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Scully KJ, Brenner L, Martin K, Ruazol M, Sawicki GS, Uluer A, Neuringer I, Yonker LM, Sicilian L, Putman MS. Continuous glucose monitoring and advanced glycation endproducts for prediction of clinical outcomes and development of cystic fibrosis-related diabetes in adults with CF. Front Endocrinol (Lausanne) 2024; 15:1293709. [PMID: 38379863 PMCID: PMC10876871 DOI: 10.3389/fendo.2024.1293709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Introductions Cystic fibrosis-related diabetes (CFRD) is associated with pulmonary decline, compromised nutritional status, and earlier mortality. Onset is often insidious, so screening for early detection of glycemic abnormalities is important. Continuous glucose monitoring (CGM) has been validated in people with CF and has been shown to detect early glycemic variability otherwise missed on 2-hour oral glucose tolerance testing (OGTT). We previously reported that CGM measures of hyperglycemia and glycemic variability are superior to hemoglobin A1c (HbA1c) in distinguishing those with and without CFRD. However, little is known about the long-term predictive value of CGM measures of glycemia for both the development of CFRD and their effect on key clinical outcomes such as weight maintenance and pulmonary function. In addition, there have been no studies investigating advanced glycation endproducts (AGE) assessed by skin autofluorescence in people with CF. Methods In this prospective observational study, CGM and HbA1c were measured at 2 to 3 time points 3 months apart in 77 adults with CF. Participants who did not have CFRD at the time of enrollment underwent OGTT at the baseline visit, and all participants had AGE readings at baseline. Follow up data including anthropometric measures, pulmonary function and CFRD status were collected by review of medical records 1- and 2-years after the baseline visits. We applied multivariable linear regression models correlating glycemic measures to change in key clinical outcomes (weight, BMI, FEV1) accounting for age, gender and elexacaftor/tezacaftor/ivacaftor (ETI) use. We also conducted logistic regression analyses comparing baseline glycemic data to development of CFRD during the 2-year follow up period. Results Of the 77 participants, 25 had pre-existing CFRD at the time of enrollment, and six participants were diagnosed with CFRD by the OGTT performed at the baseline visit. When adjusting for age, gender, and ETI use, multiple CGM measures correlated with weight and BMI decline after one year but not after two years. CGM and HbA1c at baseline did not predict decline in FEV1 (p>0.05 for all). In the 46 participants without a diagnosis of CFRD at baseline, two participants were diagnosed with CFRD over the following two years, but CGM measures at baseline did not predict progression to CFRD. Baseline AGE values were higher in individuals with CFRD and correlated with multiple measures of dysglycemia (HbA1c, AG, SD, CV, TIR, % time >140, >180, >250) as well as weight. AGE values also correlated with FEV1 decline at year 1 and weight decline at year 1 and year 2. Conclusions Several key CGM measures of hyperglycemia and glycemic variability were predictive of future decline in weight and BMI over one year in this population of adults with CF with and without CFRD. None of the baseline glycemic variables predicted progression to CFRD over 2 years. To our knowledge, this is the first report correlating AGE levels with key clinical and glycemic measures in CF. Limitations of these analyses include the small number of participants who developed CFRD (n=2) during the follow up period and the initiation of ETI by many participants, affecting their trajectory in weight and pulmonary function. These results provide additional data supporting the potential role for CGM in identifying clinically significant dysglycemia in CF. Future studies are needed to investigate CGM as a diagnostic and screening tool for CFRD and to understand the implications of AGE measures in this patient population.
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Affiliation(s)
- Kevin J. Scully
- Division of Endocrinology, Hasbro Children’s Hospital, Providence, RI, United States
| | - Laura Brenner
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Kimberly Martin
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Melanie Ruazol
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, United States
| | - Gregory S. Sawicki
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA, United States
| | - Ahmet Uluer
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA, United States
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, United States
| | - Isabel Neuringer
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Lael M. Yonker
- Division of Pediatric Pulmonary Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Leonard Sicilian
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Melissa S. Putman
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, United States
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Maliszewski G, High R, Lee J, Deschamp A. Parental Feeding Style, Parenting Stress, and Child Mealtime Behaviors in Cystic Fibrosis. J Pediatr Psychol 2024; 49:56-65. [PMID: 37944096 DOI: 10.1093/jpepsy/jsad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 11/12/2023] Open
Abstract
OBJECTIVE Nutrition and weight gain significantly contribute to overall health outcomes in children with cystic fibrosis (CF). Strong emphasis is placed on these entities by the CF team, which can cause stress for parents and impact parent and child mealtime behaviors. The current study sought to investigate the relationship between parental feeding style, parenting stress, and parent and child mealtime behaviors in families of children with CF. METHODS Forty-five parents of a child with CF between the ages of 2 and 10 years were recruited during a CF clinic appointment. They completed surveys assessing child mealtime behaviors, parental feeding style, and parental stress. Medical data including body mass index (BMI) were collected from the medical record. RESULTS There was a significant difference in behavioral feeding scores based on feeding style (F3,41 = 13.48, p <.001), with authoritarian parents reporting significantly greater mealtime behavior problems than all other parents. There was also a significant difference in parenting stress based on parental feeding style (F3,41=4.11, p <.05), with authoritarian parents showing more stress than authoritative parents (Mdiff=23.70, p <.05). Correlation analyses showed a positive relationship between behavioral feeding problems and parent stress, r(45)=0.403; p <.01. CONCLUSIONS Data suggest parents using an authoritarian feeding style experience more stress and behavioral feeding problems than other parents. More feeding problems were also associated with more stress. Findings help determine how pediatric psychologists can intervene to support positive parenting behaviors that reduce children's mealtime behavior problems and parental stress, thus improving health outcomes in this vulnerable population.
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Affiliation(s)
| | - Robin High
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Junghyae Lee
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Ashley Deschamp
- Children's Nebraska, Omaha, Nebraska, USA
- University of Nebraska Medical Center, Omaha, Nebraska, USA
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Lusman SS. Update on Cystic Fibrosis in Pediatric Patients. Curr Gastroenterol Rep 2023; 25:308-315. [PMID: 37653358 DOI: 10.1007/s11894-023-00896-3] [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] [Accepted: 08/17/2023] [Indexed: 09/02/2023]
Abstract
PURPOSE OF REVIEW Cystic fibrosis is an inherited, multisystem disease that affects the gastrointestinal system in numerous ways. This article reviews the nutritional, gastrointestinal, and hepatobiliary manifestations of cystic fibrosis with an emphasis on the effects of CFTR modulator therapy. RECENT FINDINGS The life expectancy of individuals with cystic fibrosis has increased substantially in recent years. CFTR modulator therapy improves pulmonary function and results in weight gain. An individualized approach to nutrition is encouraged. Pancreatic exocrine function may improve with intervention early in life. The use of non-invasive methods to screen for hepatobiliary involvement is recommended. Highly effective CFTR modulators lead to increased survival and improved quality of life for many individuals. Their effects on gastrointestinal symptoms and hepatobiliary disease are not fully understood. Patient-reported outcome measures and biomarkers are important clinical endpoints for studying the effects of modulators.
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Affiliation(s)
- Sarah Shrager Lusman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Irving Medical Center, 622 West 168th Street, PH 17 East - 105L, New York, NY, 10032, USA.
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Mailhot G, Denis MH, Beauchamp-Parent C, Jomphe V. Nutritional management of people living with cystic fibrosis throughout life and disease continuum: Changing times, new challenges. J Hum Nutr Diet 2023; 36:1675-1691. [PMID: 37515397 DOI: 10.1111/jhn.13214] [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] [Received: 10/31/2022] [Revised: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023]
Abstract
Cystic fibrosis (CF) is a genetic disease caused by mutations in the gene encoding for the ion channel cystic fibrosis transmembrane conductance regulator (CFTR). The management of CF disease has evolved in recent decades from treating downstream disease manifestations affecting the airways, the lungs and the gastrointestinal system to addressing the CFTR gene defect. The advent of CFTR modulators, which correct the functionality of the defective CFTR, contributes to reshaping the landscape of CF demographics, prognosis and therapies, including nutritional management. A spectrum of clinical manifestations is emerging within the same patient population where undernutrition and nutritional deficiencies coexist with excessive weight gain and metabolic derangements. Such contrasting presentations challenge current practices, require adjustments to traditional approaches, and involve more individualised interventions. This narrative review examines the current state of knowledge on the nutritional management of people living with cystic fibrosis from early life to adulthood in the era of CFTR modulation.
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Affiliation(s)
- Geneviève Mailhot
- Department of Nutrition, Faculty of Medicine, Montreal, QC, Canada
- CHU Sainte-Justine Research Center, Montreal, QC, Canada
| | | | | | - Valérie Jomphe
- Lung Transplant Program, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
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Diener BL, Huertero F, Stables-Carney T, Hoelzer M, Kier C. A new era in cystic fibrosis care: always changing and adapting. Curr Opin Pediatr 2023; 35:603-610. [PMID: 37594368 DOI: 10.1097/mop.0000000000001286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
PURPOSE OF REVIEW This review focuses on sharing the current and changing cystic fibrosis (CF) care model. This includes changes in CF care as a chronic disease with availability of new revolutionary, highly effective therapies as well as incorporation of shared decision-making, coproduction of care, quality improvement, telemedicine, and remote patient monitoring. RECENT FINDINGS Changes in the CF management, the CF patient population, and CF care team are described as well as how CF care has adapted to these changes. SUMMARY CF is a chronic, multisystem disease requiring a large specialized multidisciplinary care team for effective treatment. With improvements in CF care and new treatments, people with CF are living longer and healthier lives. As new issues arise, the CF team needs to adapt. This was highlighted by the introduction of highly effective cystic fibrosis transmembrane conductance regulator modulator therapy, which targets the cellular defect in CF, the COVID-19 pandemic, which lead to the incorporation of telehealth and remote patient monitoring into the CF care model, and the partnering with people with CF and families through shared decision-making and coproduction.
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Affiliation(s)
| | - Fredy Huertero
- Department of Pediatrics, Stony Brook Children's Hospital, Renaissance School of Medicine at Stony Brook University
| | | | - Maureen Hoelzer
- Department of Medicine, Stony Brook University Hospital, Stony Brook, New York, USA
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Downs EM, Eaton A, Witkowski P, Wijkstrom M, Walsh M, Trikudanathan G, Singh VK, Schwarzenberg SJ, Pruett TL, Posselt A, Naziruddin B, Nathan JD, Mokshagundam SP, Morgan K, Lara LF, Gardner TB, Freeman ML, Ellery K, Chinnakotla S, Beilman GJ, Adams D, Ahmad S, Abu-El-Haija M, Bellin MD. Nutritional Risks in Patients Undergoing Total Pancreatectomy Islet AutoTransplantation in the POST Consortium. J Gastrointest Surg 2023; 27:1893-1902. [PMID: 37442881 DOI: 10.1007/s11605-023-05770-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/17/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND AND AIMS Total pancreatectomy with islet autotransplantation (TPIAT) can relieve pain for individuals with acute recurrent or chronic pancreatitis. However, TPIAT may increase the risk of poor nutritional status with complete exocrine pancreatic insufficiency, partial duodenectomy, and intestinal reconstruction. Our study's objective was to evaluate nutritional status, anthropometrics, and vitamin levels before and after TPIAT. METHODS The multicenter Prospective Observational Study of TPIAT (POST) collects measures including vitamins A, D, and E levels, pancreatic enzyme dose, and multivitamin (MVI) administration before and 1-year after TPIAT. Using these data, we studied nutritional and vitamin status before and after TPIAT. RESULTS 348 TPIAT recipients were included (68% adult, 37% male, 93% Caucasian). In paired analyses at 1-year follow-up, vitamin A was low in 23% (vs 9% pre-TPIAT, p < 0.001); vitamin E was low in 11% (vs 5% pre-TPIAT, p = 0.066), and 19% had vitamin D deficiency (vs 12% pre-TPIAT, p = 0.035). Taking a fat-soluble multivitamin (pancreatic MVI) was associated with lower risk for vitamin D deficiency (p = 0.002). Adults were less likely to be on a pancreatic MVI at follow-up (34% vs 66% respectively, p < 0.001). Enzyme dosing was adequate. More adults versus children were overweight or underweight pre- and post-TPIAT. Underweight status was associated with vitamin A (p = 0.014) and E (p = 0.02) deficiency at follow-up. CONCLUSIONS Prevalence of fat-soluble vitamin deficiencies increased after TPIAT, especially if underweight. We strongly advocate that all TPIAT recipients have close post-operative nutritional monitoring, including vitamin levels. Pancreatic MVIs should be given to minimize risk of developing deficiencies.
