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Mezzomo TR, Dias MRMG, Santos T, Pereira RM. Dietary intake in individuals with phenylketonuria: an integrative review. NUTR HOSP 2024; 41:212-223. [PMID: 37705455 DOI: 10.20960/nh.04579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023] Open
Abstract
Introduction Introduction: the dietary intake of individuals with phenylketonuria (PKU) may vary widely according to different cultural eating habits, lifestyle, access to multidisciplinary team, and metabolic formulas available. Thus, knowing the dietary intake of this population makes it possible to tailor nutritional treatment strategies to impact their health. Objective: to analyze the evidence on the dietary intake of individuals with PKU. Methods: an integrative literature review was conducted on the dietary intake of individuals with PKU in the databases PUBMED, BIREME and Science Direct. Original articles that addressed the energy and macronutrient food intake of children, adolescents and/or adults with PKU were included in the study, without time restriction, in any language. A total of 384 articles were found and 27 articles were selected and analyzed. Results: evidence about the nutritional composition of their diet showed that individuals with PKU consume between 1160-2721 kcal of energy -7.2-17.4 % (32.4-76.9 g) of energy as protein, 45.9-69.2 % of energy as carbohydrates, 16.6-39 % of energy as lipids- and between 7.6 and 20 g of fiber. Conclusion: most individuals with PKU have low energy, protein and fiber intake, adequate lipid intake, and high carbohydrate intake. Metabolic control of the disease is still a challenge in all countries. Nutritional strategies to improve dietary nutritional composition and phenylalanine blood levels in individuals with PKU remain an urgent issue.
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Affiliation(s)
- Thais Regina Mezzomo
- Graduate Master's and Doctoral Program in Child and Adolescent Health. University Federal of Parana
| | | | | | - Rosana Marques Pereira
- Pos-Graduate Master's and Doctoral Program in Child and Adolescent Health. University Federal of Parana
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2
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Lim JY, Amit N, Ali NM, Leong HY, Mohamad M, Rajikan R. Effect of nutritional intervention on nutritional status among children with disorders of amino acid and nitrogen metabolism (AANMDs): A scoping review. Intractable Rare Dis Res 2021; 10:246-256. [PMID: 34877236 PMCID: PMC8630465 DOI: 10.5582/irdr.2021.01124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 12/15/2022] Open
Abstract
Disorders of amino acid and nitrogen metabolism (AANMDs) occur due to an enzyme deficiency in a normal biochemical pathway. Nutritional intervention is recognized as the mainstay of treatment for children diagnosed with AANMD. Hence, this scoping review aimed to identify the nutritional interventions available in managing AANMD disorders and their effects on nutritional status. A systematic search using PRISMA Extension for Scoping Reviews (PRISMA-ScR) method was conducted across 4 databases: PubMed, ScienceDirect (Elsevier), EBSCOhost and Cochrane Central Register of Controlled Trials (CENTRAL). Inclusion criteria for the study to be selected are: subjects aged less than 18-year-old, article published in English, utilized an experimental design and published within the past 20 years. A total of 22 articles were included in this review. The majority of the subjects are boys (55.6%) and employed a randomized controlled trial (RCT) study design (45.4%). Nutritional interventions were categorized into 4 categories which are: "protein substitute" (n = 5), "protein substitute with modified composition" (n = 6), "nutrient supplementation (n=8)", and "distribution and dosage of protein substitute (n = 3)". The most frequently assessed outcomes were biochemical parameters that gauge the effectiveness of metabolic control (68.2%). Overall, "protein substitute enriched with inhibitive amino acids", "long-chain polyunsaturated fatty acids supplementation", and "evenly distributed protein substitute" demonstrated beneficial effects towards the nutritional status, especially in terms of biochemical parameters. In summary, nutritional intervention plays a significant role in improving the nutritional status of AANMD patients. Further investigations of nutritional intervention among AANMD children using a meta-analysis approach are necessary for better comprehension of their impact in management of AANMD disorders.
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Affiliation(s)
- Jing Ying Lim
- Dietetics Program & Centre of Healthy Aging and Wellness (H-Care), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Noh Amit
- Clinical Psychology and Behavioural Health Program & Center for Community Health Studies (ReaCH), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Nazlena Mohamad Ali
- Institute of IR4.0 (IIR4.0), Universiti Kebangsaan Malaysia, Bangi, Selangor, Malaysia
| | - Huey Yin Leong
- Genetics Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Maslina Mohamad
- Dietetics & Food Service Department, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Roslee Rajikan
- Dietetics Program & Centre of Healthy Aging and Wellness (H-Care), Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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3
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Guerra IMS, Diogo L, Pinho M, Melo T, Domingues P, Domingues MR, Moreira ASP. Plasma Phospholipidomic Profile Differs between Children with Phenylketonuria and Healthy Children. J Proteome Res 2021; 20:2651-2661. [PMID: 33819046 DOI: 10.1021/acs.jproteome.0c01052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Phenylketonuria (PKU) is a disease of the catabolism of phenylalanine (Phe), caused by an impaired function of the enzyme phenylalanine hydroxylase. Therapeutics is based on the restriction of Phe intake, which mostly requires a modification of the diet. Dietary restrictions can lead to imbalances in specific nutrients, including lipids. In the present study, the plasma phospholipidome of PKU and healthy children (CT) was analyzed by hydrophilic interaction liquid chromatography-tandem mass spectrometry and gas chromatography-mass spectrometry. Using this approach, 187 lipid species belonging to nine different phospholipid classes and three ceramides were identified. Principal component analysis of the lipid species data set showed a distinction between PKU and CT groups. Univariate analysis revealed that 146 species of phospholipids were significantly different between both groups. Lipid species showing significant variation included phosphatidylcholines, containing polyunsaturated fatty acids (PUFA), which were more abundant in PKU. The high level of PUFA-containing lipid species in children with PKU may be related to a diet supplemented with PUFA. This study was the first report comparing the plasma polar lipidome of PKU and healthy children, highlighting that the phospholipidome of PKU children is significantly altered compared to CT. However, further studies with larger cohorts are needed to clarify whether these changes are specific to phenylketonuric children.
