Effect of Zinc Supplementation on Body Composition of Duchenne Muscular Dystrophy Patients: A Quasi-Experimental Study

Background

The study hypothesized that zinc supplementation would increase or preserve lean body mass in Duchenne muscular dystrophy (DMD) patients. Therefore, we aimed to evaluate the body composition of DMD patients before and after zinc supplementation.

Materials and Methods

The study is a clinical trial comprising 21 boys diagnosed with DMD. Dietary intake parameters were evaluated before zinc supplementation. Serum zinc levels, anthropometry, and body composition were measured in three moments, four months apart. The patients received 5, 10, or 15 mg of zinc bis-glycine supplementation according to age as an oral solution daily for four months. The sample was distributed into two groups according to serum zinc status: zinc deficiency (G1) or adequate zinc (G2).

Results

There was a significant difference in lean body mass between the groups: zinc deficiency (G1) or adequate zinc (G2), at three times (p=0.041, 0.016, and 0.009, respectively). After oral zinc supplementation, serum zinc levels were not different between groups. We did not observe differences when associating the parameters between times and groups.

Conclusion

Zinc supplementation was able to maintain lean body mass and fat mass in patients with DMD with previous deficiencies. Therefore, it is necessary to have a prior screening of serum zinc levels to observe changes after supplementation.

Validity of dietary assessment methods compared with doubly labeled water in children: A systematic review and meta-analysis

OBJECTIVES

We aimed to validate dietary assessment methods against the gold standard, doubly labeled water (DLW), for estimating total energy intake (TEI).

METHODS

PubMed, Scopus, Web of Science, and Google Scholar databases were searched until May 2023. Inclusion criteria encompassed studies involving participants aged 1-18 years, employing dietary assessment methods like food records, dietary histories, food frequency questionnaire (FFQ), or 24-h recalls estimating TEI alongside DLW to measure total energy expenditure (TEE). Data were pooled using random-effects meta-analysis models.

RESULTS

Thirty-three studies were identified, with sample sizes ranging from 9 to 118 participants. Meta-analysis of 22 studies identified underestimation of TEI (mean difference [MD] = -262.9 kcal/day [95% CI: -380.0, -145.8]; I2 = 93.55%) for food records compared with TEE estimated by DLW. Other dietary assessment methods, including food recalls (n = 9) (MD = 54.2 kcal/day [95% CI: -19.8, 128.1]; I2 = 49.62%), FFQ (n = 7) (MD = 44.5 kcal/day [95% CI: -317.8, 406.8]; I2 = 94.94%), and diet history (n = 3) (MD = -130.8 kcal/day [95% CI: -455.8, 194.1]; I2 = 77.48%), showed no significant differences in TEI compared with DLW-estimated TEE. All studies were of high quality.

CONCLUSION

Food records may underestimate TEI, yet additional research is needed to identify the most accurate methods for assessing children's dietary intake.

Pilot study of a virtual weight management program for Duchenne muscular dystrophy

INTRODUCTION/AIMS

Young people with Duchenne muscular dystrophy (DMD) are at increased risk of obesity. Weight management is important to families; however, several barriers exist. This pilot study aimed to investigate the feasibility and acceptability of a co-designed weight management program for DMD.

METHODS

The Supporting Nutrition and Optimizing Wellbeing Program (SNOW-P) was a single-arm diet and behavior weight management intervention delivered via weekly telehealth/phone visits over 6 weeks to young people with DMD and obesity (body mass index (BMI) ≥95th percentile) and their caregivers. Using an online survey, caregivers of boys with DMD were consulted on the structure and topics delivered in SNOW-P. Primary outcomes were feasibility and acceptability; secondary outcomes were weight, physical function, and quality of life at 6- and 12-weeks follow-up.

RESULTS

Of nineteen eligible participants, eight were enrolled (median age 11.4 years, range 4.9-15.8), and seven completed the program. Visit attendance was high (88%-100%); most participants reported high satisfaction and that participation was easy. Suggested changes included online and visual DMD-specific resources. At 6-weeks, median change in weight z-scores was -0.01 (IQR: -0.23, 0.17) indicating that on average, weight gain tracked as expected for age. Waist circumference measured by caregivers lacked accuracy and the completion rate of caregiver-reported secondary outcome measures (e.g., food diaries) was low.