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Affiliation(s)
- Elissa M Downs
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA.
| | - Anne Eaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Piotr Witkowski
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Martin Wijkstrom
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew Walsh
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Guru Trikudanathan
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Vikesh K Singh
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Sarah J Schwarzenberg
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA
| | - Timothy L Pruett
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrew Posselt
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Jaimie D Nathan
- Department of Pediatric Abdominal Transplant and Hepatopancreatobiliary Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Katherine Morgan
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Luis F Lara
- Department of Medicine, The Ohio State Wexner University Medical Center, Columbus, OH, USA
| | - Timothy B Gardner
- Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Martin L Freeman
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kate Ellery
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Srinath Chinnakotla
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gregory J Beilman
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David Adams
- Department of Surgery, The Medical University of South Carolina, Charleston, SC, USA
| | - Syed Ahmad
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Maisam Abu-El-Haija
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melena D Bellin
- Department of Pediatrics, University of Minnesota & Masonic Children's Hospital, 2450 Riverside Ave, Minneapolis, MN, AOB20155454, USA
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Leonard A, Bailey J, Bruce A, Jia S, Stein A, Fulton J, Helmick M, Litvin M, Patel A, Powers KE, Reid E, Sankararaman S, Clemm C, Reno K, Hempstead SE, DiMango E. Nutritional considerations for a new era: A CF foundation position paper. J Cyst Fibros 2023; 22:788-795. [PMID: 37230807 DOI: 10.1016/j.jcf.2023.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/13/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To provide interim advice and considerations to the CF Community around CF nutrition in the current era. METHODS The Cystic Fibrosis (CF) Foundation organized a multidisciplinary committee to develop a Nutrition Position Paper based on the rapidly changing nutrition landscape in CF, due in part to widespread use of cystic fibrosis transmembrane regulator highly effective modulator therapy (HEMT). Four workgroups were formed: Weight Management, Eating Behavior/Food Insecurity, Salt Homeostasis and Pancreatic Enzyme use. Each workgroup conducted their own focused review of the literature. RESULTS The committee summarized current understanding of issues pertaining to the four workgroup topics and provided 6 key take-aways around CF Nutrition in the new era. CONCLUSION People with CF (pwCF) are living longer, particularly with the advent of HEMT. The traditional high fat, high calorie CF diet may have negative nutritional and cardiovascular consequences as pwCF age. Individuals with CF may have poor diet quality, food insecurity, distorted body image, and an higher incidence of eating disorders. An increase in overweight and obesity may lead to new considerations for nutritional management, given potential effects of overnutrition on pulmonary and cardiometabolic parameters.
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Affiliation(s)
- Amanda Leonard
- The Johns Hopkins Children's Center, Baltimore, MD, United States of America.
| | - Julianna Bailey
- The University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Amanda Bruce
- University of Kansas Medical Center, Kansas City, Kansas United States of America
| | - Shijing Jia
- University of Michigan Medical School, Ann Arbor, Michigan, United States of America
| | - Adam Stein
- Northwestern Medicine, Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Judith Fulton
- Children's Hospital Colorado, Aurora, Colorado, United States of America
| | - Meagan Helmick
- Community Advisor to the Cystic Fibrosis Foundation, Bethesda, Maryland, United States of America
| | - Marina Litvin
- Division of Endocrinology, Metabolism and Lipid Research. Washington University School of Medicine. St. Louis, MO, United States of America
| | - Alpa Patel
- Nationwide Children's Hospital, Columbus Ohio, United States of America
| | - Kate E Powers
- Albany Medical Center, Albany, New York, United States of America
| | - Elizabeth Reid
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | | | - Cristen Clemm
- Cystic Fibrosis Foundation, Bethesda, Maryland United States of America
| | - Kim Reno
- Cystic Fibrosis Foundation, Bethesda, Maryland United States of America
| | - Sarah E Hempstead
- Cystic Fibrosis Foundation, Bethesda, Maryland United States of America
| | - Emily DiMango
- Columbia University Irving Medical Center, New York, New York, United States of America
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Zheng Y, Mostamand S. Nutrition in children with exocrine pancreatic insufficiency. Front Pediatr 2023; 11:943649. [PMID: 37215591 PMCID: PMC10196508 DOI: 10.3389/fped.2023.943649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a condition defined as pancreatic loss of exocrine function, including decreased digestive enzymes and bicarbonate secretion, which leads to maldigestion and malabsorption of nutrients. It is a common complication in many pancreatic disorders. If left undiagnosed, EPI can cause poor digestion of food, chronic diarrhea, severe malnutrition and related complications. Nutritional status and fat-soluble vitamins should be carefully assessed and monitored in patients with EPI. Early diagnosis of EPI is clinically important for appropriate nutritional support and initiating pancreatic enzyme replacement therapy (PERT) which could significantly improve patient outcomes. The evaluation of nutritional status and related unique management in children with EPI will be discussed in this review.
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Affiliation(s)
- Yuhua Zheng
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shikib Mostamand
- Gastroenterology, Hepatology, and Nutrition, Stanford Children’s Health & Stanford University School of Medicine, Palo Alto, CA, United States
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Psoter KJ, Dickinson KM, Riekert KA, Collaco JM. Early life growth trajectories in cystic fibrosis are associated with lung function at age six. J Cyst Fibros 2023; 22:395-401. [PMID: 36858852 PMCID: PMC10257762 DOI: 10.1016/j.jcf.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 02/11/2023] [Accepted: 02/20/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Higher growth percentiles are associated with more favorable lung function in cystic fibrosis (CF), prompting the creation of CF Foundation (CFF) nutritional guidelines. OBJECTIVES To describe early childhood growth trajectories within CF, to determine if growth trajectories are associated with differences in lung function at age six, and to identify factors that differ between trajectory groups. METHODS Retrospective cohort study of children diagnosed with CF and born 2000-2011 using the US CFF Patient Registry. Annualized growth parameters prior to age six were included in group-based trajectory modeling to identify unique early life growth trajectories. FEV1 percent predicted (FEV1pp) at age six was compared between trajectory groups using linear regression. Factors associated with group membership were identified using multinomial logistic regression. RESULTS 6,809 children met inclusion criteria. Six discrete growth trajectories were identified, including three groups that began with growth parameters >50th percentile, termed: "always high", "gradual decliner", "rapid decliner", and three which began with growth parameters <50th percentile, termed: "rapid riser", "gradual riser", "always low". FEV1pp at age six was highest for the Always High trajectory. The Always Low trajectory was nearly 10% lower than the Always High trajectory. Sex, ethnicity, newborn screening and pancreatic function were associated with trajectory class membership. CONCLUSIONS Distinct early life growth trajectories were identified within CF. Trajectories that met CFF nutritional guideline recommendations were associated with higher FEV1pp at age six. CF care teams should continue to partner with families to encourage interventions to support optimal growth to improve lung function in CF.
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Affiliation(s)
- Kevin J Psoter
- Division of General Pediatrics, Department of Pediatrics, Johns Hopkins University, Baltimore, MD.
| | - Kimberly M Dickinson
- Department of Pediatrics, Pulmonary Section, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Joseph M Collaco
- Division of Pediatric Pulmonology, Department of Pediatrics, Johns Hopkins University, Baltimore, Maryland
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10
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McGarry LJ, Bhaiwala Z, Lopez A, Chandler C, Pelligra CG, Rubin JL, Liou TG. Calibration and validation of modeled 5-year survival predictions among people with cystic fibrosis treated with the cystic fibrosis transmembrane conductance regulator modulator ivacaftor using United States registry data. PLoS One 2023; 18:e0283479. [PMID: 37043485 PMCID: PMC10096446 DOI: 10.1371/journal.pone.0283479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/09/2023] [Indexed: 04/13/2023] Open
Abstract
OBJECTIVES Cystic fibrosis (CF) is a rare genetic disease characterized by life-shortening lung function decline. Ivacaftor, a CF transmembrane conductance regulator modulator (CFTRm), was approved in 2012 for people with CF with specific gene mutations. We used real-world evidence of 5-year mortality impacts of ivacaftor in a US registry population to validate a CF disease-progression model that estimates the impact of ivacaftor on survival. METHODS The model projects the impact of ivacaftor vs. standard care in people with CF aged ≥6 years with CFTR gating mutations by combining parametric equations fitted to historical registry survival data, with mortality hazards adjusted for fixed and time-varying person-level characteristics. Disease progression with standard care was derived from published registry studies and the expected impact of ivacaftor on clinical characteristics was derived from clinical trials. Individual-level baseline characteristics of the registry ivacaftor-treated population were entered into the model; 5-year model-projected mortality with credible intervals (CrIs) was compared with registry mortality to evaluate the model's validity. RESULTS Post-calibration 5-year mortality projections closely approximated registry mortality in populations treated with standard care (6.4% modeled [95% CrI: 5.3% to 7.6%] vs. 6.0% observed) and ivacaftor (3.4% modeled [95% CrI: 2.7% to 4.4%] vs. 3.1% observed). The model accurately predicted 5-year relative risk of mortality (0.53 modeled [0.47 to 0.60] vs. 0.51 observed) in people treated with ivacaftor vs. standard care. CONCLUSIONS Modeled 5-year survival projections for people with CF initiating ivacaftor vs. standard care align closely with real-world registry data. Findings support the validity of modeling CF to predict long-term survival and estimate clinical and economic outcomes of CFTRm.
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Affiliation(s)
- Lisa J. McGarry
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Zahra Bhaiwala
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Andrea Lopez
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | | | | | - Jaime L. Rubin
- Vertex Pharmaceuticals Incorporated, Boston, MA, United States of America
| | - Theodore G. Liou
- Adult CF Center, University of Utah, Salt Lake City, UT, United States of America
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11
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Yuzyuk TN, Nelson HA, Johnson LM. Inherited causes of exocrine pancreatic insufficiency in pediatric patients: clinical presentation and laboratory testing. Crit Rev Clin Lab Sci 2023:1-16. [PMID: 36876586 DOI: 10.1080/10408363.2023.2179968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Pediatric patients with exocrine pancreatic insufficiency (EPI) have symptoms that include abdominal pain, weight loss or poor weight gain, malnutrition, and steatorrhea. This condition can be present at birth or develop during childhood for certain genetic disorders. Cystic fibrosis (CF) is the most prevalent disorder in which patients are screened for EPI; other disorders also are associated with pancreatic dysfunction, such as hereditary pancreatitis, Pearson syndrome, and Shwachman-Diamond syndrome. Understanding the clinical presentation and proposed pathophysiology of the pancreatic dysfunction of these disorders aids in diagnosis and treatment. Testing pancreatic function is challenging. Directly testing aspirates produced from the pancreas after stimulation is considered the gold standard, but the procedures are not standardized or widely available. Instead, indirect tests are often used in diagnosis and monitoring. Although indirect tests are more widely available and easier to perform, they have inherent limitations due to a lack of sensitivity and/or specificity for EPI.
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Affiliation(s)
- Tatiana N Yuzyuk
- Department of Pathology, University of Utah/ARUP Laboratories, Salt Lake City, UT, USA
| | - Heather A Nelson
- Department of Pathology, University of Utah/ARUP Laboratories, Salt Lake City, UT, USA
| | - Lisa M Johnson
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, USA
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The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position on the Role of the Registered Dietitian Nutritionist in the Care of the Pediatric Patient With Chronic Gastrointestinal Diseases. J Pediatr Gastroenterol Nutr 2023; 76:390-399. [PMID: 36580920 DOI: 10.1097/mpg.0000000000003695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The optimization of nutrition is essential for the growth and development of all children, including those with gastrointestinal (GI) conditions that can variably affect nutrient intake, absorption, or metabolism. Registered Dietitian Nutritionists (RDNs) are essential partners in delivering high quality care for pediatric GI disorders, but limited evidence is available to support the role of the RDN in the care of these patients. This position paper outlines the evidence supporting the role of the RDN in the management of chronic pediatric GI issues in both inpatient and outpatient settings. Gaps in the literature, opportunities for future research, and barriers to RDN access are discussed.
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Mariotti Zani E, Grandinetti R, Cunico D, Torelli L, Fainardi V, Pisi G, Esposito S. Nutritional Care in Children with Cystic Fibrosis. Nutrients 2023; 15:nu15030479. [PMID: 36771186 PMCID: PMC9921127 DOI: 10.3390/nu15030479] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/18/2023] Open
Abstract
Patients with cystic fibrosis (CF) are prone to malnutrition and growth failure, mostly due to malabsorption caused by the derangement in the chloride transport across epithelial surfaces. Thus, optimal nutritional care and support should be an integral part of the management of the disease, with the aim of ameliorating clinical outcomes and life expectancy. In this report, we analyzed the nutrition support across the different ages, in patients with CF, with a focus on the relationships with growth, nutritional status, disease outcomes and the use of the CF transmembrane conductance regulator (CFTR) modulators. The nutrition support goal in CF care should begin as early as possible after diagnosis and include the achievement of an optimal nutritional status to support the growth stages and puberty development in children, that will further support the maintenance of an optimal nutritional status in adult life. The cornerstone of nutrition in patients with CF is a high calorie, high-fat diet, in conjunction with a better control of malabsorption due to pancreatic enzyme replacement therapy, and attention to the adequate supplementation of fat-soluble vitamins. When the oral caloric intake is not enough for reaching the anthropometric nutritional goals, supplemental enteral feeding should be initiated to improve growth and the nutritional status. In the last decade, the therapeutic possibilities towards CF have grown in a consistent way. The positive effects of CFTR modulators on nutritional status mainly consist in the improvement in weight gain and BMI, both in children and adults, and in an amelioration in terms of the pulmonary function and reduction of exacerbations. Several challenges need to be overcome with the development of new drugs, to transform CF from a fatal disease to a treatable chronic disease with specialized multidisciplinary care.
