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Gama MI, Daly A, Ashmore C, Evans S, Moreira-Rosário A, Rocha JC, MacDonald A. Impact on Diet Quality and Burden of Care in Sapropterin Dihydrochloride Use in Children with Phenylketonuria: A 6 Month Follow-Up Report. Nutrients 2023; 15:3603. [PMID: 37630793 PMCID: PMC10459538 DOI: 10.3390/nu15163603] [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: 07/30/2023] [Revised: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION In phenylketonuria (PKU) changes in dietary patterns and behaviors in sapropterin-responsive populations have not been widely reported. We aimed to assess changes in food quality, mental health and burden of care in a paediatric PKU sapropterin-responsive cohort. METHODS In an observational, longitudinal study, patient questionnaires on food frequency, neophobia, anxiety and depression, impact on family and burden of care were applied at baseline, 3 and 6-months post successful sapropterin-responsiveness testing (defined as a 30% reduction in blood phenylalanine levels). RESULTS 17 children (10.8 ± 4.2 years) completed 6-months follow-up. Patients body mass index (BMI) z-scores remained unchanged after sapropterin initiation. Blood phenylalanine was stable. Natural protein increased (p < 0.001) and protein substitute intake decreased (p = 0.002). There were increases in regular cow's milk (p = 0.001), meat/fish, eggs (p = 0.005), bread (p = 0.01) and pasta (p = 0.011) intakes but special low-protein foods intake decreased. Anxiety (p = 0.016) and depression (p = 0.022) decreased in caregivers. The impact-on-family, familial-social impact (p = 0.002) and personal strain (p = 0.001) lessened. After sapropterin, caregivers spent less time on PKU tasks, the majority ate meals outside the home more regularly and fewer caregivers had to deny food choices to their children. CONCLUSION There were significant positive changes in food patterns, behaviors and burden of care in children with PKU and their families after 6-months on sapropterin treatment.
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Affiliation(s)
- Maria Inês Gama
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (M.I.G.); (A.D.); (C.A.); (S.E.)
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas da Universidade NOVA de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (A.M.-R.); (J.C.R.)
| | - Anne Daly
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (M.I.G.); (A.D.); (C.A.); (S.E.)
| | - Catherine Ashmore
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (M.I.G.); (A.D.); (C.A.); (S.E.)
| | - Sharon Evans
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (M.I.G.); (A.D.); (C.A.); (S.E.)
| | - André Moreira-Rosário
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas da Universidade NOVA de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (A.M.-R.); (J.C.R.)
- CINTESIS@RISE, Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas da Universidade NOVA de Lisboa, Campo dos Mártires da Pátria 130, 1169-056 Lisboa, Portugal; (A.M.-R.); (J.C.R.)
- CINTESIS@RISE, Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade NOVA de Lisboa, 1169-056 Lisboa, Portugal
- Reference Centre of Inherited Metabolic Diseases, Centro Hospitalar Universitário de Lisboa Central, 1169-045 Lisboa, Portugal
| | - Anita MacDonald
- Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (M.I.G.); (A.D.); (C.A.); (S.E.)
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Suitability and Allocation of Protein-Containing Foods According to Protein Tolerance in PKU: A 2022 UK National Consensus. Nutrients 2022; 14:nu14234987. [PMID: 36501017 PMCID: PMC9736047 DOI: 10.3390/nu14234987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: There is little practical guidance about suitable food choices for higher natural protein tolerances in patients with phenylketonuria (PKU). This is particularly important to consider with the introduction of adjunct pharmaceutical treatments that may improve protein tolerance. Aim: To develop a set of guidelines for the introduction of higher protein foods into the diets of patients with PKU who tolerate >10 g/day of protein. Methods: In January 2022, a 26-item food group questionnaire, listing a range of foods containing protein from 5 to >20 g/100 g, was sent to all British Inherited Metabolic Disease Group (BIMDG) dietitians (n = 80; 26 Inherited Metabolic Disease [IMD] centres). They were asked to consider within their IMD dietetic team when they would recommend introducing each of the 26 protein-containing food groups into a patient’s diet who tolerated >10 g to 60 g/day of protein. The patient protein tolerance for each food group that received the majority vote from IMD dietetic teams was chosen as its tolerance threshold for introduction. A virtual meeting was held using Delphi methodology in March 2022 to discuss and agree final consensus. Results: Responses were received from dietitians from 22/26 IMD centres (85%) (11 paediatric, 11 adult). For patients tolerating protein ≥15 g/day, the following foods were agreed for inclusion: gluten-free pastas, gluten-free flours, regular bread, cheese spreads, soft cheese, and lentils in brine; for protein tolerance ≥20 g/day: nuts, hard cheeses, regular flours, meat/fish, and plant-based alternative products (containing 5−10 g/100 g protein), regular pasta, seeds, eggs, dried legumes, and yeast extract spreads were added; for protein tolerance ≥30 g/day: meat/fish and plant-based alternative products (containing >10−20 g/100 g protein) were added; and for protein tolerance ≥40 g/day: meat/fish and plant-based alternatives (containing >20 g/100 g protein) were added. Conclusion: This UK consensus by IMD dietitians from 22 UK centres describes for the first time the suitability and allocation of higher protein foods according to individual patient protein tolerance. It provides valuable guidance for health professionals to enable them to standardize practice and give rational advice to patients.