DISCUSSION

A co-designed, telehealth/phone weight management program appeared to be feasible and acceptable in a small group of boys with DMD. An adapted, hybrid telehealth and face-to-face program is recommended for efficacy testing.

How is Physical Activity Measured in Spinal Muscular Atrophy and Duchenne Muscular Dystrophy?

BACKGROUND

Physical activity (PA) provides many substantial benefits to help reduce risk for cardiometabolic disease, improve cognitive function, and improve quality of life. Individuals with neuromuscular disorders (NMDs), such as spinal muscular atrophy (SMA) and Duchenne muscular dystrophy (DMD) are characterized by muscular weakness and fatigue, which limits the capacity to reach the recommended guidelines of PA. Measuring PA in these populations can provide insight to participation in daily activities, track disease progression, and monitor efficacy of drug treatments.

OBJECTIVE

The objective of this study was to identify how PA is measured in SMA and DMD using instrumented and self-report methods, and how these methods are employed in ambulatory and non-ambulatory groups.

METHODS

A scoping review was performed to identify studies that reported PA in these neuromuscular disorders. Inclusion was determined after a multi-stage review process by several reviewers, followed by an in-depth analysis of metrics reported by each tool that was used.

RESULTS

A total of nineteen studies were identified and included in this review. Sixteen studies included instrumented measures and four studies utilized self-reported measures, with eleven studies also reporting PA information from a non-ambulatory group. A variety of metrics have been reported using both classes of measurement tools.

CONCLUSION

Although a wide variety of research exists that details both instrumented and self-reported measurement tools, feasibility, cost, and study aims are important factors to consider in addition to testing methodology when selecting which type of tool to use. We recommend using a combination of instrumented and self-report measures to provide context to the PA measured in these populations. Improvements in both instrumented and self-report methodologies will add valuable knowledge about the disease burden and efficacy of treatment and disease management methods in SMA and DMD.

The Relation Between Nutritional Intake and Weight in 4–18 Year Old Patients with DMD: What could possibly be done to prevent weight gain?

Background: Overweight is a common problem in Duchenne muscular dystrophy (DMD) and is associated with reduced mobility and quality of life. The influence of nutritional intake on (over)weight is unclear. Objective: To investigate weight and energy and macronutrients intake compared to age-specific requirements in DMD patients (4–18 years). Methods: We assessed weight and body mass index (BMI) and the amount of energy (kcal/day) and macronutrients based on self-reported nutrition diaries. Nutritional intake was compared to requirements for 3 age-groups according to the Dutch Healthy Diet Guideline (4–8/9–13/14–18 years) using a student’s t-test, and relations with age and BMI were investigated by means of Pearson’s correlations. Results: Forty-eight patients participated, 22 ambulatory, median age 10.8 years. The majority used corticosteroids (N = 41). Overweight (BMI z-score >  2.07) was present in 19 patients; 6% (4–8 years), 73% (9–13 years) and 47% (14–18 years). Overweight was more common in non-ambulatory (61.6%) than ambulatory patients (13.6%). Patients aged 4–8 received 290 kcal/day more than required (p <  0.001). Patients aged 9–13 received 349 kcal/day (p = 0.005) less than required. Overall, intake of fibre, nuts, meat/fish/eggs/legumes and dairy was lower than recommended (p <  0.05). The difference between energy intake versus requirement correlated moderately to age (r = –0.549, p <  0.001) and BMI (r = –0.562, p <  0.001). Conclusions: Overweight was found especially in patients aged 9–18 even though they received less energy than required. Younger patients (4–8) had good weight but consumed more energy than required. All patients did not consume enough fibre, nuts, meat/fish/eggs/legumes and dairy. Limiting energy and increasing fibre/protein intake at an early age may prevent overweight at a later age.