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Affiliation(s)
- Elena Mariotti Zani
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Daniela Cunico
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Lisa Torelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giovanna Pisi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence: ; Tel.: +39-0521-903524
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Ritivoiu ME, Drăgoi CM, Matei D, Stan IV, Nicolae AC, Craiu M, Dumitrescu IB, Ciolpan AA. Current and Future Therapeutic Approaches of Exocrine Pancreatic Insufficiency in Children with Cystic Fibrosis in the Era of Personalized Medicine. Pharmaceutics 2023; 15:pharmaceutics15010162. [PMID: 36678791 PMCID: PMC9862205 DOI: 10.3390/pharmaceutics15010162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/17/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023] Open
Abstract
This review presents current updates of pancreatic enzyme replacement therapy in children with cystic fibrosis based on literature published in the last decade and some special considerations regarding pancreatic enzyme replacement therapy in the era of new therapies, such as cystic fibrosis transmembrane conductance regulator modulator therapies. Few articles evaluate the efficacy of pancreatic enzyme replacement therapy in the pediatric population, and most studies also included children and adults with cystic fibrosis. Approximately 85% of cystic fibrosis patients have exocrine pancreatic insufficiency and need pancreatic enzyme replacement therapy. Fecal elastase is the most commonly used diagnostic test for exocrine pancreatic insufficiency, although this value can fluctuate over time. While it is used as a diagnostic test, it cannot be used for monitoring the effectiveness of pancreatic enzyme replacement therapy and for adjusting doses. Pancreatic enzyme replacement therapy, the actual treatment for exocrine pancreatic insufficiency, is essential in children with cystic fibrosis to prevent malabsorption and malnutrition and needs to be urgently initiated. This therapy presents many considerations for physicians, patients, and their families, including types and timing of administration, dose monitoring, and therapy failures. Based on clinical trials, pancreatic enzyme replacement therapy is considered effective and well-tolerated in children with cystic fibrosis. An important key point in cystic fibrosis treatment is the recent hypothesis that cystic fibrosis transmembrane conductance regulator modulators could improve pancreatic function, further studies being essential. Pancreatic enzyme replacement therapy is addressed a complication of the disease (exocrine pancreatic insufficiency), while modulators target the defective cystic fibrosis transmembrane conductance regulator protein. Exocrine pancreatic insufficiency in cystic fibrosis remains an active area of research in this era of cystic fibrosis transmembrane conductance regulator modulator therapies. This new therapy could represent an example of personalized medicine in cystic fibrosis patients, with each class of modulators being addressed to patients with specific genetic mutations.
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Affiliation(s)
- Mirela-Elena Ritivoiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Cristina Manuela Drăgoi
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
- Correspondence: (C.M.D.); (A.C.N.)
| | - Dumitru Matei
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Iustina Violeta Stan
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Alina Crenguţa Nicolae
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
- Correspondence: (C.M.D.); (A.C.N.)
| | - Mihai Craiu
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
| | - Ion-Bogdan Dumitrescu
- Faculty of Pharmacy, “Carol Davila” University of Medicine and Pharmacy, 020956 Bucharest, Romania
| | - Alina Angelica Ciolpan
- Faculty of Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Alessandrescu-Rusescu National Institute for Mother and Child Health, 020395 Bucharest, Romania
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15
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Escaldelai FMD, Silva Filho LVRFD, Neri LDCL, Bergamaschi DP. Quality of anthropometric data measured in children and adolescents with cystic fibrosis: a scoping review. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 41:e2021333. [PMID: 36888749 PMCID: PMC9984155 DOI: 10.1590/1984-0462/2023/41/2021333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 05/06/2022] [Indexed: 03/08/2023]
Abstract
OBJECTIVE This study aimed to identify methodological aspects involved in determining anthropometric measurements among studies assessing the nutritional status of individuals with cystic fibrosis (CF). METHODS A search of the literature was performed on MEDLINE via Pubmed, Embase, and Web of Science databases. The population comprised children and adolescents with CF. Observational studies and clinical trials using anthropometric and body composition measures and indices determined by dual-energy X-ray absorptiometry (DXA) and bioelectrical impedance assessment (BIA) were included. Use of a standardized procedure for data collection was defined when details on the instruments and their calibration were given, the measuring procedures were described, and when it was clear measures had been determined by a trained team, or the use of an anthropometric reference manual was cited. Data extracted were expressed as absolute and relative frequencies. RESULTS A total of 32 articles were included, and a total of 233 measures or indices were observed. The most frequently used measures were body mass index (kg/m2; 35%), weight (kg; 33%), and height (cm; 33%). Among the 28 studies that used anthropometric measures, 21 (75%) provided a complete or partial description of the measurement instruments used, 3 (11%) reported information on equipment calibration, 10 (36%) indicated the measurement procedures employed by assessors, and 2 (7%) stated a trained team had carried out the measurements. CONCLUSIONS The poor description of measuring procedures precluded a meaningful evaluation of data quality. Scientific debate on this theme can help raise awareness of the need to ensure quality in collecting and fully presenting data.
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Wilson A, Altman K, Schindler T, Schwarzenberg SJ. Updates in Nutrition Management of Cystic Fibrosis in the Highly Effective Modulator Era. Clin Chest Med 2022; 43:727-742. [PMID: 36344077 DOI: 10.1016/j.ccm.2022.06.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Attainment and maintenance of good nutrition has been an important aspect of management in cystic fibrosis (CF) for decades. In the era of highly effective modulator therapy for CF, the quality of the nutrients we recommend is increasingly important. Our therapy must support our patients' health for many years beyond what we previously thought. Preventing cardiovascular disease, reducing hyperlipidemia, and optimizing lean body mass for active, longer lives now join the long-standing goal of promoting lung function through nutrition. This chapter summarizes recent developments in nutrition in people with CF, with an eye to the evolution of our practice.
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Affiliation(s)
- Alexandra Wilson
- Cystic Fibrosis Clinical Research, Clinical Research Services, National Jewish Health, 1400 Jackson Street, K333, Denver, CO 80206, USA
| | - Kimberly Altman
- Gunnar Esiason Adult Cystic Fibrosis and Lung Center, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Terri Schindler
- Pediatric Pulmonology, University Hospitals Cleveland Medical Center, Rainbow Babies and Children's Hospital
| | - Sarah Jane Schwarzenberg
- Department of Pediatrics; University of Minnesota Masonic Children's Hospital, Academic Office Building, 2450 Riverside Avenue South AO-201, Minneapolis, MN 55454, USA.
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Kadenczki O, Dezsofi A, Cseh A, Szucs D, Vass N, Nemes E, Tarnok A, Szakos E, Guthy I, Kovacs M, Karoliny A, Czelecz J, Kiss C, Müller KE. Disease Activity Is Associated with Obesity in Newly Diagnosed Pediatric Patients with Ulcerative Colitis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16091. [PMID: 36498163 PMCID: PMC9738058 DOI: 10.3390/ijerph192316091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/25/2022] [Accepted: 11/26/2022] [Indexed: 06/17/2023]
Abstract
Malnutrition and inflammatory bowel disease (IBD) are interrelated conditions. Our aim was to assess the prevalence of malnutrition, to compare anthropometric parameters in the evaluation of nutritional status in pediatric IBD, and to investigate the association between anthropometric parameters and disease activity indices (AI). Pediatric patients with newly diagnosed IBD recorded between 2010 and 2016 in the Hungarian Pediatric IBD Registry were included in this cross-sectional study. Body weight, body mass index (BMI), weight-for-height, and ideal body weight percent (IBW%) were analyzed. Pearson linear and non-linear correlations and polynomial regression analyses were performed to assess correlation between nutritional status and AI. p-values < 0.05 were considered significant. Anthropometric data of 1027 children with IBD (Crohn’s disease (CD): 699; ulcerative colitis (UC): 328; mean age 13.7 years) were analyzed. IBW% identified more obese patients than BMI both in CD (7.02% vs. 2.28%) and UC (12.17% vs. 5.48%). Significant negative correlation was found among anthropometric parameters and AI in CD. In contrast, polynomial regression analysis revealed a U-shaped correlation curve between IBW% and AI in UC. Our findings show that obesity has a bimodal association with disease activity in pediatric UC. Furthermore, IBW% was more useful to identify obese pediatric patients with IBD.
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Affiliation(s)
- Orsolya Kadenczki
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Antal Dezsofi
- 1st Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary
| | - Aron Cseh
- 1st Department of Pediatrics, Semmelweis University, 1083 Budapest, Hungary
| | - Daniel Szucs
- Department of Pediatrics, University of Szeged, 6725 Szeged, Hungary
| | - Noemi Vass
- Department of Pediatrics, University of Szeged, 6725 Szeged, Hungary
| | - Eva Nemes
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Andras Tarnok
- Department of Pediatrics, Medical School, University of Pécs, 7623 Pécs, Hungary
| | - Erzsebet Szakos
- Borsod Abaúj Zemplén County University Teaching Hospital, University of Miskolc, 3526 Miskolc, Hungary
| | - Ildiko Guthy
- Szabolcs-Szatmár-Bereg County Hospitals, University Teaching Hospital, 4400 Nyíregyháza, Hungary
| | - Marta Kovacs
- Petz Aladar Teaching Hospital, 9024 Győr, Hungary
| | - Anna Karoliny
- Heim Pal National Pediatric Institute, 1089 Budapest, Hungary
| | - Judit Czelecz
- Bethesda Children’s Hospital, 1146 Budapest, Hungary
| | - Csongor Kiss
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Katalin Eszter Müller
- Heim Pal National Pediatric Institute, 1089 Budapest, Hungary
- Institute of Translation Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
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Lei WS, Kilberg MJ, Zemel BS, Rubenstein RC, Harris C, Sheikh S, Kelly A, Kindler JM. Bone metabolism and incretin hormones following glucose ingestion in young adults with pancreatic insufficient cystic fibrosis. J Clin Transl Endocrinol 2022; 30:100304. [PMID: 36110921 PMCID: PMC9467887 DOI: 10.1016/j.jcte.2022.100304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/12/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Gut-derived incretin hormones, including glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide 1 (GLP-1), regulate post-prandial glucose metabolism by promoting insulin production. GIP, GLP-1, and insulin contribute to the acute bone anti-resorptive effect of macronutrient ingestion by modifying bone turnover. Cystic fibrosis (CF) is associated with exocrine pancreatic insufficiency (PI), which perturbs the incretin response. Cross-talk between the gut and bone ("gut-bone axis") has not yet been studied in PI-CF. The objectives of this study were to assess changes in biomarkers of bone metabolism during oral glucose tolerance testing (OGTT) and to test associations between incretins and biomarkers of bone metabolism in individuals with PI-CF. Methods We performed a secondary analysis of previously acquired blood specimens from multi-sample OGTT from individuals with PI-CF ages 14-30 years (n = 23). Changes in insulin, incretins, and biomarkers of bone resorption (C-terminal telopeptide of type 1 collagen [CTX]) and formation (procollagen type I N-terminal propeptide [P1NP]) during OGTT were computed. Results CTX decreased by 32% by min 120 of OGTT (P < 0.001), but P1NP was unchanged. Increases in GIP from 0 to 30 mins (rho = -0.48, P = 0.03) and decreases in GIP from 30 to 120 mins (rho = 0.62, P = 0.002) correlated with decreases in CTX from mins 0-120. Changes in GLP-1 and insulin were not correlated with changes in CTX, and changes in incretins and insulin were not correlated with changes in P1NP. Conclusions Intact GIP response was correlated with the bone anti-resorptive effect of glucose ingestion, represented by a decrease in CTX. Since incretin hormones might contribute to development of diabetes and bone disease in CF, the "gut-bone axis" warrants further attention in CF during the years surrounding peak bone mass attainment.