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Affiliation(s)
- Inês M S Guerra
- Mass Spectrometry Center, LAQV-REQUIMTE, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
| | - Luísa Diogo
- Reference Center of Inherited Metabolic Diseases, Hospital Pediátrico, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal
| | - Marisa Pinho
- ECOMARE, CESAM-Center for Environmental and Marine Studies, Department of Biology, University of Aveiro, Campus de Santiago, 3810-193 Aveiro, Portugal
| | - Tânia Melo
- Mass Spectrometry Center, LAQV-REQUIMTE, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.,CESAM-Centre for Environmental and Marine Studies, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
| | - Pedro Domingues
- Mass Spectrometry Center, LAQV-REQUIMTE, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
| | - M Rosário Domingues
- Mass Spectrometry Center, LAQV-REQUIMTE, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.,CESAM-Centre for Environmental and Marine Studies, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
| | - Ana S P Moreira
- Mass Spectrometry Center, LAQV-REQUIMTE, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal.,CICECO-Aveiro Institute of Materials, Department of Chemistry, University of Aveiro, Campus Universitário de Santiago, 3810-193 Aveiro, Portugal
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4
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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] [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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5
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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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6
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Lipids and phenylketonuria: Current evidences pointed the need for lipidomics studies. Arch Biochem Biophys 2020; 688:108431. [DOI: 10.1016/j.abb.2020.108431] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/06/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
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7
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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] [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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8
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Demmelmair H, MacDonald A, Kotzaeridou U, Burgard P, Gonzalez-Lamuno D, Verduci E, Ersoy M, Gokcay G, Alyanak B, Reischl E, Müller-Felber W, Faber FL, Handel U, Paci S, Koletzko B. Determinants of Plasma Docosahexaenoic Acid Levels and Their Relationship to Neurological and Cognitive Functions in PKU Patients: A Double Blind Randomized Supplementation Study. Nutrients 2018; 10:nu10121944. [PMID: 30544518 PMCID: PMC6316534 DOI: 10.3390/nu10121944] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/07/2018] [Accepted: 11/30/2018] [Indexed: 01/03/2023] Open
Abstract
Children with phenylketonuria (PKU) follow a protein restricted diet with negligible amounts of docosahexaenoic acid (DHA). Low DHA intakes might explain subtle neurological deficits in PKU. We studied whether a DHA supply modified plasma DHA and neurological and intellectual functioning in PKU. In a double-blind multicentric trial, 109 PKU patients were randomized to DHA doses from 0 to 7 mg/kg&day for six months. Before and after supplementation, we determined plasma fatty acid concentrations, latencies of visually evoked potentials, fine and gross motor behavior, and IQ. Fatty acid desaturase genotypes were also determined. DHA supplementation increased plasma glycerophospholipid DHA proportional to dose by 0.4% DHA per 1 mg intake/kg bodyweight. Functional outcomes were not associated with DHA status before and after intervention and remained unchanged by supplementation. Genotypes were associated with plasma arachidonic acid levels and, if considered together with the levels of the precursor alpha-linolenic acid, also with DHA. Functional outcomes and supplementation effects were not significantly associated with genotype. DHA intakes up to 7 mg/kg did not improve neurological functions in PKU children. Nervous tissues may be less prone to low DHA levels after infancy, or higher doses might be required to impact neurological functions. In situations of minimal dietary DHA, endogenous synthesis of DHA from alpha-linolenic acid could relevantly contribute to DHA status.
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Affiliation(s)
- Hans Demmelmair
- Division Metabolic and Nutritional Medicine, LMU-Ludwig-Maximilians-Universität Munich, Dr. von Hauner Children's Hospital, 80337 Munich, Germany.
| | | | - Urania Kotzaeridou
- Division of Neuropediatrics and Metabolic Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany.
| | - Peter Burgard
- Division of Neuropediatrics and Metabolic Medicine, Heidelberg University Hospital, 69120 Heidelberg, Germany.
| | | | - Elvira Verduci
- Department of Pediatrics, San Paolo Hospital Milano, 20142 Milano, Italy.
| | - Melike Ersoy
- Department of Pediatric Nutrition and Metabolism, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey.
| | - Gulden Gokcay
- Department of Pediatric Nutrition and Metabolism, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey.
| | - Behiye Alyanak
- Department of Child Psychiatry, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey.
| | - Eva Reischl
- Research Unit of Molecular Epidemiology, Institute of Epidemiology, Helmholtz Zentrum München, 85764 Neuherberg, Germany.
| | - Wolfgang Müller-Felber
- Division Metabolic and Nutritional Medicine, LMU-Ludwig-Maximilians-Universität Munich, Dr. von Hauner Children's Hospital, 80337 Munich, Germany.
| | - Fabienne Lara Faber
- Division Metabolic and Nutritional Medicine, LMU-Ludwig-Maximilians-Universität Munich, Dr. von Hauner Children's Hospital, 80337 Munich, Germany.
| | - Uschi Handel
- Division Metabolic and Nutritional Medicine, LMU-Ludwig-Maximilians-Universität Munich, Dr. von Hauner Children's Hospital, 80337 Munich, Germany.
| | - Sabrina Paci
- Department of Pediatrics, San Paolo Hospital Milano, 20142 Milano, Italy.
| | - Berthold Koletzko
- Division Metabolic and Nutritional Medicine, LMU-Ludwig-Maximilians-Universität Munich, Dr. von Hauner Children's Hospital, 80337 Munich, Germany.