Parents' Inadequate Estimate of Their Children's Objectively Physical Activity Level

This study aimed to investigate parents' estimation of their preschool children's leisure-time physical activity (PA) and the correlation between parents' reported participation in PA with their children in leisure time and their children's PA levels. A total of 244 Norwegian preschool children aged 4-6 and their parents were enrolled in the study. According to standard protocols, the children's PA level was measured with Actigraph GT1M accelerometers. The parents completed a questionnaire that provided information about their estimation of their children's PA and their reported participation in their children's PA. Correlation analyses and scatter plots showed no significant association between parents' estimation of their children's PA level at leisure time and the children's objectively measured PA level. Only 5% of the parents estimated their children's PA level correctly. In general, the parents overestimated their children's PA levels by three times. Furthermore, the results found no significant correlation between children's PA levels at leisure time and parents' reported participation in PA with their children. Our findings indicate that parents' self-estimation of their children's PA is inaccurate, which is problematic. Considering that the PA levels of many children are too low to fulfill internationally established health recommendations, parents' 'wrong' perception about their children's PA urgently needs to be addressed and rectified.

The association between dietary factors and body weight and composition in boys with Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy (DMD) is a X-linked neuromuscular disorder. Boys with DMD have high rates of obesity, but little is known about dietary factors that may contribute to weight gain in this population. This study aimedto explore the relationship between dietary factors, body mass index (BMI) z-score, body composition and motor function and to describe dietary intake in boys with DMD.

METHODOLOGY

A cross-sectional analysis of 3-day food diaries from ambulant and steroid treated boys with DMD aged 5-13 years was conducted. Correlation analysis explored the relationship between dietary factors, BMI z-score, fat mass % (FM%) and lean mass (LM%).

RESULTS

Themedian agewas 8.5 years [interquartile range (IQR) 7.2, 10.5]. Median energy/kg/day in those within a healthy weight range (n=11) was316 kJ/kg/day [IQR 276, 355] and greater than estimated requirements; and forthose above a healthy weight (n=26) energy intake was 185kJ/kg/day [IQR 143, 214] and lower than estimated requirements. Energy/kg/day was negatively associatedwith BMI z-score (r=-0. 650) and FM% (r=-0.817)but positively associated with LM% (r=0.805, all analyses p =<0.01). Younger age was associated (r=-0.609 p=<0.01) with a higher energy/kg/day. For all participants vegetable, grains, meat/alternatives and dairy intake was sub-optimal.

PRINCIPAL CONCLUSIONS

Younger boys with DMD within a healthy weight range are overconsuming energy dense nutrient poor foods. A focus on improving diet quality during early childhood may prove a useful strategy to reduce excess weight gain and support healthier eating habits in this vulnerable clinical population. This article is protected by copyright. All rights reserved.

Development of clinical practice guidelines for allied health and nursing assessment and management of Duchenne muscular dystrophy

PURPOSE

To provide evidence-based guidance specific to allied health and nursing practice for the assessment and management of individuals with Duchenne muscular dystrophy (DMD).

MATERIALS AND METHODS

Thirteen key focus areas were identified in consultation with health professionals and consumer advocacy groups. A series of systematic literature reviews were conducted to identify assessment and management strategies for each key focus area. A consensus process using modified Delphi methodology, including an Australia-New Zealand expert consensus meeting, was conducted. Recommendations underwent consultative review with key groups before being finalised and prepared for dissemination.

RESULTS

This clinical practice guideline (CPG) generated 19 evidence-based recommendations, 117 consensus-based recommendations and five research recommendations across the 13 focus areas to inform allied health assessment and management of individuals with DMD.

CONCLUSIONS

The resulting recommendations can be used in conjunction with existing medical CPGs to improve, standardise and advocate for allied health and rehabilitation care in DMD. The process used here may be useful for the development of CPGs in other rare diseases.Implications for rehabilitationImplementation-ready evidence-based statements to guide clinical care of individuals with DMD are provided with the potential to improve participation, function in the community and quality of life.A model for developing best practice statements for other rare neurological diseases is described.Allied health and nursing health professionals should focus research efforts to generate quality evidence to support rehabilitation practice.