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Affiliation(s)
- Wang Shin Lei
- Department of Nutritional Sciences, The University of Georgia, Athens, GA, USA
| | - Marissa J. Kilberg
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S. Zemel
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ronald C. Rubenstein
- Division of Allergy and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Clea Harris
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Saba Sheikh
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M. Kindler
- Department of Nutritional Sciences, The University of Georgia, Athens, GA, USA
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Wysocka-Wojakiewicz P, Woś H, Wielkoszyński T, Pyziak-Skupień A, Grzybowska-Chlebowczyk U. Vitamin Status in Children with Cystic Fibrosis Transmembrane Conductance Regulator Gene Mutation. Nutrients 2022; 14:nu14214661. [PMID: 36364923 PMCID: PMC9654413 DOI: 10.3390/nu14214661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background: The issue of vitamin metabolism in children with cystic fibrosis screen positive, inconclusive diagnosis (CFSPID) is not well known. The aim of this study was to determine the status of vitamins A, D, E, and C in the blood of a group of children with CFSPID. Material and Methods: A total of 89 children were enrolled in the study (Me: 3.6 years, 52.8% boys), as follows: 28 with CFSPID, 31 with CF (cystic fibrosis), and 30 HC (healthy children). Their blood concentrations of vitamins A, D, E, and C, and their dietary intake of these vitamins were analysed in the study groups on the basis of a three-day food diary. Results: The patients with CFSPID had significantly higher serum vitamin D (p = 0.01) and E (p = 0.04) concentrations, compared to the children with CF. None of the children with CFSPID revealed vitamin A or E deficiencies. Patients with CF had been consuming significantly higher vitamin D and E amounts (p = 0.01). The vitamin concentrations did not depend either on the pancreatic/liver function or on anthropometric parameters. In total, 32.14% of patients with CF did not cover the baseline recommended calorie intake, and 53.6% and 36% did not take the recommended vitamin E and vitamin A intake, respectively. Conclusion: Children with CF and CFSPID did not fully cover the dietary recommendations for vitamin supply, but vitamin deficiency was found only in CF.
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Affiliation(s)
- Paulina Wysocka-Wojakiewicz
- Department of Pediatrics, Faculty of Medical Sciences, Medical University of Silesia, 40-752 Katowice, Poland
- Correspondence:
| | - Halina Woś
- Faculty of Health Sciences, University of Bielsko-Biala, 43-309 Bielsko-Biała, Poland
| | - Tomasz Wielkoszyński
- Higher School of Strategic Planning and Laboratory Medicine Centre, 41-303 Dąbrowa Górnicza, Poland
| | - Aleksandra Pyziak-Skupień
- Department of Children’s Diabetology, Silesian Medical University in Katowice, 40-752 Katowice, Poland
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Macdougall A, Jarvis D, Keogh RH, Bowerman C, Bilton D, Davies G, Carr SB, Stanojevic S. Trajectories of early growth and subsequent lung function in cystic fibrosis: An observational study using UK and Canadian registry data. J Cyst Fibros 2022:S1569-1993(22)00658-0. [PMID: 36088206 DOI: 10.1016/j.jcf.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/18/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Understanding the pulmonary impact of changes in early life nutritional status over time in a paediatric CF population may help inform how to use nutritional assessment to guide clinical care. National registry data provides an opportunity to study patterns of weight gain over time at the level of the individual, and thus to gain detailed understanding of the relationship between early weight trajectories and later lung function in children with Cystic Fibrosis (CF). METHODS Using data from the United Kingdom (UK) and Canadian CF Registries, a mixed effects linear regression model was used to describe children's weight and BMI z-score trajectories from age 1 to 5 years. The intercept (weight-for-age at age 1) and slope (weight-for-age trajectory) from this model were then used as covariates in a linear regression of first lung function measurement at age 6 years. RESULTS In both the UK and Canadian data, greater weight-for-age z-score at age 1 year and greater change in weight-for-age over time were associated with higher FEV1% predicted. A greater weight-for-age z-score at age 1 year was associated with a higher FEV1% predicted (UK: 3.78% (95% CI: 1.76; 4.70); Canada: 3.20% (95%CI: 1.76, 4.70)). These associations were reproduced for BMI z-scores and FVC% predicted. CONCLUSIONS Early weight-for-age, specifically at age 1 year, and weight-for-age trajectories across early childhood are associated with later lung function. This relationship persists after adjustment for potential confounders. Current guidelines may need to be updated to place less emphasis on a specific cut-off (such as the 10th percentile) and encourage tracking of weight-for-age over time.
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Affiliation(s)
- Amy Macdougall
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Deborah Jarvis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom
| | - Cole Bowerman
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada
| | - Diana Bilton
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, Sydney Street, London, United Kingdom
| | - Gwyneth Davies
- UCL Great Ormond Street Institute of Child Health, London, UK, Great Ormond Street Hospital for Children and GOSH NIHR BRC, London, United Kingdom
| | - Siobhán B Carr
- Royal Brompton Hospital and Imperial College London, United Kingdom
| | - Sanja Stanojevic
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Canada
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21
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Abstract
PURPOSE OF REVIEW This review aims to discuss recent developments in the nutritional management in chronic pancreatitis. RECENT FINDINGS Nutritional assessment should be comprehensive and include dietary history, anthropometry, and biochemical nutritional parameters. Micronutrients should be evaluated at least yearly and dual-energy X-ray absorptiometry (DEXA) at every 2-yearly intervals. Studies on pancreatic enzyme replacement therapy (PERT) have primarily evaluated coefficient of fat excretion (CFA), coefficient of nitrogen excretion (CNA), and stool weight. Two RCTs, in which patients were treated with PERT for 7 days in a blinded manner and subsequently extended for 6-12 months in an open-label manner, showed improvement in nutritional parameters. However, two subsequent RCTs failed to show any benefit, and the most recent observational study demonstrated persistence of malnutrition even after PERT. The reason for the latter findings were nonadherence to PERT and poor oral intake of calories. Therefore, it is essential to educate the patients on adherence, counsel on taking high-protein, high-calorie diet, and supplement nutrients in those with inadequate oral intake. Other associated manifestations, such as diabetes and related complications, and anxiety/depression could also contribute to malnutrition directly or indirectly, and should, therefore, be adequately managed. SUMMARY Nutritional assessment should be performed meticulously. Nutritional therapy should not be restricted to only PERT and nutritional supplementation, but should also include dietary counselling and disease related education.
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22
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Sankararaman S, Hendrix SJ, Schindler T. Update on the management of vitamins and minerals in cystic fibrosis. Nutr Clin Pract 2022; 37:1074-1087. [PMID: 35997322 PMCID: PMC9544449 DOI: 10.1002/ncp.10899] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/27/2022] [Accepted: 07/16/2022] [Indexed: 11/10/2022] Open
Abstract
Advancements in respiratory and nutrition management have significantly improved the survival of patients with cystic fibrosis (CF). With the availability of several nutrition interventions such as oral/enteral nutrition supplements, enteric‐coated pancreatic enzymes, and water‐miscible CF‐specific vitamin supplements, frank vitamin deficiencies—with the exception of vitamin D—are rarely encountered in current clinical practice. Whereas they were previously considered as micronutrients, our current understanding of fat‐soluble vitamins and minerals as antioxidants, immunomodulators, and disease biomarkers has been evolving. The impact of highly effective modulators on the micronutrient status of patients with CF remains elusive. This narrative review focuses on the updates on the management of fat‐soluble vitamins and other micronutrients in CF in the current era and identifies the gaps in our knowledge.
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Affiliation(s)
- Senthilkumar Sankararaman
- Department of Pediatrics, Division of Pediatric Gastroenterology, UH Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Sara J Hendrix
- Department of Nutrition Services, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Terri Schindler
- Department of Pediatrics, Division of Pediatric Pulmonology, UH Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
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Lai HJ, Song J, Lu Q, Murali SG, Gajapathy M, Wilk BM, Brown DM, Worthey EA, Farrell PM. Genetic factors help explain the variable responses of young children with cystic fibrosis to vitamin D supplements. Clin Nutr ESPEN 2022; 51:367-376. [DOI: 10.1016/j.clnesp.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/11/2022] [Accepted: 07/28/2022] [Indexed: 10/15/2022]
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24
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Albedewi H, Bindayel I, Albarrag A, Banjar H. Correlation of Gut Microbiota, Vitamin D Status, and Pulmonary Function Tests in Children With Cystic Fibrosis. Front Nutr 2022; 9:884104. [PMID: 35757256 PMCID: PMC9218790 DOI: 10.3389/fnut.2022.884104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Children with cystic fibrosis (CF) are expected to have suboptimal serum vitamin D status and altered gut microbiota. The altered gut microbiota is hypothesized to have a pro-inflammatory effect that further complicates the existing respiratory inflammation. Emerging evidence suggests an association between vitamin D and gut microbiota. The aim of this study was to assess the relationships between 25-hydroxyvitamin D [25(OH)D] status, pulmonary function, and fecal bacteria in children with CF. Methods In this cross-sectional study, a total of 35 children with CF (8.7 ± 2.83 years) and 24 controls without CF (9 ± 2.7 years) were included in this study. Serum 25(OH)D status was measured using the Elecsys vitamin D total II assay. In the CF group, gut microbiota composition was assessed using real-time PCR analysis. Pulmonary function tests (PFTs) were measured using spirometry. Comparisons between the CF and non-CF controls were conducted using the independent sample t-test. In the CF group, one-way analysis of variance (ANOVA) was used to assess differences in PFTs and gut microbiota composition across the three vitamin D subgroups. The correlations between 25(OH)D status and PFTs, or gut microbiota composition, and PFTs with gut microbiota composition were analyzed using the Pearson's correlation coefficient test. Results Children with CF had significantly lower serum 25(OH)D levels compared with children without CF (44.3 ± 22.4 vs. 59 ± 25.5, respectively, P = 0.026). Children with CF with optimal serum 25(OH)D level had significantly higher levels of Bacteroidetes, Firmicutes, and total bacteria (P = 0.007, P = 0.007, and P = 0.022, respectively). The level of Firmicutes was found to be significantly higher in mild forced expiratory volume in 1 s (FEV1) compared with moderate FEV1 (P = 0.032), whereas the level of the other bacteria species was comparable across FEV1 severity groups. Conclusion Our findings may encourage studies that target and modify gut microbiota to potentially achieve better outcomes in terms of respiratory function in CF.
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Affiliation(s)
- Hadeel Albedewi
- Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Iman Bindayel
- Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed Albarrag
- Department of Pathology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hanaa Banjar
- Department of Pediatrics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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25
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Corbera-Hincapie MA, Atteih SE, Stransky OM, Weiner DJ, Yann IM, Kazmerski TM. Experiences and Perspectives of Individuals with Cystic Fibrosis and Their Families Related to Food Insecurity. Nutrients 2022; 14:nu14132573. [PMID: 35807754 PMCID: PMC9268710 DOI: 10.3390/nu14132573] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 12/10/2022] Open
Abstract
Food insecurity (FI) rates among people with cystic fibrosis (CF) are significantly higher than in the general US population. This study explored the experiences and perceptions of adults and parents of children with CF surrounding FI. We recruited parents of children with CF ages 0–18 years and adults with CF ages 18 years and older from a large, accredited U.S. CF care center and the Cystic Fibrosis Foundation Community Voice to participate in a qualitative study using semi-structured telephone interviews to explore experiences and preferences related to food insecurity. Two coders independently reviewed each transcript to apply the codebook and identify any emerging codes using an ongoing, iterative process to identify central themes. We interviewed 20 participants (six adults with CF and 14 parents of children with CF) and identified five major themes: (1) FI in CF is influenced by a variety of factors, ranging from nutritional demands to competing financial barriers; (2) FI impacts CF health outcomes; (3) Open patient-provider communication around FI is vital; (4) FI screening and discussions should be normalized in CF care; (5) Comprehensive FI resources are vital. FI is an important topic that should routinely be addressed with the CF care team to destigmatize and encourage individuals to be more forthcoming about their FI status. Results from this study will inform future larger investigations on the impact of FI on CF health and aid in the design and planning of targeted interventions and advocacy efforts.
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Affiliation(s)
- Montserrat A. Corbera-Hincapie
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (S.E.A.); (D.J.W.); (I.M.Y.); (T.M.K.)
- Correspondence: ; Tel.: +1-786-412-1300
| | - Samar E. Atteih
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (S.E.A.); (D.J.W.); (I.M.Y.); (T.M.K.)
| | - Olivia M. Stransky
- Center for Innovative Research on Gender Health Equity (CONVERGE), Pittsburgh, PA 15224, USA;
| | - Daniel J. Weiner
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (S.E.A.); (D.J.W.); (I.M.Y.); (T.M.K.)
| | - Iris M. Yann
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (S.E.A.); (D.J.W.); (I.M.Y.); (T.M.K.)
| | - Traci M. Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (S.E.A.); (D.J.W.); (I.M.Y.); (T.M.K.)