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9
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Exploring Drivers of Liking of Low-Phenylalanine Products in Subjects with Phenyilketonuria Using Check-All-That-Apply Method. Nutrients 2018; 10:nu10091179. [PMID: 30154357 PMCID: PMC6165379 DOI: 10.3390/nu10091179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 01/30/2023] Open
Abstract
The aim of the present study was to apply the Check-all-that-apply (CATA) method in an ambulatory context involving subjects with phenylketonuria (PKU) to obtain a sensory description and to find the drivers of liking of low-phenylalanine products (Glycomacropeptide vs. L-amino acids formulas). 86 subjects with PKU (age range: 8–55 years) evaluated 8 samples: 4 L-amino acid formulas and 4 Glycomacropeptide (GMP) formulas, flavored with neutral, chocolate, strawberry and tomato aromas. Participants were asked to indicate which sensory attributes characterized each formulations and to score the overall liking. Significant differences were found regarding liking scores (F = 65.29; p < 0.001). GMP samples flavored with chocolate and strawberry, described as sweets, with a mild and natural taste and odor, were the most appreciated. Overall, GMP formulas obtained higher liking scores compared to L-amino acid formulas. Tomato flavored samples, described as bitter, salty, with artificial color, with strong taste and odor, obtained the lowest scores. In conclusion, CATA questionnaire seems to be a suitable method also in ambulatory context since this approach suggested that different foods and beverages with GMP could be developed to improve dietary treatment compliance of subjects with PKU from school age onwards.
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10
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Alptekin IM, Koc N, Gunduz M, Cakiroglu FP. The impact of phenylketonuria on PKU patients' quality of life: Using of the phenylketonuria-quality of life (PKU-QOL) questionnaires. Clin Nutr ESPEN 2018; 27:79-85. [PMID: 30144897 DOI: 10.1016/j.clnesp.2018.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 06/14/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND & AIMS Phenylketonuria (PKU) has a very high prevalence throughout the world. Nowadays, number of studies about impact of this metabolic disease on patients increasing. The aim of our study is to examine PKU patients' quality of life according to PKU-QOL questionnaires. METHODS Patients (n = 63) diagnosed with PKU were included this study; child (9-11 years (n = 20)), adolescent (12-15 years (n = 22)) and adult (18-35 years (n = 21)). PKU-QOL questionnaires (include 4 modules) developed for PKU patients were used. In accordance with purpose, data were analysed by nonparametric tests (Kruskal Wallis One-Way Analysis of Variance Test and Mann-Whitney U Test), according to results of normality tests. RESULTS Most of the individuals were female (65,1%) and mean age was 15,7 ± 6,4 years. Symptoms; there were statistically significant differences in all domains excluding tiredness. Especially, median score of slow thinking was very frequent symptom in children as 100,0. PKU in general; there were found that median scores were higher in children. Phe-free amino acid supplement administration: as the age increased, scores were lower. Dietary protein restriction: Overall difficulty following dietary protein restriction and Food enjoyment were found similar in groups (p > 0,05). CONCLUSIONS It was concluded that PKU affects younger people more negatively.
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Affiliation(s)
- Ismail Mucahit Alptekin
- Ankara University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Turkey.
| | - Nevra Koc
- Ankara Hematology Oncology Children's Training and Research Hospital, Department of Metabolism, Turkey
| | - Mehmet Gunduz
- Ankara Hematology Oncology Children's Training and Research Hospital, Department of Metabolism, Turkey
| | - Funda Pinar Cakiroglu
- Ankara University, Faculty of Health Sciences, Department of Nutrition and Dietetics, Turkey
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11
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Verduci E, Banderali G, Moretti F, Lassandro C, Cefalo G, Radaelli G, Salvatici E, Giovannini M. Diet in children with phenylketonuria and risk of cardiovascular disease: A narrative overview. Nutr Metab Cardiovasc Dis 2016; 26:171-177. [PMID: 26708644 DOI: 10.1016/j.numecd.2015.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 09/18/2015] [Accepted: 10/11/2015] [Indexed: 02/03/2023]
Abstract
AIMS The aim of this paper is to review the possible relationship of restricted phenylalanine (Phe) diet, a diet primarily comprising low-protein foods and Phe-free protein substitutes, with major cardiovascular risk factors (overweight/obesity, blood lipid profile, plasma levels of homocysteine, adiponectin and free asymmetric dimethylarginine (ADMA), oxidative stress and blood pressure) in PKU children. DATA SYNTHESIS In PKU children compliant with diet, blood total cholesterol, low-density lipoprotein cholesterol (LDL-C), plasma ADMA levels and diastolic pressure were reported to be lower and plasma adiponectin levels to be higher compared to healthy controls. No difference was observed in overweight prevalence and in high-density lipoprotein cholesterol (HDL-C) levels. Inconsistent results were found for plasma homocysteine levels and antioxidant status. CONCLUSIONS PKU children compliant with diet seem to display non-different cardiovascular risks compared with the healthy population. Well-designed longitudinal studies are required to clarify the potential underlying mechanisms associated with PKU and cardiovascular risk factors.
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Affiliation(s)
- E Verduci
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - G Banderali
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - F Moretti
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - C Lassandro
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - G Cefalo
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - G Radaelli
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - E Salvatici
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
| | - M Giovannini
- Department of Pediatrics, San Paolo Hospital, Department of Health Science, University of Milan, Via A. Di Rudinì 8, I-20142 Milan, Italy.
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Abstract
BACKGROUND Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low-phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24-hour period is unclear, and there is variation in recommendations among treatment centres. This is an update of a Cochrane review first published in 2005, and previously updated in 2008. OBJECTIVES To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low-phenylalanine diet. SEARCH METHODS We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine-free and low-phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials.Date of the most recent search of the Group's Inborn Errors of Metabolism Trials Register: 03 April 2014. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed trial quality. MAIN RESULTS Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators will be contacted for further information. AUTHORS' CONCLUSIONS No conclusions could be drawn about the short- or long-term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care.