Effect of a multicomponent nutritional supplement on functional outcomes for Duchenne muscular dystrophy: A randomized controlled trial

BACKGROUND & AIMS

Duchenne muscular dystrophy (DMD) is an X-linked neuromuscular condition causing progressive muscle weakness and premature death. Whilst effective treatments such as gene therapy are developed, families often seek complementary therapies such as nutrition supplements to help their son maintain function; however, there is limited evidence supporting the use of nutritional supplements in DMD. This study aimed to compare the effect of a Standard nutritional supplement with an Enhanced nutritional supplement combining three nutriceuticals on functional outcomes in ambulatory boys with Duchenne muscular dystrophy (DMD).

DESIGN

A 50-week double blinded, randomized, controlled crossover trial was conducted in four Australian neuromuscular centres. Primary outcome measures were 6-min walk distance (6MWD) and community ambulation (StepWatch™ Activity Monitoring). Secondary outcome measures included body composition and quality of life. Serum 25-hydroxyvitamin D was measured.

RESULTS

Twenty-seven boys completed the intervention. Traditional crossover analysis demonstrated the Enhanced supplement compared to the Standard supplement was associated with a difference of +12 (95% CI: -16, 40) metres in 6MWD, +0.5 (95% CI: -53, 54) inactive minutes per day and -95 (95% CI: -887, 696) steps per day. A mixed effect model indicated a potentially clinically important effect of the Enhanced supplement on the 6MWD of +31 (95% CI: -19, 81) metres. Mean serum 25 hydroxyvitamin D levels at week 50 was 94 (95% CI: 84, 104) nmol/L. There was no observable effect of either supplement regime on body composition or quality of life.

CONCLUSIONS

Whilst a positive effect of the Enhanced supplement on functional outcomes was observed, this finding was inconclusive due to the small sample size. The results do not support the use of combined nutritional supplements to improve body composition or quality of life in DMD. A dose of 2000 IU vitamin D was an adequate dose to raise serum 25-hydroxyvitamin D over 50 weeks.

CLINICAL TRIAL REGISTRY

Registry #: ACTRN12610000462088, http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12610000462088.

A systematic review of the validity of dietary assessment methods in children when compared with the method of doubly labelled water

Assessing energy intake (EI) in children and adolescents is essential for monitoring population nutrition trends and interpreting clinical outcomes. The aim of this review was to examine the validity of dietary assessment methods for estimating EI in children and adolescents when compared with total energy expenditure (TEE) measured using doubly labelled water (DLW). Six online databases were searched to identify articles published in English. Studies were included if they were conducted in participants aged ≤18 years, if they estimated EI via a dietary assessment method, and if they compared this estimate to TEE measured using the DLW method. The search strategy identified 345 articles, of which 13 articles (12 studies) (n = 306 children) met the selection criteria. Five studies were carried out in children aged 5-11 years with dietary intake of children reported by parents/caregivers. The most common dietary assessment methods used were food frequency questionnaires (n = 5) and weighed food records (n = 4). All methods were found to have some level of misreporting. Child characteristics including weight status, age, and sex were not found to consistently influence the accuracy of reported EI. Five studies employing technology-assisted approaches for assessing dietary intake in children were identified and reported mixed findings. Validity studies using DLW remain sparse in the literature. Studies including participants less than 5 years or older than 11 years, and from diverse ethnicities and socioeconomic backgrounds are warranted to explore other demographic differences that may affect the accuracy of dietary assessment methods. While reported in few studies, technology-assisted methods were found to perform equally well in estimating intakes when compared to DLW and other traditional forms of dietary assessment.

Feasibility and Acceptability of a Self-Report Activity Diary in Families of Children With and Without Special Needs

This study was conducted to examine the feasibility and acceptability of a self-report activity diary completed by parents and older children to assess the child's daily activity in children with and without special needs. The study included 36 child/parent dyads stratified by child age and diagnosis. Parents (n = 36) and children ≥13 years (n = 12) were asked to report on the child's daily activity using an activity diary. Feasibility was determined based on successfully returned diaries and acceptability via post-study interview. Activity diaries were submitted by 94% of the parents and 100% of the children, with 83% and 80%, respectively, successfully completed. Comments provided post-study regarding the diaries were primarily on the format and were generally negative. The activity diary was feasible to use, but not well accepted within our sample of children with and without special needs or their parents. Further research is needed to create valid physical activity assessment measures that are population specific for individuals with special needs.