- Center for Innovative Research on Gender Health Equity (CONVERGE), Pittsburgh, PA 15224, USA;
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26
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Marpole R, Wilson AC. Benefits of reviewing pancreatic function in children with cystic fibrosis. Pediatr Pulmonol 2022; 57:1537-1539. [PMID: 35258175 PMCID: PMC9313857 DOI: 10.1002/ppul.25884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 02/27/2022] [Accepted: 03/05/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Rachael Marpole
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Division of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia, Crawley, Western Australia, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Andrew C Wilson
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Division of Paediatrics, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia, Crawley, Western Australia, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Nedlands, Western Australia, Australia
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27
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Greaney C, Bohan K, Tecklenborg S, Casserly B, Green J, Van de Ven P, Robinson K, Tierney A. Diet quality in cystic fibrosis – associations with patient reported outcome measures and enablers and barriers to eating a healthy diet: A protocol paper for a mixed methods study. HRB Open Res 2022; 5:33. [PMID: 36091185 PMCID: PMC9428499 DOI: 10.12688/hrbopenres.13533.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/20/2022] Open
Abstract
Background: People with cystic fibrosis (PWCF) have increased energy requirements. However, in recent years concerns have emerged regarding the ‘cystic fibrosis (CF) diet’ in terms of reliance on energy-dense, nutrient poor foods, which tend to be higher in saturated fat, sugar, and salt. These foods lack essential nutrients and are aetiologically linked with diet-related chronic diseases. The aim is to explore habitual dietary intakes in PWCF and (i) assess adherence to CF dietary guidelines and population specific healthy eating guidelines; (ii) derive a diet quality score and the inflammatory potential for the average diet consumed by PWCF and assess associations with patient reported outcome measures; (iii) assess drivers for current consumption patterns and enablers and barriers to eating a healthy diet. Methods: The aim is to recruit between 100-180 PWCF. A mixed methods study will be performed. Using three-day food diaries and food frequency questionnaires, aims (i) and (ii) will be addressed. The Dietary Approaches to Stop Hypertension (DASH) score and Healthy Eating Index-International (HEI-I) will derive diet quality scores. The Dietary Inflammatory Index (DII®) will ascertain inflammatory potential of the diet. Validated questionnaires will be used to report health related quality of life measures. Online focus groups and semi-structured interview with PWCF will address aim (iii). Conclusions: It is timely to revise dietary priorities and targets for CF. However, a greater understanding of what adults with CF currently consume and what they require in terms of nutrition and dietary guidance into the future is needed. In doing so, this research will help to clarify nutrition priorities and simplify the dietary aspects of CF treatment, thereby supporting adherence.
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Affiliation(s)
- Cian Greaney
- School of Allied Health, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Katie Bohan
- School of Allied Health, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Sarah Tecklenborg
- Cystic Fibrosis Ireland, 24 Lower Rathmines Rd, Rathmines, Dublin, Ireland
| | - Brian Casserly
- Department of Respiratory Medicine, University Hospital Limerick, Dooradoyle, Limerick, V94 F858, Ireland
| | - James Green
- School of Allied Health, University of Limerick, Limerick, V94 T9PX, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Pepijn Van de Ven
- Department of Electronic and Computer Engineering, University of Limerick, Limerick, V94 T9PX, Ireland
- Health Implementation Science and Technology Cluster, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Katie Robinson
- School of Allied Health, University of Limerick, Limerick, V94 T9PX, Ireland
- Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Audrey Tierney
- School of Allied Health, University of Limerick, Limerick, V94 T9PX, Ireland
- Health Implementation Science and Technology Cluster, Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
- Department of Dietetics, Human Nutrition and Sport, La Trobe University, Melbourne, Victoria, 3086, Australia
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Neri LDCL, Simon MISDS, Ambrósio VLS, Barbosa E, Garcia MF, Mauri JF, Guirau RR, Neves MA, Cunha CDAP, Nogueira MC, Alves ACDC, Gurmini J, Servidoni MDF, Epifanio M, Athanazio R. Brazilian Guidelines for Nutrition in Cystic Fibrosis. EINSTEIN-SAO PAULO 2022; 20:eRW5686. [PMID: 35384985 PMCID: PMC8967313 DOI: 10.31744/einstein_journal/2022rw5686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 01/12/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To develop a scientific consensus on nutrition in cystic fibrosis. METHODS Sixteen coordinators elaborated relevant questions on nutritional therapy in cystic fibrosis, which were divided into six sections: nutritional assessment, nutritional recommendations, nutritional intervention, dietary counseling, special situations and enzyme replacement, and gastrointestinal manifestations. Two to three specialists in the field were responsible for each section and obtaining answers formulated based on standardized bibliographic searches. The available literature was searched in the PubMed®/MEDLINE database, after training and standardization of search strategies, to write the best level of evidence for the questions elaborated. Issues related to disagreement were discussed until a consensus was reached among specialists, based on the current scientific literature. RESULTS Forty-two questions were prepared and objectively answered, resulting in a consensus of nutritional therapy in cystic fibrosis. CONCLUSION This work enabled establishing a scientific consensus for nutritional treatment of cystic fibrosis patients.
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Affiliation(s)
- Lenycia de Cassya Lopes Neri
- Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Eliana Barbosa
- Hospital Infantil Joana de Gusmão, Florianópolis, SC, Brazil
| | | | | | | | | | | | | | - Anna Carolina Di Creddo Alves
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Matias Epifanio
- Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Rodrigo Athanazio
- Instituto do Coração (InCor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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29
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Lai HJ, Chin LH, Murali S, Bach T, Sander D, Farrell PM. Vitamins A, D, E status as related to supplementation and lung disease markers in young children with cystic fibrosis. Pediatr Pulmonol 2022; 57:935-944. [PMID: 35018747 PMCID: PMC8930603 DOI: 10.1002/ppul.25825] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 12/22/2021] [Accepted: 01/08/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND The variable response to fat-soluble vitamin supplementation in young children with cystic fibrosis (CF), and factors contributing to this variability, remain under-investigated. OBJECTIVE To determine if recommended supplement doses normalize serum vitamins A (retinol), D (25-hydroxy-vitamin D, 25OHD), and E (α-tocopherol), and identify factors predictive of achieving sufficiency, in children with CF in the first 3 years of life. DESIGN We studied 144 infants born during 2012-2017 and diagnosed with CF through newborn screening. Serum retinol, 25OHD, α-tocopherol and plasma cytokines interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-α were measured in early infancy and yearly thereafter. Vitamin supplement intakes and respiratory microbiology were assessed every 1-2 months in infancy and quarterly thereafter. RESULTS The prevalence of vitamin D insufficiency (<30 ng/ml) at all ages combined was significantly higher (22%) compared to vitamin A (<200 ng/ml, 3%) and vitamin E (<5 µg/ml, 5%). All children were vitamin A sufficient by age 2 years. Vitamin E insufficiency was rare. Only 42% were early responders of vitamin D and 17% remain insufficient despite high supplement intakes. IL-6 was positively correlated, while IL-8, IL-10, and TNF-α were negatively correlated, with retinol and 25OHD. Multiple regression analysis revealed that supplement dose, season, α-tocopherol, pancreatic insufficiency, respiratory infections and IL-10 were significant predictors of 25OHD. CONCLUSION Diagnosis through newborn screening coupled with supplementation normalized serum retinol and α-tocopherol in almost all infants with CF by age 3 years. However, response to vitamin D supplements in young children with CF occurred later and variably despite early and sustained supplementation.
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Affiliation(s)
- HuiChuan J Lai
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Lyanne H Chin
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sangita Murali
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Taiya Bach
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Danielle Sander
- Department of Nutritional Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Philip M Farrell
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
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30
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Understanding Cystic Fibrosis Comorbidities and Their Impact on Nutritional Management. Nutrients 2022; 14:nu14051028. [PMID: 35268004 PMCID: PMC8912424 DOI: 10.3390/nu14051028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Cystic fibrosis (CF) is a chronic, multisystem disease with multiple comorbidities that can significantly affect nutrition and quality of life. Maintaining nutritional adequacy can be challenging in people with cystic fibrosis and has been directly associated with suboptimal clinical outcomes. Comorbidities of CF can result in significantly decreased nutritional intake and intestinal absorption, as well as increased metabolic demands. It is crucial to utilize a multidisciplinary team with expertise in CF to optimize growth and nutrition, where patients with CF and their loved ones are placed in the center of the care model. Additionally, with the advent of highly effective modulators (HEMs), CF providers have begun to identify previously unrecognized nutritional issues, such as obesity. Here, we will review and summarize commonly encountered comorbidities and their nutritional impact on this unique population.
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31
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Nutrition in Cystic Fibrosis—Some Notes on the Fat Recommendations. Nutrients 2022; 14:nu14040853. [PMID: 35215502 PMCID: PMC8875685 DOI: 10.3390/nu14040853] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 12/15/2022] Open
Abstract
Nutrition is important in cystic fibrosis (CF) because the disease is associated with a higher energy consumption, special nutritional deficiencies, and malabsorption mainly related to pancreatic insufficiency. The clinical course with deterioration of lung function has been shown to relate to nutrition. Despite general recommendation of high energy intake, the clinical deterioration is difficult to restrain suggesting that special needs have not been identified and specified. It is well-known that the CF phenotype is associated with lipid abnormalities, especially in the essential or conditionally essential fatty acids. This review will concentrate on the qualitative aspects of fat metabolism, which has mainly been neglected in dietary fat recommendations focusing on fat quantity. For more than 60 years it has been known and confirmed that the patients have a deficiency of linoleic acid, an n-6 essential fatty acid of importance for membrane structure and function. The ratio between arachidonic acid and docosahexaenoic acid, conditionally essential fatty acids of the n-6 and n-3 series, respectively, is often increased. The recently discovered relations between the CFTR modulators and lipid metabolism raise new interests in this field and together with new technology provide possibilities to specify further specify personalized therapy.
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32
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Shape JM, Sala MA. Nutrition management in adults with cystic fibrosis. Nutr Clin Pract 2022; 37:256-264. [PMID: 35118712 DOI: 10.1002/ncp.10842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 11/12/2022] Open
Abstract
Cystic fibrosis (CF) is a lethal, monogenic, autosomal recessive disease with manifestations in multiple organ systems, including the lungs and gastrointestinal tract, that impact adequate nutrition. This review discusses important aspects of nutrition in adults with CF with a focus on exocrine pancreatic insufficiency, CF-related diabetes, and gastrointestinal motility, as well as how advanced lung disease, CF transmembrane conductance regulator modulators, and aging impact nutrition in CF.
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Affiliation(s)
- Jessica M Shape
- Clinical Nutrition Services, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Marc A Sala
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Grant JJ, McDade EJ, Zobell JT, Young DC. The indispensable role of pharmacy services and medication therapy management in cystic fibrosis. Pediatr Pulmonol 2022; 57 Suppl 1:S17-S39. [PMID: 34347382 DOI: 10.1002/ppul.25613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2021] [Accepted: 08/02/2021] [Indexed: 11/06/2022]
Abstract
Care for people with cystic fibrosis (PWCF) is highly complex and requires a multidisciplinary approach where the pharmacist plays a vital role. The purpose of this manuscript is to serve as a guideline for pharmacists and pharmacy technicians who provide care for PWCF by providing background and current recommendations for the use of cystic fibrosis (CF)-specific medications in both the acute and ambulatory care settings. The article explores current literature surrounding the role of pharmacists and pharmacy technicians, proven pharmacy models to emulate, and pharmacokinetic idiosyncrasies unique to the CF population while also identifying areas of future research. Clinical recommendations for the use of CF-specific medications are broken down by organ system including mechanism of action, adverse events, dosages, and monitoring parameters. The article also includes quick reference tables essential to the acute and chronic medication therapy management of PWCF.
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Affiliation(s)
- Jonathan J Grant
- Department of Outpatient Pharmacy-Specialty Services, The John's Hopkins Hospital, Baltimore, Maryland, USA
| | - Erin J McDade
- Pharmacy Department, Texas Children's Hospital, Houston, Texas, USA
| | - Jeffery T Zobell
- Pharmacy Department, Intermountain Primary Children's Hospital, Salt Lake City, Utah, USA
| | - David C Young
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
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Gabel ME, Fox CK, Grimes RA, Lowman JD, McDonald CM, Stallings VA, Michel SH. Overweight and cystic fibrosis: An unexpected challenge. Pediatr Pulmonol 2022; 57 Suppl 1:S40-S49. [PMID: 34738328 DOI: 10.1002/ppul.25748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/06/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
Achieving a healthy weight balance has been a central focus of care for people who have cystic fibrosis (CF). Over the years, the emphasis has primarily been on promoting weight gain to optimize pulmonary outcomes. With continued improvements in CF care, including highly effective CF modulators available for many people, the CF community is now experiencing a new challenge: addressing the concern that some people are gaining weight excessively. While at this time, we do not know to what extent overweight and obesity will affect health outcomes for people with CF, it is likely that excessive weight gain may have negative health impacts similar to those seen in the general population. In this paper, we review the history of nutritional guidelines for people with CF, as well as more recent trends toward overweight and obesity for some. A multidisciplinary approach is needed to collaboratively start the oftentimes difficult conversation regarding excessive weight gain, and to identify resources to help people achieve and maintain a healthy weight through diet, exercise, and behavioral modification.
