory status, body composition, muscle strength, bone mineral density (BMD), bone remodeling biomarkers, and plasmatic levels of vitamins. Methods: Cross-sectional study. Patients were clinically stable adults recruited from the CF unit. A 4-day prospective dietary questionnaire was conducted; in addition to respiratory variables, body composition, and BMD (through densitometry, DXA), muscle strength (JAMAR dynamometer), fat-soluble vitamins, and bone remodeling biomarkers (vitamins A, D, and E; osteocalcin, OC; undercarboxylated osteocalcin, ucOC; degradation of the C-terminal telopeptides of type I collagen, CTX; and receptor activator of nuclear factor-kappaB ligand, RANKL) were also evaluated. Results: The study included 59 subjects with CF (57.6% female, mean age 29.3 ± 9.4 years, and BMI 22.0 ± 3.6 kg/m²). In this study, 22% (13) patients were taking ONS and presented, compared with those not taking them, significantly more total and mild exacerbations and lower BMI; moreover, they showed a significantly higher total daily calorie intake in addition to a higher consumption of carbohydrates, proteins, and lipids per kg of body weight, omega-3 fatty acids, and vitamins A, D, and E. Vitamin E plasmatic levels were significantly higher in the group on ONS, as was the case with RANKL; finally, a lower rate of vitamin D deficiency was also found. Conclusions: ONS were used by patients with worse respiratory and nutritional statuses and their use was associated with a higher intake of macro- and micronutrients and with better plasmatic levels of fat-soluble vitamins.

Osteopenia and Osteoporosis in Patients with Bronchiectasis: Association with Respiratory Parameters, Body Composition, Muscle Strength and Bone Remodeling Biomarkers

The prevalence of osteopenia/osteoporosis has not been sufficiently studied in people with bronchiectasis not due to cystic fibrosis (BC), nor has its relationship with other variables (clinical, body composition and bone turnover and inflammation markers) been sufficiently studied. Our aim was to determine the prevalence of osteopenia and osteoporosis and related factors in patients with BC. We did a cross-sectional study in people with BC in a clinically stable state. Spirometric parameters, annual exacerbations and analysis with bone turnover markers (BTM) and inflammation markers were evaluated. Densitometry (DXA) was performed for body composition, bone mineral density (BMD) and handgrip strength. 123 patients were studied (65% women, mean age 49.6 ± 18.8, Body Mass Index (BMI) 24.8 ± 4.7 kg/m²). 62.8% and 62.5% of men and women, respectively, had normal bone mineral density, 30.2% and 22.2% osteopenia and 7% and 15% osteoporosis. 52 patients (56.2%) had low fat-free mass: 68.9% women and 28.6% men. Patients with decreased bone mass had significantly lower muscle strength, maximum expiratory volume in the first second (FEV1%), vitamin D, higher levels of C-terminal telopeptide of type 1 collagen (CTX) and total osteocalcin and underarboxylated osteocalcin (ucOC). We observed significant and negative correlations between BMD and the number of serious exacerbations per year CTX and undercarboxylated osteocalcin. We observed significant positive correlations between BMD, fat free mass index (FFMI) and handgrip dynamometry. The study suggest that the prevalence of osteoporosis was high in relation to the demographic characteristics. Respiratory parameters, body composition, muscle strength and bone remodeling markers were associated with a lower bone mineral density.