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Affiliation(s)
- Sarah HL Yi
- Emory Genetics Metabolic Nutrition Program2165 N. Decatur RoadDecaturGeorgiaUSA30033
| | - Rani H Singh
- Emory University School of MedicineDepartment of Human Genetics2165 North Decatur RoadDecaturGeorgiaUSA30033
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Camp KM, Parisi MA, Acosta PB, Berry GT, Bilder DA, Blau N, Bodamer OA, Brosco JP, Brown CS, Burlina AB, Burton BK, Chang CS, Coates PM, Cunningham AC, Dobrowolski SF, Ferguson JH, Franklin TD, Frazier DM, Grange DK, Greene CL, Groft SC, Harding CO, Howell RR, Huntington KL, Hyatt-Knorr HD, Jevaji IP, Levy HL, Lichter-Konecki U, Lindegren ML, Lloyd-Puryear MA, Matalon K, MacDonald A, McPheeters ML, Mitchell JJ, Mofidi S, Moseley KD, Mueller CM, Mulberg AE, Nerurkar LS, Ogata BN, Pariser AR, Prasad S, Pridjian G, Rasmussen SA, Reddy UM, Rohr FJ, Singh RH, Sirrs SM, Stremer SE, Tagle DA, Thompson SM, Urv TK, Utz JR, van Spronsen F, Vockley J, Waisbren SE, Weglicki LS, White DA, Whitley CB, Wilfond BS, Yannicelli S, Young JM. Phenylketonuria Scientific Review Conference: state of the science and future research needs. Mol Genet Metab 2014; 112:87-122. [PMID: 24667081 DOI: 10.1016/j.ymgme.2014.02.013] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 01/17/2023]
Abstract
New developments in the treatment and management of phenylketonuria (PKU) as well as advances in molecular testing have emerged since the National Institutes of Health 2000 PKU Consensus Statement was released. An NIH State-of-the-Science Conference was convened in 2012 to address new findings, particularly the use of the medication sapropterin to treat some individuals with PKU, and to develop a research agenda. Prior to the 2012 conference, five working groups of experts and public members met over a 1-year period. The working groups addressed the following: long-term outcomes and management across the lifespan; PKU and pregnancy; diet control and management; pharmacologic interventions; and molecular testing, new technologies, and epidemiologic considerations. In a parallel and independent activity, an Evidence-based Practice Center supported by the Agency for Healthcare Research and Quality conducted a systematic review of adjuvant treatments for PKU; its conclusions were presented at the conference. The conference included the findings of the working groups, panel discussions from industry and international perspectives, and presentations on topics such as emerging treatments for PKU, transitioning to adult care, and the U.S. Food and Drug Administration regulatory perspective. Over 85 experts participated in the conference through information gathering and/or as presenters during the conference, and they reached several important conclusions. The most serious neurological impairments in PKU are preventable with current dietary treatment approaches. However, a variety of more subtle physical, cognitive, and behavioral consequences of even well-controlled PKU are now recognized. The best outcomes in maternal PKU occur when blood phenylalanine (Phe) concentrations are maintained between 120 and 360 μmol/L before and during pregnancy. The dietary management treatment goal for individuals with PKU is a blood Phe concentration between 120 and 360 μmol/L. The use of genotype information in the newborn period may yield valuable insights about the severity of the condition for infants diagnosed before maximal Phe levels are achieved. While emerging and established genotype-phenotype correlations may transform our understanding of PKU, establishing correlations with intellectual outcomes is more challenging. Regarding the use of sapropterin in PKU, there are significant gaps in predicting response to treatment; at least half of those with PKU will have either minimal or no response. A coordinated approach to PKU treatment improves long-term outcomes for those with PKU and facilitates the conduct of research to improve diagnosis and treatment. New drugs that are safe, efficacious, and impact a larger proportion of individuals with PKU are needed. However, it is imperative that treatment guidelines and the decision processes for determining access to treatments be tied to a solid evidence base with rigorous standards for robust and consistent data collection. The process that preceded the PKU State-of-the-Science Conference, the conference itself, and the identification of a research agenda have facilitated the development of clinical practice guidelines by professional organizations and serve as a model for other inborn errors of metabolism.
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Affiliation(s)
- Kathryn M Camp
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Melissa A Parisi
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | - Gerard T Berry
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Deborah A Bilder
- Department of Psychiatry, University of Utah, Salt Lake City, UT 84108, USA.
| | - Nenad Blau
- University Children's Hospital, Heidelberg, Germany; University Children's Hospital, Zürich, Switzerland.
| | - Olaf A Bodamer
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | - Jeffrey P Brosco
- University of Miami Mailman Center for Child Development, Miami, FL 33101, USA.
| | | | | | - Barbara K Burton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA.
| | - Christine S Chang
- Agency for Healthcare Research and Quality, Rockville, MD 20850, USA.
| | - Paul M Coates
- Office of Dietary Supplements, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Amy C Cunningham
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - John H Ferguson
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | | | | | - Dorothy K Grange
- Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO 63110, USA.
| | - Carol L Greene
- University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Stephen C Groft
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Cary O Harding
- Oregon Health & Science University, Portland, OR 97239, USA.
| | - R Rodney Howell
- University of Miami Miller School of Medicine, Miami, FL 33136, USA.
| | | | - Henrietta D Hyatt-Knorr
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Indira P Jevaji
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD 20817, USA.
| | - Harvey L Levy
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Uta Lichter-Konecki
- George Washington University, Children's National Medical Center, Washington, DC 20010, USA.
| | | | | | | | | | - Melissa L McPheeters
- Vanderbilt Evidence-based Practice Center, Institute for Medicine and Public Health, Nashville, TN 37203, USA.
| | - John J Mitchell
- McGill University Health Center, Montreal, Quebec H3H 1P3, Canada.
| | - Shideh Mofidi
- Maria Fareri Children's Hospital of Westchester Medical Center, Valhalla, NY 10595, USA.
| | - Kathryn D Moseley
- University of Southern California Keck School of Medicine, Los Angeles, CA 90033, USA.