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Affiliation(s)
- Megan E Gabel
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA
| | - Claudia K Fox
- Department of Pediatrics, Center for Pediatric Obesity Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Rachel A Grimes
- Department of Psychiatry, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - John D Lowman
- Department of Physical Therapy, Gregory Fleming James Cystic Fibrosis Research Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Catherine M McDonald
- Department of Clinical Nutrition, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Virginia A Stallings
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Suzanne H Michel
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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Lahiri T, Sullivan JS. Recent advances in the early treatment of cystic fibrosis: Bridging the gap to highly effective modulator therapy. Pediatr Pulmonol 2022; 57 Suppl 1:S60-S74. [PMID: 34473419 DOI: 10.1002/ppul.25660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 08/22/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022]
Abstract
Highly effective modulator therapy (HEMT) for cystic fibrosis (CF) has been touted as one of the greatest advances to date in CF care. As these therapies are now available for many older children and adults with CF, marked improvement of their nutritional status, pulmonary and gastrointestinal symptoms has been observed. However, most infants and younger children are not current candidates for HEMT due to age and/or cystic fibrosis transmembrane conductance regulator (CFTR) mutation. For these young children, it is essential to provide rigorous monitoring and care to avoid potential disease sequelae while awaiting HEMT availability. The following article highlights recent advances in the care of infants and young children with CF with regard to surveillance and treatment of nutritional, pulmonary, and gastrointestinal disorders. Recent clinical trials in this population are also reviewed.
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Affiliation(s)
- Thomas Lahiri
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jillian S Sullivan
- Divisions of Pediatric Pulmonology and Gastroenterology, University of Vermont Children's Hospital, Burlington, Vermont, USA
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van Dorst JM, Tam RY, Ooi CY. What Do We Know about the Microbiome in Cystic Fibrosis? Is There a Role for Probiotics and Prebiotics? Nutrients 2022; 14:nu14030480. [PMID: 35276841 PMCID: PMC8840103 DOI: 10.3390/nu14030480] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 12/12/2022] Open
Abstract
Cystic fibrosis (CF) is a life-shortening genetic disorder that affects the cystic fibrosis transmembrane conductance regulator (CFTR) protein. In the gastrointestinal (GI) tract, CFTR dysfunction results in low intestinal pH, thick and inspissated mucus, a lack of endogenous pancreatic enzymes, and reduced motility. These mechanisms, combined with antibiotic therapies, drive GI inflammation and significant alteration of the GI microbiota (dysbiosis). Dysbiosis and inflammation are key factors in systemic inflammation and GI complications including malignancy. The following review examines the potential for probiotic and prebiotic therapies to provide clinical benefits through modulation of the microbiome. Evidence from randomised control trials suggest probiotics are likely to improve GI inflammation and reduce the incidence of CF pulmonary exacerbations. However, the highly variable, low-quality data is a barrier to the implementation of probiotics into routine CF care. Epidemiological studies and clinical trials support the potential of dietary fibre and prebiotic supplements to beneficially modulate the microbiome in gastrointestinal conditions. To date, limited evidence is available on their safety and efficacy in CF. Variable responses to probiotics and prebiotics highlight the need for personalised approaches that consider an individual’s underlying microbiota, diet, and existing medications against the backdrop of the complex nutritional needs in CF.
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Affiliation(s)
- Josie M. van Dorst
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Rachel Y. Tam
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
| | - Chee Y. Ooi
- Discipline of Paediatrics & Child Health, Randwick Clinical Campus, School of Clinical Medicine, UNSW Medicine & Health, UNSW, Sydney 2031, Australia; (J.M.v.D.); (R.Y.T.)
- Molecular and Integrative Cystic Fibrosis (miCF) Research Centre, Sydney 2031, Australia
- Department of Gastroenterology, Sydney Children’s Hospital Randwick, Sydney 2031, Australia
- Correspondence:
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Scully KJ, Jay LT, Freedman S, Sawicki GS, Uluer A, Finkelstein JS, Putman MS. The Relationship between Body Composition, Dietary Intake, Physical Activity, and Pulmonary Status in Adolescents and Adults with Cystic Fibrosis. Nutrients 2022; 14:nu14020310. [PMID: 35057491 PMCID: PMC8777582 DOI: 10.3390/nu14020310] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 02/01/2023] Open
Abstract
Measures of body fat and lean mass may better predict important clinical outcomes in patients with cystic fibrosis (CF) than body mass index (BMI). Little is known about how diet quality and exercise may impact body composition in these patients. Dual X-ray absorptiometry (DXA) body composition, 24-h dietary recall, and physical activity were assessed in a cross-sectional analysis of 38 adolescents and adults with CF and 19 age-, race-, and gender-matched healthy volunteers. Compared with the healthy volunteers, participants with CF had a lower appendicular lean mass index (ALMI), despite no observed difference in BMI, and their diets consisted of higher glycemic index foods with a greater proportion of calories from fat and a lower proportion of calories from protein. In participants with CF, pulmonary function positively correlated with measures of lean mass, particularly ALMI, and negatively correlated with multiple measures of body fat after controlling for age, gender, and BMI. Higher physical activity levels were associated with greater ALMI and lower body fat. In conclusion, body composition measures, particularly ALMI, may better predict key clinical outcomes in individuals with CF than BMI. Future longitudinal studies analyzing the effect of dietary intake and exercise on body composition and CF-specific clinical outcomes are needed.
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Affiliation(s)
- Kevin J. Scully
- Division of Endocrinology, Boston Children’s Hospital, Boston, MA 02115, USA;
- Harvard Medical School, Boston, MA 02115, USA; (S.F.); (G.S.S.); (A.U.); (J.S.F.)
| | - Laura T. Jay
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Steven Freedman
- Harvard Medical School, Boston, MA 02115, USA; (S.F.); (G.S.S.); (A.U.); (J.S.F.)
- Division of Gastroenterology, Beth Israel Deaconess Hospital, Boston, MA 02115, USA
| | - Gregory S. Sawicki
- Harvard Medical School, Boston, MA 02115, USA; (S.F.); (G.S.S.); (A.U.); (J.S.F.)
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Ahmet Uluer
- Harvard Medical School, Boston, MA 02115, USA; (S.F.); (G.S.S.); (A.U.); (J.S.F.)
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
| | - Joel S. Finkelstein
- Harvard Medical School, Boston, MA 02115, USA; (S.F.); (G.S.S.); (A.U.); (J.S.F.)
- Division of Endocrinology, Massachusetts General Hospital, Boston, MA 02115, USA
| | - Melissa S. Putman
- Harvard Medical School, Boston, MA 02115, USA; (S.F.); (G.S.S.); (A.U.); (J.S.F.)
- Division of Endocrinology, Massachusetts General Hospital, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-857-218-5017; Fax: +1-617-730-0194
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Grammatikopoulou MG, Vassilakou T, Goulis DG, Theodoridis X, Nigdelis MP, Petalidou A, Gkiouras K, Poulimeneas D, Alexatou O, Tsiroukidou K, Marakis G, Daniil Z, Bogdanos DP. Standards of Nutritional Care for Patients with Cystic Fibrosis: A Methodological Primer and AGREE II Analysis of Guidelines. CHILDREN (BASEL, SWITZERLAND) 2021; 8:1180. [PMID: 34943375 PMCID: PMC8699992 DOI: 10.3390/children8121180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/25/2021] [Accepted: 12/09/2021] [Indexed: 12/25/2022]
Abstract
Although many Clinical Practice Guidelines (CPGs) have been published for the care of patients with Cystic Fibrosis (CF), including a variety of nutrition recommendations, the quality of these CPGs has never been evaluated. The aim of this study was to compare, review, and critically appraise CPGs for the nutritional management of CF, throughout the lifespan. We searched PubMed, Guidelines International Network (GIN), ECRI Institute, and Guidelines Central for CPGs, with information on the nutritional management of CF. Retrieved CPGs were appraised by three independent reviewers, using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument and checklist. A total of 22 CPGs (seven solely nutrition oriented), by 14 different publishers, were retrieved. The Thoracic Society of Australia and New Zealand CPGs scored the highest overall quality (94.4%), while the Paediatric Gastroenterology Society/Dietitians Association of Australia CPGs had the lowest score (27.8%). Great variation in AGREE II domain-specific scores was observed in all CPGs, suggesting the existence of different strengths and weaknesses. Despite the availability of several CPGs, many appear outdated, lacking rigor, transparency, applicability, and efficiency, while incorporating bias. Considering that CPGs adherence is associated with better outcomes and the need for improving life expectancy in patients with CF, the development of CPGs of better quality is deemed necessary.
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Affiliation(s)
- Maria G. Grammatikopoulou
- Department of Nutritional Sciences & Dietetics, Faculty of Health Sciences, Alexander Campus, International Hellenic University, 57400 Thessaloniki, Greece;
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece; (K.G.); (A.P.)
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece; (D.G.G.); (M.P.N.)
- 3rd Department of Pediatrics, Hippokration General Hospital of Thessaloniki, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Tonia Vassilakou
- Department of Public Health Policy, School of Public Health, University of West Attica, Athens University Campus, 11521 Athens, Greece;
| | - Dimitrios G. Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece; (D.G.G.); (M.P.N.)
| | - Xenophon Theodoridis
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Meletios P. Nigdelis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Papageorgiou General Hospital, Medical School, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece; (D.G.G.); (M.P.N.)
| | - Arianna Petalidou
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece; (K.G.); (A.P.)
| | - Konstantinos Gkiouras
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece; (K.G.); (A.P.)
- Medical School, Faculty of Health Sciences, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Dimitrios Poulimeneas
- Department of Nutrition & Dietetics, Harokopio University, 17676 Athens, Greece; (D.P.); (O.A.)
| | - Olga Alexatou
- Department of Nutrition & Dietetics, Harokopio University, 17676 Athens, Greece; (D.P.); (O.A.)
| | - Kyriaki Tsiroukidou
- 3rd Department of Pediatrics, Hippokration General Hospital of Thessaloniki, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Georgios Marakis
- Nutrition and Food Standards Unit, Risk Assessment and Nutrition Directorate, Hellenic Food Authority, 11526 Athens, Greece;
| | - Zoe Daniil
- Department of Respiratory Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece;
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41110 Larissa, Greece; (K.G.); (A.P.)
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Mangas-Sánchez C, Garriga-García M, Serrano-Nieto MJ, García-Romero R, Álvarez-Beltrán M, Crehuá-Gaudiza E, Muñoz-Codoceo R, Suárez-Cortina L, Vicente-Santamaría S, Martínez-Costa C, Díaz-Martin JJ, Bousoño-García C, González-Jiménez D. Vitamin D Status in Pediatric and Young Adult Cystic Fibrosis Patients. Are the New Recommendations Effective? Nutrients 2021; 13:nu13124413. [PMID: 34959965 PMCID: PMC8703649 DOI: 10.3390/nu13124413] [Citation(s) in RCA: 5] [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: 11/08/2021] [Revised: 12/05/2021] [Accepted: 12/07/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction: In recent years, guidelines for vitamin D supplementation have been updated and prophylactic recommended doses have been increased in patients with cystic fibrosis (CF). Objective: To evaluate safety and efficacy of these new recommendations. Results: Two cohorts of pancreatic insufficient CF patients were compared before (cohort 1: 179 patients) and after (cohort 2: 71 patients) American CF Foundation and European CF Society recommendations were published. Cohort 2 patients received higher Vitamin D doses: 1509 (1306–1711 95% CI) vs 1084 (983–1184 95% CI) IU/Day (p < 0.001), had higher 25 OH vitamin D levels: 30.6 (27.9–33.26 95% CI) vs. 27.4 (25.9–28.8 95% CI) ng/mL (p = 0.028), and had a lower prevalence of insufficient vitamin D levels (<30 ng/mL): 48% vs 65% (p = 0.011). Adjusted by confounding factors, patients in cohort 1 had a higher risk of vitamin D insufficiency: OR 2.23 (1.09–4.57 95% CI) (p = 0.028). Conclusion: After the implementation of new guidelines, CF patients received higher doses of vitamin D and a risk of vitamin D insufficiency decreased. Despite this, almost a third of CF patients still do not reach sufficient serum calcidiol levels.