Serum Phospholipid Fatty Acid Composition in Cystic Fibrosis Patients with and without Liver Cirrhosis

Background/Aims: Cystic fibrosis (CF) liver disease is the third most frequent cause of death in CF patients. Although it alters fatty acid (FA) metabolism, data concerning the profile of FA in CF patients with liver cirrhosis is lacking. This study aimed to assess the FA composition of serum phospholipids in CF patients with and without liver cirrhosis. Methods: The study comprised 25 CF patients with liver cirrhosis and 25 without it. We assessed Z-scores for body height and weight, lung function, exocrine pancreatic sufficiency and colonization with Pseudomonas aeruginosa. FAs' profile of serum glycerophospholipids was quantified by gas chromatography mass spectrometry. Results: In CF patients with liver cirrhosis, the levels of C16:0 were higher and the amounts of C20:2n-6, C20:3n-6, C20:4n-6, and all the n-3 polyunsaturated FAs (PUFAs) (C18:3n-3, C20:5n-3, C22:5n-3, C22:6n-3) were lower than those in CF subjects without liver cirrhosis. The n-6/n-3, C20:4n-6/C18:2n-6, total n-6/C18:2n-6, C20:5n-3/C18:3n-3 and total n-3/C18:3n-3 ratios did not differ between the 2 groups. Conclusions: Liver cirrhosis may associate with profound abnormalities in the composition of serum glycerophospholipids FAs in CF patients. None of the analyzed clinical factors could explain the greater prevalence of low levels of PUFAs in this CF subgroup.

Inflammation and Oxidation Biomarkers in Patients with Cystic Fibrosis: The Influence of Azithromycin

OBJECTIVE

In addition to their antibiotic effect, macrolides appear to modulate the inflammatory response in cystic fibrosis (CF) and could influence oxidative stress. The objective of this study was to assess oxidation biomarkers and levels of inflammation and to determine whether there is an association between these parameters and the intake of macrolides.

MATERIALS AND METHODS

The subjects included in this cross-sectional study were, on the one hand, clinically stable patients with CF and, on the other, healthy controls. The following serum and plasma inflammatory and oxidative stress biomarkers were measured: interleukin-6 (IL-6), reactive C protein (RCP), tumor necrosis alpha (TNF-α), glutathione peroxidase (GPx), total antioxidant capacity (TAC), catalase (CAT), and superoxide dismutase (SOD), together with markers of lipid peroxidation (8-isoprostanes and thiobarbituric acid reactive substances [TBARS]). Clinical, anthropometric, lung function, radiological, and analytical variables (albumin, prealbumin, vitamins, and zinc) were also recorded.

RESULTS

We studied 36 adults with CF and 41 controls. No differences were observed in age, gender, or anthropometric variables. The patients had significantly higher levels of IL-6, TNF-α, RCP, TBARS, and isoprostanes, and lower levels of SOD than the controls. Twenty-three of the patients were treated with azithromycin, and they had more severe clinical and radiological parameters than those who were not but nevertheless presented significantly lower levels of TNF-α. No differences were observed in the markers of oxidation.

CONCLUSION

Inflammation and oxidation biomarkers were increased in patients with CF compared with controls. The use of azithromycin was associated with reduced TNF-α levels and did not influence oxidation parameters.

Cellular and plasma oxidative stress biomarkers are raised in adults with bronchiectasis

BACKGROUND & AIMS

Oxidative stress is believed to play an important role in the pathophysiology of bronchiectasis. The aims of this study were to evaluate the oxidative stress status in bronchiectasis patients.

METHODS

This cross-sectional study included 90 clinically stable adults with bronchiectasis of any aetiology (36 with cystic fibrosis [CF] and 54 without CF) plus 50 healthy controls. Plasma and serum oxidative stress biomarkers were measured using commercial kits. Cellular oxidative stress biomarkers in white blood cells (mitochondrial membrane potential, intracellular glutathione, superoxide anion and hydrogen peroxide) were analyzed by flow cytometry.

RESULTS

Compared with the control group, the catalase activity and lipid peroxidation (TBARs and 8-isoprostanes) were significantly increased in the patient group and the total antioxidant capacity and the activity of superoxide dismutase were decreased. Intracellular superoxide anion and hydrogen peroxide were significantly elevated in the patients versus the controls in total leukocytes, lymphocytes, monocytes and neutrophils. Compared to the controls, the mitochondrial membrane potential was significantly lower in neutrophils and intracellular glutathione in monocytes. No significant differences were observed between CF and non-CF bronchiectasis patients in the oxidative stress biomarkers studied.