| | - Christine M Mueller
- Office of Orphan Products Development, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Andrew E Mulberg
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Lata S Nerurkar
- Office of Rare Diseases Research, National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20982, USA.
| | - Beth N Ogata
- University of Washington, Seattle, WA 98195, USA.
| | - Anne R Pariser
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD 20993, USA.
| | - Suyash Prasad
- BioMarin Pharmaceutical Inc., San Rafael, CA 94901, USA.
| | - Gabriella Pridjian
- Tulane University Medical School, Hayward Genetics Center, New Orleans, LA 70112, USA.
| | | | - Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | | | | | - Sandra M Sirrs
- Vancouver General Hospital, University of British Columbia, Vancouver V5Z 1M9, Canada.
| | | | - Danilo A Tagle
- National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Susan M Thompson
- The Children's Hospital at Westmead, Sydney, NSW 2145, Australia.
| | - Tiina K Urv
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Jeanine R Utz
- University of Minnesota, Minneapolis, MN 55455, USA.
| | - Francjan van Spronsen
- University of Groningen, University Medical Center of Groningen, Beatrix Children's Hospital, Netherlands.
| | - Jerry Vockley
- University of Pittsburgh, Pittsburgh, PA 15224, USA.
| | - Susan E Waisbren
- Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Linda S Weglicki
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD 20892, USA.
| | - Desirée A White
- Department of Psychology, Washington University, St. Louis, MO 63130, USA.
| | | | - Benjamin S Wilfond
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA 98101, USA.
| | | | - Justin M Young
- The Young Face, Facial Plastic and Reconstructive Surgery, Cumming, GA 30041, USA.
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Singh RH, Rohr F, Frazier D, Cunningham A, Mofidi S, Ogata B, Splett PL, Moseley K, Huntington K, Acosta PB, Vockley J, Van Calcar SC. Recommendations for the nutrition management of phenylalanine hydroxylase deficiency. Genet Med 2014; 16:121-31. [PMID: 24385075 PMCID: PMC3918542 DOI: 10.1038/gim.2013.179] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 10/16/2013] [Indexed: 11/09/2022] Open
Abstract
The effectiveness of a phenylalanine-restricted diet to improve the outcome of individuals with phenylalanine hydroxylase deficiency (OMIM no. 261600) has been recognized since the first patients were treated 60 years ago. However, the treatment regime is complex, costly, and often difficult to maintain for the long term. Improvements and refinements in the diet for phenylalanine hydroxylase deficiency have been made over the years, and adjunctive therapies have proven to be successful for certain patients. Yet evidence-based guidelines for managing phenylalanine hydroxylase deficiency, optimizing outcomes, and addressing all available therapies are lacking. Thus, recommendations for nutrition management were developed using evidence from peer-reviewed publications, gray literature, and consensus surveys. The areas investigated included choice of appropriate medical foods, integration of adjunctive therapies, treatment during pregnancy, monitoring of nutritional and clinical markers, prevention of nutrient deficiencies, providing of access to care, and compliance strategies. This process has not only provided assessment and refinement of current nutrition management and monitoring recommendations but also charted a direction for future studies. This document serves as a companion to the concurrently published American College of Medical Genetics and Genomics guideline for the medical treatment of phenylalanine hydroxylase deficiency.
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Affiliation(s)
- Rani H. Singh
- Division of Medical Genetics, Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fran Rohr
- Division of Genetics and Metabolism, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dianne Frazier
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Amy Cunningham
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Shideh Mofidi
- Inherited Metabolic Disease Center, Maria Fareri Children's Hospital, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Beth Ogata
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | - Kathryn Moseley
- Department of Pediatrics, University of Southern California Medical Center, Los Angeles, California, USA
| | - Kathleen Huntington
- Metabolic Clinic, Institute for Development and Disability, Oregon Health Science University, Portland, Oregon, USA
| | | | - Jerry Vockley
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Department of Human Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sandra C. Van Calcar
- Division of Genetics and Metabolism, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Lower n-3 long-chain polyunsaturated fatty acid values in patients with phenylketonuria: a systematic review and meta-analysis. Nutr Res 2013; 33:513-20. [DOI: 10.1016/j.nutres.2013.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 04/30/2013] [Accepted: 05/02/2013] [Indexed: 11/18/2022]
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Supplementierung inklusive therapeutische Formelnahrung. PÄDIATRISCHE GASTROENTEROLOGIE, HEPATOLOGIE UND ERNÄHRUNG 2013. [PMCID: PMC7498803 DOI: 10.1007/978-3-642-24710-1_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Einer der Unterschiede in der Zusammensetzung von Muttermilch und künstlichen Säuglingsnahrungen auf Kuhmilchbasis besteht im Gehalt an langkettigen mehrfach ungesättigten Fettsäuren („long chain polyunsaturated fatty acids“, LCPUFA). Die Zugabe von Nervon-, Docosapentaen- und Docosahexaensäure zu Formulamilchen wurde empfohlen (Sala-Vila et al. 2004) und inzwischen teilweise von den Herstellern umgesetzt, obwohl auch festgestellt wurde, dass dies keinen Vorteil erbringt, wenn bereits 10 % der Energie als Linolensäure und 1 % als α-Linolensäure zugeführt werden (Auestad et al. 2004).