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Affiliation(s)
- Carmen Mangas-Sánchez
- Pediatric Gastroenterology and Nutrition Section, Hospital Central de Asturias, 33011 Oviedo, Spain; (C.M.-S.); (C.B.-G.); (D.G.-J.)
| | - María Garriga-García
- Cystic Fibrosis Section, Hospital Ramón y Cajal, 28034 Madrid, Spain; (M.G.-G.); (L.S.-C.); (S.V.-S.)
| | | | - Ruth García-Romero
- Pediatric Gastroenterology and Nutrition Section, Hospital Miguel Servet, 50009 Zaragoza, Spain;
| | - Marina Álvarez-Beltrán
- Pediatric Gastroenterology and Nutrition Section, Hospital Vall d’ Hebron, 08035 Barcelona, Spain;
| | - Elena Crehuá-Gaudiza
- Pediatric Gastroenterology and Nutrition Section, Hospital Clínico de Valencia, 46010 Valencia, Spain; (E.C.-G.); (C.M.-C.)
| | - Rosana Muñoz-Codoceo
- Pediatric Gastroenterology and Nutrition Section, Hospital Infantil Niño Jesús, 28009 Madrid, Spain;
| | - Lucrecia Suárez-Cortina
- Cystic Fibrosis Section, Hospital Ramón y Cajal, 28034 Madrid, Spain; (M.G.-G.); (L.S.-C.); (S.V.-S.)
| | - Saioa Vicente-Santamaría
- Cystic Fibrosis Section, Hospital Ramón y Cajal, 28034 Madrid, Spain; (M.G.-G.); (L.S.-C.); (S.V.-S.)
| | - Cecilia Martínez-Costa
- Pediatric Gastroenterology and Nutrition Section, Hospital Clínico de Valencia, 46010 Valencia, Spain; (E.C.-G.); (C.M.-C.)
| | - Juan José Díaz-Martin
- Pediatric Gastroenterology and Nutrition Section, Hospital Central de Asturias, 33011 Oviedo, Spain; (C.M.-S.); (C.B.-G.); (D.G.-J.)
- Correspondence:
| | - Carlos Bousoño-García
- Pediatric Gastroenterology and Nutrition Section, Hospital Central de Asturias, 33011 Oviedo, Spain; (C.M.-S.); (C.B.-G.); (D.G.-J.)
| | - David González-Jiménez
- Pediatric Gastroenterology and Nutrition Section, Hospital Central de Asturias, 33011 Oviedo, Spain; (C.M.-S.); (C.B.-G.); (D.G.-J.)
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40
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Bauer SE, Lai HJ, McDonald CM, Asfour F, Slaven JE, Ren CL. Zinc status and growth in infants and young children with cystic fibrosis. Pediatr Pulmonol 2021; 56:3768-3776. [PMID: 34499426 PMCID: PMC8629965 DOI: 10.1002/ppul.25666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/20/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Zinc deficiency is associated with poor growth in children without cystic fibrosis (CF), but its impact on growth in children with CF is unknown. OBJECTIVE To determine the prevalence of low serum Zn (sZn) and its relationship with growth in the first 3 years of life in children with CF. METHODS We utilized data from infants with CF who were enrolled in a longitudinal study of nutrition and lung health and had sZn measured as part of clinical care. Cross-sectional correlations between sZn levels and growth z scores were assessed by Pearson's correlation coefficient. To identify factors associated with sZn status and its association to longitudinal growth patterns, multiple regression analysis with repeated measures were performed using generalized estimating equations. RESULTS A total of 106 sZn measurements from 53 infants were identified. Seventeen infants (32%) had intermittent Zn insufficiency, defined as at least one sZn <70 mcg/dl in their first 3 years of life. There were no significant cross-sectional associations between sZn and growth z scores. However, analysis of longitudinal growth patterns revealed that weight- and length-for-age z scores in children with intermittent Zn insufficiency were lower during early infancy and their weight-for-length z scores at age 3 years were also lower compared to those who were always Zn sufficient. CONCLUSION Low sZn occurs in one-third of children with CF in the first 3 years of life. Cross-sectional and longitudinal analyses revealed discrepant associations between sZn and growth. Therefore, prospective studies are needed to understand the role of Zn in growth in CF.
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Affiliation(s)
- Sarah E Bauer
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - HuiChuan J Lai
- Department of Nutritional Sciences, University of Wisconsin, Madison, Wisconsin, USA.,Department of Pediatrics, University of Wisconsin, Madison, Wisconsin, USA.,Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, USA
| | - Catherine M McDonald
- Department of Clinical Nutrition, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Fadi Asfour
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - James E Slaven
- Department of Biostatistics & Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Clement L Ren
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA
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41
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Kutney KA, Sandouk Z, Desimone M, Moheet A. Obesity in cystic fibrosis. J Clin Transl Endocrinol 2021; 26:100276. [PMID: 34868883 PMCID: PMC8626670 DOI: 10.1016/j.jcte.2021.100276] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/05/2021] [Accepted: 11/12/2021] [Indexed: 11/12/2022] Open
Abstract
The prevalence of obesity in patients with cystic fibrosis (CF) is increasing and around one-third of adults with CF are now overweight or obese. The causes of excess weight gain in CF are likely multifactorial, including: adherence to the high-fat legacy diet, reduced exercise tolerance, therapeutic advances, and general population trends. Increased weight has generally been considered favorable in CF, correlating with improved pulmonary function and survival. While the optimal BMI for overall health in CF is unknown, most studies demonstrate minimal improvement in pulmonary function when BMI exceeds 30 kg/m2. Dyslipidemia and cardiovascular disease are important co-morbidities of obesity in the general population, but are uncommon in CF. In people with CF, obesity is associated with hypertension and higher cholesterol levels. With longer life expectancy and rising obesity rates, there may be an increase in cardiovascular disease among people with CF in coming years. Overweight CF patients are more likely to be insulin resistant, taking on features of type 2 diabetes. Treating obesity in people with CF requires carefully weighing the metabolic risks of overnutrition with the impact of low or falling BMI on lung function. This article describes current knowledge on the epidemiology, causes, consequence, and treatment of obesity in people with CF.
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Affiliation(s)
- Katherine A. Kutney
- Department of Pediatrics, Division of Pediatric Endocrinology, University Hospitals, Rainbow Babies and Children’s Hospital Case Western Reserve University, 11100 Euclid Ave, Suite 737, Cleveland, OH 44106, USA
| | - Zahrae Sandouk
- Department of Internal Medicine, Division of Endocrinology, University of Michigan, USA
| | - Marisa Desimone
- Division of Endocrinology, Diabetes, and Metabolism, SUNY Upstate Medical University, USA
| | - Amir Moheet
- Department of Medicine, University of Minnesota, USA
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Corbera-Hincapie MA, Kurland KS, Hincapie MR, Fabio A, Weiner DJ, Kim SC, Kazmerski TM. Geospatial Analysis of Food Deserts and Their Impact on Health Outcomes in Children with Cystic Fibrosis. Nutrients 2021; 13:3996. [PMID: 34836250 PMCID: PMC8621515 DOI: 10.3390/nu13113996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/04/2021] [Accepted: 11/06/2021] [Indexed: 11/20/2022] Open
Abstract
Food insecurity (FI) is defined as "the limited or uncertain access to adequate food." One root cause of FI is living in a food desert. FI rates among people with cystic fibrosis (CF) are higher than the general United States (US) population. There is limited data on the association between food deserts and CF health outcomes. We conducted a retrospective review of people with CF under 18 years of age at a single pediatric CF center from January to December 2019 using demographic information and CF health parameters. Using a Geographic Information System, we conducted a spatial overlay analysis at the census tract level using the 2015 Food Access Research Atlas to assess the association between food deserts and CF health outcomes. We used multivariate logistic regression analysis and adjusted for clinical covariates and demographic covariates, using the Child Opportunity Index (COI) to calculate odds ratios (OR) with confidence intervals (CI) for each health outcome. People with CF living in food deserts and the surrounding regions had lower body mass index/weight-for-length (OR 3.18, 95% CI: 1.01, 9.40, p ≤ 0.05 (food desert); OR 4.41, 95% CI: 1.60, 12.14, p ≤ 0.05 (600 ft buffer zone); OR 2.83, 95% CI: 1.18, 6.76, p ≤ 0.05 (1200 ft buffer zone)). Food deserts and their surrounding regions impact pediatric CF outcomes independent of COI. Providers should routinely screen for FI and proximity to food deserts. Interventions are essential to increase access to healthy and affordable food.
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Affiliation(s)
- Montserrat A. Corbera-Hincapie
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.R.H.); (D.J.W.); (S.C.K.); (T.M.K.)
| | - Kristen S. Kurland
- School of Architecture, Heinz College of Information Systems and Public Policy, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Mark R. Hincapie
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.R.H.); (D.J.W.); (S.C.K.); (T.M.K.)
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh Epidemiology Data Center, Pittsburgh, PA 15260, USA;
| | - Daniel J. Weiner
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.R.H.); (D.J.W.); (S.C.K.); (T.M.K.)
| | - Sandra C. Kim
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.R.H.); (D.J.W.); (S.C.K.); (T.M.K.)
| | - Traci M. Kazmerski
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA; (M.R.H.); (D.J.W.); (S.C.K.); (T.M.K.)
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Breastfeeding in Cystic Fibrosis: A Systematic Review on Prevalence and Potential Benefits. Nutrients 2021; 13:nu13093263. [PMID: 34579139 PMCID: PMC8469582 DOI: 10.3390/nu13093263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022] Open
Abstract
Breastfeeding (BF) is considered the normative standard of feeding for all infants. However, the impact of BF in patients with cystic fibrosis (CF) is not completely defined. Therefore, we conducted a systematic review to evaluate BF prevalence in the CF population and its impact on anthropometric and pulmonary outcomes. We searched MEDLINE, Embase and the Cochrane Library for original articles published in English up to 4 December 2020 that report the prevalence of BF and/or any measure of association between BF and anthropometric or pulmonary outcomes. Nine observational studies were identified (six retrospective cohort studies, one prospective cohort study, one survey and one case–control study within a retrospective cohort). The BF rate in CF patients is lower than that of the healthy population (approximately 50–60% of infants were breastfed at any time). The benefits in anthropometric outcomes of BF for >2 months in this at-risk population are unclear. A few relatively small studies suggest a potential benefit of BF in reducing lung infections, although data are inconsistent. The currently available data are insufficient to draw definite conclusions on the benefits of exclusive BF in anthropometric and pulmonary outcomes in CF. Clinical trials evaluating well-defined BF promotion interventions are needed.
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Granados A, Beach EA, Christiansen AJ, Patterson BW, Wallendorf M, Arbeláez AM. The association between body composition, leptin levels and glucose dysregulation in youth with cystic fibrosis. J Cyst Fibros 2021; 20:796-802. [PMID: 34183284 PMCID: PMC8552309 DOI: 10.1016/j.jcf.2021.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 05/31/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Optimization of nutritional status is recommended in patients with cystic fibrosis (CF) given the association between lower body mass index (BMI) and poor clinical outcomes. However, higher BMI and body fat correlate with glucose impairment and higher leptin levels in the general population. Differences in body composition and leptin levels between the categories of glucose tolerance were assessed in youth with CF and healthy controls. METHODS In a cross-sectional study, 59 adolescents and young adults with CF and 15 healthy controls matched by age and gender, underwent body composition analysis using dual energy X-ray absorptiometry (DXA) and a 2-hour oral glucose tolerance test (OGTT). Measures of insulin sensitivity, β-cell insulin secretion and fasting leptin levels were obtained. RESULTS Of the participants with CF, 62% were classified as abnormal glucose tolerant and 22% with cystic fibrosis related diabetes (CFRD). Patients with CFRD had a lower fat mass index (FMI) z-score, wt z-score and leptin levels compared to the control group (-1.86 vs. - 0.59, p=0.01; -1.86 vs 0.44, p=<0.001 and 7.9 vs vs. 27.7 µg/L, p=0.01). Leptin correlated positively with FMI z-score, BMI, weight z-score and indices of insulin secretion. FMI z-score correlated positively with higher insulin resistance (HOMA-IR), and lower insulin sensitivity (Matsuda index) (r=0.31; p =0.01 and r=-0.29; p=0.02, respectively) in the CF group. CONCLUSIONS This study shows that despite new therapeutic strategies, youth with CF have lower body fat, weight z-score and leptin levels, particularly in subjects with early onset CFRD.