CONCLUSIONS

Biomarkers of oxidative stress, both in plasma and intracellular were raised in patients with bronchiectasis compared with controls. No differences were seen in the CF patients compared with the others.

Dietary intake and nutritional status in a Scandinavian adult cystic fibrosis-population compared with recommendations

BACKGROUND

Malnutrition is a well-known complication in cystic fibrosis (CF). There is good evidence that maintaining a normal body-weight correlates well with improved survival in CF. Energy intake in excess of 120% of the estimated average requirement (EAR) has been advised since 1980s.

OBJECTIVES

To investigate the nutritional intake and status in the adult Scandinavian CF-population.

SUBJECTS/METHODS

A cross-sectional multi-centre study was used to investigate the nutritional status of 456 adult CF-patients (2003 2006). Height and weight were measured and body mass index (BMI) and z-scores were calculated. Pulmonary function was examined by dynamic spirometry. A 7-day pre-coded food record (FR) obtained energy and nutrient intake data in 180 patients.

RESULTS

The mean energy intake was 114 (SD 30.0)% of EAR and thus significantly lower than the target of 120% EAR (p< 0.001) for patients with pancreatic insufficiency (PI) (n=136). Mean BMI was 22.0 (SD 2.9), the prevalence of BMI <18 was 13% and the prevalence of BMI ≥25 was 15% (n=136). Mean BMI was 20.8 (SD 2.4) in PI-patients with FEV(1) <70% and 23.2% (SD 3.0), in PI-patients with FEV(1) ≥70%, mean difference 2.4, (95% CI: 1.5, 3.3) (p<0.001), but there was no difference in energy intake. BMI ≥18.5 and a reported energy intake <120% were revealed in 54% of the PI-patients.

CONCLUSIONS

The energy intake did not reach the recommended 120% EAR, but the prevalence of underweight was lower than reported in other studies. The recommendation may exceed the requirement for a number of CF-patients. The nutritional status must still be closely monitored and nutritional advice and intervention should be individualised and adjusted to actual needs.

[Validation of the Spanish version of the Revised Cystic Fibrosis Quality of Life Questionnaire in adolescents and adults (CFQR 14+ Spain)]

BACKGROUND

The aim of this study was to assess the validity and reliability of the Spanish version of the revised disease-specific health related quality of life questionnaire for adolescents and adults with cystic fibrosis (CFQR 14+ Spain).

METHODS

A total of 43 cystic fibrosis (CF) patients completed the CFQR 14+ Spain. Forced expiratory volume in 1 second, in percentage of predicted - FEV(1) (%)-, number of respiratory exacerbations, 6-minute walk test, Bhalla score (based on computerized tomography of the chest), fat-free mass index, body mass index (BMI), faecal fat and St George's Respiratory Questionnaire were included as measurements of health status.

RESULTS

Ten out of the twelve scales had alpha coefficients above 0.70. Test-retest correlations (Spearman) ranged from 0.49 to 0.95 and they were significant in all scales. Intraclass correlations ranged from 0.47 to 0.95 (ten out of the twelve scales were >0.70) forty out of the fifty ítems have correlations between items and scale above 0.70. All the CFQR+14 scales, except the digestive symptoms scale, discriminated significantly between patients with mild, moderate and severe disease (according to FEV(1) (%)). Other respiratory parameters also discriminated significantly between patients with mild-moderate and severe disease. Only some scales discriminated significantly between nourished and malnourished patients. All of the scales met standards for floor effects (<15% of the responders with the lowest score) but not for ceiling effects (only five out of the twelve).

CONCLUSION

The Spanish CFQR14+ (Spain) is a reliable and valid instrument for measuring the health-related quality of life in Spanish adolescents and adults with CF, though with the exception of a few of its subscales.