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Yi S, Kable J, Evatt M, Singh R. A randomized, placebo-controlled, double-blind trial of supplemental docosahexaenoic acid on cognitive processing speed and executive function in females of reproductive age with phenylketonuria: A pilot study. Prostaglandins Leukot Essent Fatty Acids 2011; 85:317-27. [PMID: 22000478 PMCID: PMC4324569 DOI: 10.1016/j.plefa.2011.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Revised: 09/07/2011] [Accepted: 09/11/2011] [Indexed: 10/16/2022]
Abstract
Low blood docosahexaenoic acid (DHA) is reported in patients with phenylketonuria (PKU); however, the functional implications in adolescents and adults are unknown. This pilot study investigated the effect of supplemental DHA on cognitive performance in 33 females with PKU ages 12-47 years. Participants were randomly assigned to receive DHA (10mg/kg/day) or placebo for 4.5 months. Performance on cognitive processing speed and executive functioning tasks was evaluated at baseline and follow up. Intention-to-treat and per protocol analyses were performed. At follow up, biomarkers of DHA status were significantly higher in the DHA-supplemented group. Performance on the cognitive tasks and reported treatment-related adverse events did not differ. While no evidence of cognitive effect was seen, a larger sample size is needed to be conclusive, which may not be feasible in this population. Supplementation was a safe and effective way to increase biomarkers of DHA status (www.clinicaltrials.gov; Identifier: NCT00892554).
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Affiliation(s)
- S.H.L. Yi
- Emory University, Nutrition & Health Sciences Program of the Graduate Division of Biological & Biomedical Sciences, Atlanta, GA, United States
| | - J.A. Kable
- Emory University, School of Medicine, Department of Pediatrics, United States
| | - M.L. Evatt
- Department of Veterans Affairs Medical Center, Atlanta, GA, United States
- Emory University School of Medicine, Department of Neurology, United States
| | - R.H. Singh
- Emory University, Nutrition & Health Sciences Program of the Graduate Division of Biological & Biomedical Sciences, Atlanta, GA, United States
- Emory University School of Medicine, Department of Human Genetics, 2165 N. Decatur Road, Decatur, GA 30033, United States
- Corresponding author at: Emory University School of Medicine, Department of Human Genetics, 2165 N. Decatur Road, Decatur, GA 30033, United States. Tel.: +1 404 778 8519; fax: +1 404 778 8562. (R.H. Singh)
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Feillet F, Agostoni C. Nutritional issues in treating phenylketonuria. J Inherit Metab Dis 2010; 33:659-64. [PMID: 20151202 DOI: 10.1007/s10545-010-9043-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 11/25/2009] [Accepted: 12/22/2009] [Indexed: 11/29/2022]
Abstract
A phenylalanine (Phe)-restricted diet is the mainstay of phenylketonuria (PKU) treatment, and, in recent years, the nutritional management of PKU has become more complex in order to optimize patients' growth, development and diet compliance. Dietary restriction of Phe creates a diet similar to a vegan diet, and many of the nutritional concerns and questions applicable to vegans who wish to avoid animal products are also relevant to patients with PKU. Owing to their nutritional characteristics, breast milk and breastfeeding should be given greater consideration as a useful food in patients with PKU and in those with other inborn errors of metabolism. Further key issues for consideration include the quality of the available amino acid substitutes, the neurotrophic and neuroprotective effects of added long-chain polyunsaturated fatty acids (e.g. docosahexaenoic acid), micronutrient deficiencies, bone disease and antioxidant status. Long-term dietary guidance and monitoring of the nutritional status of patients with PKU should be part of a follow-up programme that continues for life.
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Affiliation(s)
- François Feillet
- Centre de référence des maladies héréditaires du métabolisme de Nancy, INSERM U 954, Hôpital d'Enfants, CHU Brabois, Allée du Morvan, Vandoeuvre les Nancy 54500, France.
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Enns GM, Koch R, Brumm V, Blakely E, Suter R, Jurecki E. Suboptimal outcomes in patients with PKU treated early with diet alone: revisiting the evidence. Mol Genet Metab 2010; 101:99-109. [PMID: 20678948 DOI: 10.1016/j.ymgme.2010.05.017] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 05/27/2010] [Accepted: 05/28/2010] [Indexed: 11/22/2022]
Abstract
BACKGROUND The National Institute of Health (NIH) published a Consensus Statement on the screening and management of Phenylketonuria (PKU) in 2000. The panel involved in the development of this consensus statement acknowledged the lack of data regarding the potential for more subtle suboptimal outcomes and the need for further research into treatment options. In subsequent years, the approval of new treatment options for PKU and outcome data for patients treated from the newborn period by dietary therapy alone have become available. We hypothesized that a review of the PKU literature since 2000 would provide further evidence related to neurocognitive, psychosocial, and physical outcomes that could serve as a basis for reassessment of the 2000 NIH Consensus Statement. METHODS A systematic review of literature residing in PubMed, Scopus and PsychInfo was performed in order to assess the outcome data over the last decade in diet-alone early-treated PKU patients to assess the need for new recommendations and validity of older recommendations in light of new evidence. RESULTS The majority of publications (140/150) that contained primary outcome data presented at least one suboptimal outcome compared to control groups or standardized norms/reference values in at least one of the following areas: neurocognitive/psychosocial (N=60; 58 reporting suboptimal outcomes); quality of life (N=6; 4 reporting suboptimal outcomes); brain pathology (N=32; 30 reporting suboptimal outcomes); growth/nutrition (N=34; 29 reporting suboptimal outcomes); bone pathology (N=9; 9 reporting suboptimal outcomes); and/or maternal PKU (N=19; 19 reporting suboptimal outcomes). CONCLUSIONS Despite the remarkable success of public health programs that have instituted newborn screening and early introduction of dietary therapy for PKU, there is a growing body of evidence that suggests that neurocognitive, psychosocial, quality of life, growth, nutrition, bone pathology and maternal PKU outcomes are suboptimal. The time may be right for revisiting the 2000 NIH Consensus Statement in order to address a number of important issues related to PKU management, including treatment advancements for metabolic control in PKU, blood Phe variability, neurocognitive and psychological assessments, routine screening measures for nutritional biomarkers, and bone pathology.
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Affiliation(s)
- G M Enns
- Division of Medical Genetics, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Stanford, CA 94305-5208,USA.