Relationships between muscle size, strength, and physical activity in adults with muscular dystrophy

BACKGROUND

Muscular dystrophy (MD) is characterized by progressive muscle wasting and weakness, yet few comparisons to non-MD controls (CTRL) of muscle strength and size in this adult population exist. Physical activity (PA) is promoted to maintain health and muscle strength within MD; however, PA reporting in adults with MD is limited to recall data, and its impact on muscle strength is seldom explored.

METHODS

This study included 76 participants: 16 non-MD (CTRL, mean age 35.4), 15 Duchenne MD (DMD, mean age 24.2), 18 Becker's MD (BMD, mean age 42.4), 13 limb-girdle MD (LGMD, mean age 43.1), and 14 facioscapulohumeral MD (mean age 47.7). Body fat (%) and lean body mass (LBM) were measured using bioelectrical-impedance. Gastrocnemius medialis (GM) anatomical cross-sectional area (ACSA) was determined using B-mode ultrasound. Isometric maximal voluntary contraction (MVC) was assessed during plantar flexion (PFMVC) and knee extension (KEMVC). PA was measured for seven continuous days using triaxial accelerometry and was expressed as daily average minutes being physically active (TPAmins ) or average daily percentage of waking hours being sedentary (sedentary behaviour). Additionally, 10 m walk time was assessed.

RESULTS

Muscular dystrophy groups had 34-46% higher body fat (%) than CTRL. DMD showed differences in LBM with 21-28% less LBM than all other groups. PFMVC and KEMVC were 36-75% and 24-92% lower, respectively, in MD groups than CTRL. GM ACSA was 47% and 39% larger in BMD and LGMD, respectively, compared with CTRL. PFMVC was associated with GM ACSA in DMD (P = 0.026, R = 0.429) and CTRL (P = 0.015, R = 0.553). MD groups were 14-38% more sedentary than CTRL groups, while DMD were more sedentary than BMD (14%), LGMD (8%), and facioscapulohumeral MD (14%). Sedentary behaviour was associated with LBM in DMD participants (P = 0.021, R = -0.446). TPAmins was associated with KEMVC (P = 0.020, R = 0.540) in BMD participants, while TPAmins was also the best predictor of 10 m walk time (P < 0.001, R2  = 0.540) in ambulant MD, revealed by multiple linear regression.

CONCLUSIONS

Quantified muscle weakness and impaired 10 m walking time is reported in adults with MD. Muscle weakness and 10 m walk time were associated with lower levels of TPA in adults with MD. Higher levels of sedentary behaviour were associated with reduced LBM in DMD. These findings suggest a need for investigations into patterns of PA behaviour, and relevant interventions to reduce sedentary behaviour and encourage PA in adults with MD regardless of impairment severity.

The relationship between dietary intake, growth and body composition in Phenylketonuria

AIM

Phenylketonuria (PKU) is an inborn error of protein metabolism that results from perturbation in phenylalanine hydroxylase activity leading to elevated blood levels of phenylalanine (phe). We aimed to explore the relationships between dietary patterns (total-protein, natural-protein, amino-acid formula), and the ratio of protein to energy intake with growth and body composition.

METHOD

Longitudinal prospective data (1-6 measurements) of growth, dietary intake and body composition in patients treated with phe-restricted diet only (D-PKU; n=32), and tetrahydrobiopterin (BH₄)±phe-restricted diet (BH₄-PKU; n=5) were collected over a two-year period. Healthy siblings provided control data (n=21).