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Affiliation(s)
- Andrea Granados
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO. USA.
| | - Elizabeth A Beach
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO. USA
| | - Andrew J Christiansen
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO. USA
| | - Bruce W Patterson
- University of Nebraska Medical Center, Department of Surgery, Omaha, NE. USA
| | - Michael Wallendorf
- Washington University School of Medicine, Department of Medicine, St. Louis, MO. USA; Washington University School of Medicine, Division of Biostatistics, St. Louis, MO. USA
| | - Ana María Arbeláez
- Washington University School of Medicine, Department of Pediatrics, St. Louis, MO. USA
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McDonald CM, Alvarez JA, Bailey J, Bowser EK, Farnham K, Mangus M, Padula L, Porco K, Rozga M. Academy of Nutrition and Dietetics: 2020 Cystic Fibrosis Evidence Analysis Center Evidence-Based Nutrition Practice Guideline. J Acad Nutr Diet 2021; 121:1591-1636.e3. [PMID: 32565399 PMCID: PMC8542104 DOI: 10.1016/j.jand.2020.03.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Indexed: 12/13/2022]
Abstract
The Academy of Nutrition and Dietetics Evidence Analysis Center conducted a systematic review of the literature to develop an evidence-based practice guideline for primary nutrition issues in cystic fibrosis (CF). This guideline is designed to complement and build upon existing evidence-based CF nutrition guidelines. The objective of this guideline was to provide recommendations for registered dietitian nutritionists in the United States delivering medical nutrition therapy to individuals with CF and their families that fill gaps in current evidence-based guidelines on topics that are crucial in order to improve health and prevent disease progression. This guideline provides 28 nutrition recommendations to guide medical nutrition therapy, including nutrition screening, nutrition assessment, and dietary intake. For topics outside the scope of this guideline, practitioners are referred to external, evidence-based recommendations. The CF landscape is evolving rapidly with breakthroughs in cystic fibrosis transmembrane regulator modulators changing CF at a cellular level. Medical nutrition therapy for individuals with CF from infancy through advanced age requires novel and individualized approaches. The Academy Evidence Analysis Library CF guidelines provide a framework for expanding upon current knowledge to determine effective nutrition strategies for individuals with CF through long and healthy futures.
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Prieur MG, Christon LM, Mueller A, Smith BA, Georgiopoulos AM, Boat TF, Filigno SS. Promoting emotional wellness in children with cystic fibrosis, Part I: Child and family resilience. Pediatr Pulmonol 2021; 56 Suppl 1:S97-S106. [PMID: 32658376 DOI: 10.1002/ppul.24958] [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: 05/01/2020] [Revised: 07/09/2020] [Accepted: 07/10/2020] [Indexed: 01/06/2023]
Abstract
Attention should be given to individual and family well-being from a child's first interaction with the medical team and continuing throughout development, especially for families who experience chronic illnesses, such as cystic fibrosis (CF). While much attention has been given to the mental health of people with CF 12 years and older, this paper explores various areas for CF teams to assess and provide additional resources during the first 12 years of a child's life to promote child and family wellness. In this paper, we discuss parental mental health, social determinants of health, adherence/self-care, nutrition, attention to family lifestyle factors, engagement with school and peers, and modulator therapy for this age group of people with CF. This is the first of two companion papers which examines emotional wellness of children during the early years. The second paper examines mental health assessment and intervention for children under 12. Both encourage teams to strive to promote optimal child and family emotional health and wellness, emphasizing holistic health promotion and prevention, early identification, and intervention.
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Affiliation(s)
- Mary G Prieur
- Departments of Psychiatry and Pediatricsm School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lillian M Christon
- Department of Psychiatry and Behavioral Science, Medical University of South Carolina, Charleston, South Carolina
| | | | - Beth A Smith
- Division of Child & Adolescent Psychiatry, University at Buffalo-The State University of New York, Buffalo, New York
| | | | - Thomas F Boat
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stephanie S Filigno
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Zysman-Colman ZN, Kilberg MJ, Harrison VS, Chesi A, Grant SFA, Mitchell J, Sheikh S, Hadjiliadis D, Rickels MR, Rubenstein RC, Kelly A. Genetic potential and height velocity during childhood and adolescence do not fully account for shorter stature in cystic fibrosis. Pediatr Res 2021; 89:653-659. [PMID: 32386398 PMCID: PMC7649126 DOI: 10.1038/s41390-020-0940-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 02/27/2020] [Accepted: 04/27/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite improved health, shorter stature is common in cystic fibrosis (CF). We aimed to describe height velocity (HV) and contribution of height-related genetic variants to height (HT) in CF. METHODS HV cohort: standard deviation scores (-Z) for HT, mid-parental height-adjusted HT (MPAH), and HV were generated using our Pediatric Center's CF Foundation registry data. HV-Z was compared with population means at each age (5-17 y), the relationship of HV-Z with HT-Z assessed, and HT-Z compared with MPAH-Z. GRS cohort: HT genetic risk-Z (HT-GRS-Z) were determined for pancreatic exocrine sufficient (PS) and insufficient (PI) youth and adults from our CF center and their relationships with HT-Z assessed. RESULTS HV cohort: average HV-Z was normal across ages in our cohort but was 1.5× lower (p < 0.01) for each SD decrease in HT-Z. MPAH-Z was lower than HT-Z (p < 0.001). GRS cohort: HT-GRS-Z more strongly correlated with HT-Z and better explained height variance in PS (rho = 0.42; R2= 0.25) vs. PI (rho = 0.27; R2 = 0.11). CONCLUSIONS Despite shorter stature compared with peers and mid-parental height, youth with CF generally have normal linear growth in mid- and late childhood. PI tempered the heritability of height. These results suggest that, in CF, final height is determined early in life in CF and genetic potential is attenuated by other factors. IMPACT Children with CF remain shorter than their healthy peers despite advances in care. Our study demonstrates that children with CF have persistent shorter stature from an early age and fail to reach their genetic potential despite height velocities comparable to those of average maturing healthy peers and similar enrichment in known height increasing single-nucleotide polymorphisms (SNPs). Genetic risk scores better explained variability in pancreatic sufficient than in pancreatic insufficient individuals, suggesting that other modifying factors are in play for pancreatic insufficient individuals with CF. Given the CF Foundation's recommendation to target not only normal body mass index, but normal height percentiles as well, this study adds valuable insight to this discussion.
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Affiliation(s)
| | - Marissa J. Kilberg
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Victor S. Harrison
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alessandra Chesi
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Struan F. A. Grant
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA,Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jonathan Mitchell
- Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Saba Sheikh
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Denis Hadjiliadis
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael R. Rickels
- Division of Endocrinology, Diabetes & Metabolism, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ronald C. Rubenstein
- Division of Pulmonary Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA,corresponding author: Ronald C. Rubenstein, Pulmonary Medicine and Cystic Fibrosis Center, The Children’s Hospital of Philadelphia, Abramson Research Center Room 410A, 34th & Civic Center Blvd, Philadelphia, PA 19104, Phone: 215-590-1281, Fax: 215-590-1283,
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA
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Middour-Oxler B, Gettis M, Dye B. Decreased Wait Time and Increased Satisfaction With Bedside Pancreatic Enzyme Dosing for the Inpatient Adolescent With Cystic Fibrosis: A Quality Improvement Project Comparing Enzyme Self-Administration to Nurse Administration. J Patient Exp 2021; 8:2374373520981490. [PMID: 34179359 PMCID: PMC8205326 DOI: 10.1177/2374373520981490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
For children with cystic fibrosis (CF), enzymes are essential with meals to absorb nutrients and ensure adequate growth. When hospitalized, CF patients typically rely on nurse-administered medications. Recently, a pediatric hospital unit began allowing adolescents with CF enzymes at the bedside. Postimplementation, a satisfaction questionnaire was administered to participating patients and nurses measuring patient and nurse satisfaction with access to bedside enzymes versus nurse administration and overall time for enzyme delivery. The survey utilized a 5-point Likert scale. The wait time for pancreatic enzymes decreased for self-administered enzymes when compared to those that were nurse administered. All (11/11) patients and 86% (12/14) of nurses preferred the self-administration of enzymes. Hospitalized pediatric CF patients and nurses had higher levels of satisfaction with enzyme self-administration. Immediate access to enzymes in room safes impact patient autonomy, reflecting home self-care practices. Decreases in wait times optimize nutritional growth and healing while hospitalized. As a result, a new limited scope policy allowing patient-administered enzymes is now in place in the pediatric inpatient CF unit.
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Affiliation(s)
- Brandi Middour-Oxler
- Division of Pulmonary, Allergy/Immunology, Cystic Fibrosis and Sleep, Department of Pediatrics, Emory University, Atlanta, GA, USA.,Children's Healthcare of Atlanta and Emory University Center for Cystic Fibrosis, Emory University, Atlanta, GA, USA
| | - Margaret Gettis
- Children's Healthcare of Atlanta, Scottish Rite, Atlanta, GA, USA
| | - Betsy Dye
- Children's Healthcare of Atlanta, Scottish Rite, Atlanta, GA, USA
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Calvo-Lerma J, Roca M, Boon M, Colombo C, de Koning B, Fornés-Ferrer V, Masip E, Garriga M, Bulfamante A, Asensio-Grau A, Andrés A, de Boeck K, Hulst J, Ribes-Koninckx C. Association between faecal pH and fat absorption in children with cystic fibrosis on a controlled diet and enzyme supplements dose. Pediatr Res 2021; 89:205-210. [PMID: 32247283 DOI: 10.1038/s41390-020-0860-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/31/2019] [Accepted: 02/19/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Despite treatment with pancreatic enzyme replacement therapy (PERT), patients with cystic fibrosis (CF) can still suffer from fat malabsorption. A cause could be low intestinal pH disabling PERT. The aim of this study was to assess the association between faecal pH (as intestinal pH surrogate) and coefficient of fat absorption (CFA). Additionally, faecal free fatty acids (FFAs) were quantified to determine the amount of digested, but unabsorbed fat. METHODS In a 24-h pilot study, CF patients followed a standardised diet with fixed PERT doses, corresponding to theoretical optimal doses determined by an in vitro digestion model. Study variables were faecal pH, fat and FFA excretion, CFA and transit time. Linear mixed regression models were applied to explore associations. RESULTS In 43 patients, median (1st, 3rd quartile) faecal pH and CFA were 6.1% (5.8, 6.4) and 90% (84, 94), and they were positively associated (p < 0.001). An inverse relationship was found between faecal pH and total fat excretion (p < 0.01), as well as total FFA (p = 0.048). Higher faecal pH was associated with longer intestinal transit time (p = 0.049) and the use of proton pump inhibitors (p = 0.009). CONCLUSIONS Although the clinical significance of faecal pH is not fully defined, its usefulness as a surrogate biomarker for intestinal pH should be further explored. IMPACT Faecal pH is a physiological parameter that may be related to intestinal pH and may provide important physiopathological information on CF-related pancreatic insufficiency. Faecal pH is correlated with fat absorption, and this may explain why pancreatic enzyme replacement therapy is not effective in all patients with malabsorption related to CF. Use of proton pump inhibitors is associated to higher values of faecal pH. Faecal pH could be used as a surrogate biomarker to routinely monitor the efficacy of pancreatic enzyme replacement therapy in clinical practice. Strategies to increase intestinal pH in children with cystic fibrosis should be targeted.
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Affiliation(s)
- Joaquim Calvo-Lerma
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain. .,Research Institute of Food Engineering for Development, Universitat Politècnica de València, 46022, Valencia, Spain.
| | - Maria Roca
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain
| | - Mieke Boon
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals, 3000, Leuven, Belgium
| | - Carla Colombo
- CF Center, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122, Milan, Italy
| | - Barbara de Koning
- Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Etna Masip
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain
| | - Maria Garriga
- Hospital Universitario Ramón y Cajal, 28034, Madrid, Spain
| | - Anna Bulfamante
- CF Center, Università degli Studi di Milano, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122, Milan, Italy
| | - Andrea Asensio-Grau
- Research Institute of Food Engineering for Development, Universitat Politècnica de València, 46022, Valencia, Spain
| | - Ana Andrés
- Research Institute of Food Engineering for Development, Universitat Politècnica de València, 46022, Valencia, Spain
| | - Kris de Boeck
- Pediatric Pulmonology and Cystic Fibrosis Unit, Department of Pediatrics, University Hospitals, 3000, Leuven, Belgium
| | - Jessie Hulst
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - Carmen Ribes-Koninckx
- Cystic Fibrosis Unit, Instituto de Investigación Sanitaria La Fe de Valencia, 46026, Valencia, Spain
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50
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Fat-soluble Vitamin Deficiency is Common in Children With Chronic Pancreatitis Undergoing Total Pancreatectomy With Islet Autotransplantation. J Pediatr Gastroenterol Nutr 2021; 72:123-126. [PMID: 32960829 DOI: 10.1097/mpg.0000000000002950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
The prevalence of fat-soluble vitamin (FSV) deficiency in children undergoing total pancreatectomy with islet autotransplantation (TPIAT) for chronic pancreatitis (CP) is unknown. We quantified FSV deficiency in 100 children (age ≤18) undergoing TPIAT. FSV levels (vitamins A, E, D) and clinical history were abstracted from medical records. Vitamin A was low in 4% before and 7% at 1 year after TPIAT, vitamin E in 17% and 18%, and vitamin D in 22% and 24%, respectively, regardless of pancreatic enzyme or vitamin supplement dosing. Longer duration of CP was associated with pre-TPIAT vitamin D insufficiency (P = 0.0002). This remained significant in a multivariate regression model (adjusted P = 0.01). On multivariate analysis, there were no significant predictors of low FSV levels post-TPIAT. FSV deficiencies are common among children undergoing TPIAT and patients who have had longer disease duration may be at increased risk. All children should be monitored for FSV deficiency after TPIAT.
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