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Fekete K, Decsi T. Long-chain polyunsaturated fatty acids in inborn errors of metabolism. Nutrients 2010; 2:965-74. [PMID: 22254065 PMCID: PMC3257717 DOI: 10.3390/nu2090965] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 09/06/2010] [Accepted: 09/13/2010] [Indexed: 11/16/2022] Open
Abstract
The treatment of children with inborn errors of metabolism (IEM) is mainly based on restricted dietary intake of protein-containing foods. However, dietary protein restriction may not only reduce amino acid intake, but may be associated with low intake of polyunsaturated fatty acids as well. This review focuses on the consequences of dietary restriction in IEM on the bioavailability of long-chain polyunsaturated fatty acids (LCPUFAs) and on the attempts to ameliorate these consequences. We were able to identify during a literature search 10 observational studies investigating LCPUFA status in patients with IEM and six randomized controlled trials (RCTs) reporting effect of LCPUFA supplementation to the diet of children with IEM. Decreased LCPUFA status, in particular decreased docosahexaenoic acid (DHA) status, has been found in patients suffering from IEM based on the evidence of observational studies. LCPUFA supplementation effectively improves DHA status without detectable adverse reactions. Further research should focus on functional outcomes of LCPUFA supplementation in children with IEM.
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Affiliation(s)
- Katalin Fekete
- Department of Pediatrics, University of Pécs, József A. u. 7., H-7623 Pécs, Hungary.
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21
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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 mental handicap; 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. 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 STRATEGY 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: 05 March 2009. 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.
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Affiliation(s)
- Vanessa J Poustie
- Alder Hey Children's NHS Foundation TrustInstitute of Child Health, University of LiverpoolEaton RoadLiverpoolMerseysideUKL12 2AP
| | - Joanne Wildgoose
- Bradford Royal InfirmaryPhysio Corridor, Level 1Duckworth LaneBradfordUKBD9 6RJ
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Koletzko B, Beblo S, Demmelmair H, Müller-Felber W, Hanebutt FL. Does dietary DHA improve neural function in children? Observations in phenylketonuria. Prostaglandins Leukot Essent Fatty Acids 2009; 81:159-64. [PMID: 19615874 DOI: 10.1016/j.plefa.2009.06.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Children with phenylketonuria (PKU) have a restricted protein intake and thus low dietary intakes of long-chain polyunsaturated fatty acids (LC-PUFA), which may cause subtle neurological deficits. We measured plasma phospholipid fatty acids and visual evoked potential (VEP) in 36 children with well-controlled PKU (6.3+/-0.6 years, 19 girls), before and after 3 months of supplementing fish oil capsules providing 15 mg docosahexaenoic acid (DHA)/kg daily. The motometric Rostock-Oseretzky Scale (ROS) was performed before and after supplementation in the 24 PKU children aged >4 years. VEP latencies and ROS were also assessed in omnivorous, age-matched controls without fish oil supply at baseline and after 3 months. Fish oil supply increased plasma phospholipid eicosapentaenoic acid (EPA) (0.40+/-0.03 vs 3.31+/-0.19%, p<0.001) and DHA (2.37+/-0.10 vs 7.05+/-0.24%, p<0.001), but decreased arachidonic acid (AA) (9.26+/-0.23 vs 6.76+/-0.16%, p<0.001). Plasma phenylalanine was unchanged. VEP latencies and ROS results significantly improved after fish oil in PKU children, but remained unchanged in controls. The improvements of VEP latencies, fine motor and coordination skills indicate that preformed n-3 LC-PUFA are needed for neural normalcy in PKU children. The optimal type and dose of supply still needs to be determined. Since PKU children are generally healthy and have normal energy and fatty acid metabolism, these data lead us to conclude that childhood populations in general require preformed n-3 LC-PUFA to achieve optimal neurological function.
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Affiliation(s)
- Berthold Koletzko
- Division of Metabolic Diseases and Nutritional Medicine, Dr. von Hauner Children's Hospital, University of Munich Medical Centre, Lindwurmstr. 4, 80337 Munich, Germany.
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Ahring K, Bélanger-Quintana A, Dokoupil K, Gokmen Ozel H, Lammardo AM, MacDonald A, Motzfeldt K, Nowacka M, Robert M, van Rijn M. Dietary management practices in phenylketonuria across European centres. Clin Nutr 2009; 28:231-6. [PMID: 19362397 DOI: 10.1016/j.clnu.2009.03.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 03/06/2009] [Accepted: 03/15/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dietary phenylalanine restriction is the cornerstone of phenylketonuria (PKU) management. However, there are no European consensus guidelines for its optimal dietary care. METHODS Detailed information on the routine dietary management of PKU was obtained from 10 European centres using structured questionnaires. Each centre was represented by one dietitian/nutritionist or physician (European Nutritionist Expert Panel). RESULTS All centres screened for PKU within the first 10 days of life. PKU prevalence was highest in Turkey. The training, roles and responsibilities of dietitians and nutritionists varied widely; in some centres dietitians were responsible for managing the diet, while in others this was performed by a physician. There were marked differences in target blood phenylalanine concentrations, the dosages of protein substitutes, systems for allocating daily phenylalanine allowance, and the definition of foods that could be eaten without restriction ('free foods'). Eighty percent (n=8/10) of centres encouraged breastfeeding together with protein substitute in infants with PKU. CONCLUSIONS Important differences exist among centres across Europe in the dietary management of PKU, and in support systems designed to assist patients in managing their diets. Further studies are needed to compare different dietary treatments with the aim of identifying best practice to optimise phenylalanine control and dietary adherence.