RESULTS

There were no significant differences in weight-, height-, BMI z-score or percent body fat mass (%fatmass) between the D-PKU, BH₄-PKU and control groups or between the all-types of PKU combined and controls, which confirmed 'normal' growth in the PKU cohort. Total-protein intake in the all-types of PKU group met or exceeded WHO safe protein recommendations. There were no significant relationships between anthropometric and dietary variables. Significant negative correlations were found in body composition: %fatmass and total-protein intake (r_s=-0.690, p≤0.001), natural-protein intake (r_s=-0.534, p=0.001), and AAF intake (r_s=-0.510, p=0.001). Age was significantly correlated with %fatmass (r_s=0.493, p=0.002) A total-protein intake of 1.5-2.6g/kg/day and natural-protein intake >0.5g/kg/day were associated with improved body composition. An apparent safe P:E ratio of 3.0-4.5g protein/100kcal was strongly associated with appropriate growth outcomes.

CONCLUSIONS

Clinical decision-making needs to consider both the enhancement of natural-protein tolerance and the application of an apparent 'safe' protein to energy ratio to support optimal growth and body composition in PKU.

Measuring Habitual Physical Activity in Neuromuscular Disorders: A Systematic Review

BACKGROUND

Free-living or habitual physical activity (HPA) refers to someone's performance in his or her free-living environment. Neuromuscular disorders (NMD) manifest through HPA, and the observation of HPA can be used to identify clinical risks and to quantify outcomes in research. This review summarizes and analyses previous studies reporting the assessment of HPA in NMD, and may serve as the basis for evidence-based decision-making when considering assessing HPA in this population.

METHODS

A systematic review was performed to identify all studies related to HPA in NMD, followed by a critical appraisal of the assessment methodology and a final review of the identified HPA tools.

RESULTS

A total of 22 studies were selected, reporting on eight different direct tools (or activity monitors) and ten structured patient-reported outcomes. Overall, HPA patterns in NMD differ from healthy control populations. There was a noticeable lack of validation studies for these tools and outcome measures in NMD. Very little information regarding feasibility and barriers for the application of these tools in this population have been published.

CONCLUSIONS

The variety and heterogeneity of tools and methods in the published literature makes the comparison across different studies difficult, and methodological guidelines are warranted. We propose a checklist of considerations for the assessment and reporting of HPA in NMD.

Modeling the dynamics of BMI changes during adolescence. The Oporto Growth, Health and Performance Study

OBJECTIVES

The aims of this study were twofold: (i) to model changes in body mass index (BMI) of 10-18-year-old adolescents, and (ii) to investigate the effects of total physical activity (TPA), physical fitness (PF), sleep duration and fruit/vegetable consumption in BMI trajectories across time.

METHODS

Data were obtained from the Oporto Growth, Health and Performance Study and comprised 6894 adolescents (3418 girls) divided into four age cohorts (10, 12, 14 and 16 years) measured annually for 3 years. BMI was computed using the standard formula (kg m(-2)); TPA was estimated with the Baecke questionnaire; PF measures included 1-mile run/walk, 50 yard dash (50YD), standing long jump (SLJ), handgrip strength (HGr) and agility shuttle run. Longitudinal changes in BMI were analyzed using the multilevel modeling approach.

RESULTS

The average BMI at age of peak of height velocity was 20.7±0.07 kg m(-2) for girls (P<0.001) and 20.58±0.06 kg m(-2) for boys (P<0.001). The annual increment in BMI was 1.36±0.04 kg m(-2), P<0.001 and 1.23±0.03 kg m(-2), P<0.001 for girls and boys, respectively. PF were related to BMI trajectories in both sexes (Girls: β1mile=0.12±0.02, P<0.001; βSLJ=-0.01±0.00, P<0.001; β50YD=0.28±0.05, P<0.001; βHGr=-8.91±0.54, P<0.001; Boys: β1mile=0.18±0.02, P<0.001; βSLJ=-0.01±0.00, P<0.001; β50YD=0.26±0.04, P<0.001; and βHGr=-8.15±0.45, P<0.001). TPA only showed significant, but positive, association with girls' BMI trajectories (β=0.10±0.03, P=0.001). After adjusting for the covariates, sleep duration and fruit/vegetable intake did not show any significant association with BMI trajectories either sex.

CONCLUSIONS

BMI increased linearly with age in both gender. PF levels are negatively associated with BMI across time in both boys and girls. Therefore, promotion of PF in the adolescent years seems to be effective in the early prevention of obesity.