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Abstract
BACKGROUND Phenylketonuria is an inherited metabolic disorder characterised by an absence or deficiency of the enzyme phenylalanine hydroxylase. The aim of treatment is to lower blood phenylalanine concentrations to the recommended therapeutic range to prevent developmental delay and support normal growth. Current treatment consists of a low-phenylalanine diet in combination with a protein substitute which is free from or low in phenylalanine. Guidance regarding the use, dosage, and distribution of dosage of the protein substitute over a 24-hour period is unclear, and there is variation in recommendations among treatment centres. OBJECTIVES To assess the benefits and adverse effects of protein substitute, its dosage, and distribution of dose in children and adults with phenylketonuria who are adhering to a low-phenylalanine diet. SEARCH STRATEGY We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register which consists of references identified from comprehensive electronic database searches and hand searches of relevant journals and abstract books of conference proceedings. We also contacted manufacturers of the phenylalanine-free and low-phenylalanine protein substitutes for any data from published and unpublished randomised controlled trials.Date of the most recent search of the Group's Trials Register: April 2008. SELECTION CRITERIA All randomised or quasi-randomised controlled trials comparing: any dose of protein substitute with no protein substitute; an alternative dosage; or the same dose, but given as frequent small doses throughout the day compared with the same total daily dose given as larger boluses less frequently. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed trial quality. MAIN RESULTS Three trials (69 participants) are included in this review. One trial investigated the use of protein substitute in 16 participants, while a further two trials investigated the dosage of protein substitute in a total of 53 participants. Due to issues with data presentation in each trial, described in full in the review, formal statistical analyses of the data were impossible. Investigators are being contacted for further information. AUTHORS' CONCLUSIONS No conclusions could be drawn about the short- or long-term use of protein substitute in phenylketonuria due to the lack of adequate or analysable trial data. Additional data and randomised controlled trials are needed to investigate the use of protein substitute in phenylketonuria. Until further evidence is available, current practice in the use of protein substitute should continue to be monitored with care.
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Affiliation(s)
- Sarah H L Yi
- Graduate Program in Nutrition & Health Sciences of the Graduate Division of Biological and Biomedical Sciences, Emory University, 2165 North Decatur Road, Decatur, Georgia 30033, USA
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Weigel C, Rauh M, Kiener C, Rascher W, Knerr I. Effects of Various Dietary Amino Acid Preparations for Phenylketonuric Patients on the Metabolic Profiles along with Postprandial Insulin and Ghrelin Responses. ANNALS OF NUTRITION AND METABOLISM 2007; 51:352-8. [PMID: 17726313 DOI: 10.1159/000107678] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Accepted: 02/13/2007] [Indexed: 11/19/2022]
Abstract
AIM We investigated the metabolic profiles along with insulin and ghrelin responses following ingestion of various amino acid (AA) substitutes commonly used in the treatment of phenylketonuria to study the effects of added macronutrients. METHODS Twenty healthy and 6 phenylketonuric adults ingested AA mixtures with or without carbohydrates and fat (Anamix, Easiphen, or p-am 3; 0.35 g AA/kg body weight); milk powder shakes were used for control purposes. Serum AA, glucose, urea, insulin, and ghrelin were measured over 5 h. RESULTS Peak AA concentrations were achieved at around 60 min postprandially for supplemented AA powders and control shakes, significantly later than for pure AA. Of interest, the mean Phe/Tyr ratio declined by 40-50% in phenylketonuric patients following intake of Easiphen, Anamix, or p-am 3. The insulin peaks, up to 500% as compared with baseline, occurred at 30 min and were approximately 100% higher after intake of AA plus macronutrients. Glucose and urea remained constant. Ghrelin showed a nadir at 60 min, followed by a rise leading to a 30% increase of initial concentrations for pure AA as compared with more constant levels for preparations with macronutrients. CONCLUSION An oral AA bolus together with macronutrients retards hyperaminoacidemia, displays a higher insulin secretion, normoglycemia, and more stable ghrelin concentrations, whereas the pure AA tested here exerted weaker anabolic effects.
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Affiliation(s)
- C Weigel
- Children and Youth Hospital, University of Erlangen-Nurnberg, Erlangen, Germany
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26
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Koletzko B, Sauerwald T, Demmelmair H, Herzog M, von Schenck U, Böhles H, Wendel U, Seidel J. Dietary long-chain polyunsaturated fatty acid supplementation in infants with phenylketonuria: a randomized controlled trial. J Inherit Metab Dis 2007; 30:326-32. [PMID: 17431817 DOI: 10.1007/s10545-007-0491-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Revised: 01/16/2007] [Accepted: 02/14/2007] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pre- and postnatal tissue accretion of long-chain polyunsaturated fatty acids (LCPUFA) has been related to visual and cognitive development in healthy children in several studies. Children with phenylketonuria (PKU) consume diets with very low contents of preformed LCPUFA. We studied prospectively the LCPUFA status in infants with PKU without or with LCPUFA supplementation during the first year of life. SUBJECTS AND METHODS Infants with PKU were enrolled at diagnosis (<4 weeks of age) and randomized double blind to phenylalanine-free amino acid supplements without LCPUFA (n = 11) or with both arachidonic (AA, 0.46 wt%) and docosahexaenoic acids (DHA, 0.27 wt%) (n = 10). At enrolment and again at 1, 2, 3, 4, 6, 9 and 12 months, plasma phospholipid fatty acids were measured and dietary intakes were calculated from dietary protocols. RESULTS Unsupplemented patients showed a marked LCPUFA depletion to levels clearly below those observed in healthy breast-fed infants. In contrast, supplemented infants had stable and higher LCPUFA levels than unsupplemented infants, reaching significant differences for AA values at 3, 4 and 6 months, and for DHA values at 1, 3, 4, 6, 9 and 12 months. Plasma phospholipid levels correlated closely with estimated dietary intakes of preformed LCPUFA. CONCLUSION Low LCPUFA intakes with PKU diets induce marked depletion of AA and particularly of DHA in the first year of life. Thus endogenous synthesis of LCPUFA from precursors supplied by diet seems unable to compensate for low LCPUFA intakes. LCPUFA supplementation of PKU diets during the first year of life effectively enhances LCPUFA status to levels comparable to those of healthy breast-fed infants.
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Affiliation(s)
- B Koletzko
- Department of Paediatrics, University of Munich, Munich, Germany.
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