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Evers RAF, van Wegberg AMJ, MacDonald A, Huijbregts SCJ, Leuzzi V, van Spronsen FJ. Dietary Liberalization in Tetrahydrobiopterin-Treated PKU Patients: Does It Improve Outcomes? Nutrients 2022; 14:nu14183874. [PMID: 36145250 PMCID: PMC9504284 DOI: 10.3390/nu14183874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose: this systematic review aimed to assess the effects of dietary liberalization following tetrahydrobiopterin (BH4) treatment on anthropometric measurements, nutritional biomarkers, quality of life, bone density, mental health and psychosocial functioning, and burden of care in PKU patients. Methods: the PubMed, Cochrane, and Embase databases were searched on 7 April 2022. We included studies that reported on the aforementioned domains before and after dietary liberalization as a result of BH4 treatment in PKU patients. Exclusion criteria were: studies written in a language other than English; studies that only included data of a BH4 loading test; insufficient data for the parameters of interest; and wrong publication type. Both within-subject and between-subject analyses were assessed, and meta-analyses were performed if possible. Results: twelve studies containing 14 cohorts and 228 patients were included. Single studies reported few significant differences. Two out of fifteen primary meta-analyses were significant; BMI was higher in BH4-treated patients versus controls (p = 0.02; standardized mean difference (SMD) (95% confidence interval (CI)) = −0.37 (−0.67, −0.06)), and blood cholesterol concentrations increased after starting BH4 treatment (p = 0.01; SMD (CI) = −0.70 (−1.26, −0.15)). Conclusion: there is no clear evidence that dietary liberalization after BH4 treatment has a positive effect on anthropometric measurements, nutritional biomarkers, or quality of life. No studies could be included for bone density, mental health and psychosocial functioning, and burden of care.
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Affiliation(s)
- Roeland A. F. Evers
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - Annemiek M. J. van Wegberg
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Birmingham B4 6NH, UK
| | - Stephan C. J. Huijbregts
- Department of Clinical Child and Adolescent Studies-Neurodevelopmental Disorders, Faculty of Social Sciences, Leiden University, 2300 RB Leiden, The Netherlands
| | - Vincenzo Leuzzi
- Unit of Child Neurology and Psychiatry, Department of Human Neuroscience, Sapienza University of Rome, 00185 Rome, Italy
| | - Francjan J. van Spronsen
- Division of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
- Correspondence: ; Tel.: +31-(0)50-3614147
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van Wegberg A, Evers R, Burgerhof J, van Dam E, Heiner-Fokkema MR, Janssen M, de Vries MC, van Spronsen FJ. Effect of BH4 on blood phenylalanine and tyrosine variations in patients with phenylketonuria. Mol Genet Metab 2021; 133:49-55. [PMID: 33766497 DOI: 10.1016/j.ymgme.2021.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with phenylketonuria, stability of blood phenylalanine and tyrosine concentrations might influence brain chemistry and therefore patient outcome. This study prospectively investigated the effects of tetrahydrobiopterin (BH4), as a chaperone of phenylalanine hydroxylase on diurnal and day-to-day variations of blood phenylalanine and tyrosine concentrations. METHODS Blood phenylalanine and tyrosine were measured in dried blood spots (DBS) four times daily for 2 days (fasting, before lunch, before dinner, evening) and once daily (fasting) for 6 days in a randomized cross-over design with a period with BH4 and a period without BH4. The sequence was randomized. Eleven proven BH4 responsive PKU patients participated, 5 of them used protein substitutes during BH4 treatment. Natural protein intake and protein substitute dosing was adjusted during the period without BH4 in order to keep DBS phenylalanine levels within target range. Patients filled out a 3-day food diary during both study periods. Variations of DBS phenylalanine and Tyr were expressed in standard deviations (SD) and coefficient of variation (CV). RESULTS BH4 treatment did not significantly influence day-to-day phenylalanine and tyrosine variations nor diurnal phenylalanine variations, but decreased diurnal tyrosine variations (median SD 17.6 μmol/l, median CV 21.3%, p = 0.01) compared to diet only (median SD 34.2 μmol/l, median CV 43.2%). Consequently, during BH4 treatment diurnal phenylalanine/tyrosine ratio variation was smaller, while fasting tyrosine levels tended to be higher. CONCLUSION BH4 did not impact phenylalanine variation but decreased diurnal tyrosine and phenylalanine/tyrosine ratio variations, possibly explained by less use of protein substitute and increased tyrosine synthesis.
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Affiliation(s)
- Amj van Wegberg
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Raf Evers
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Jgm Burgerhof
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - E van Dam
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, the Netherlands
| | - M R Heiner-Fokkema
- Department of Laboratory Medicine, Laboratory of Metabolic Diseases, University of Groningen, University Medical Centre Groningen, the Netherlands
| | - McH Janssen
- Department of Internal Medicine, Radboudumc, Nijmegen, the Netherlands
| | - M C de Vries
- Department of Pediatrics, Radboudumc Nijmegen, the Netherlands
| | - F J van Spronsen
- Division of Metabolic Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, the Netherlands.
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Sousa C, Almeida MF, Sousa Barbosa C, Martins E, Janeiro P, Tavares de Almeida I, MacDonald A, Rocha JC. The European Phenylketonuria Guidelines and the challenges on management practices in Portugal. J Pediatr Endocrinol Metab 2019; 32:623-629. [PMID: 31141484 DOI: 10.1515/jpem-2018-0527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/01/2019] [Indexed: 12/30/2022]
Abstract
Background Phenylketonuria (PKU) management practices differ between and within countries. In 2007, the Portuguese Society for Metabolic Disorders (SPDM) approved the Portuguese Consensus (PC) for the nutritional treatment of PKU. The recently published European PKU Guidelines (EPG, 2017) systematically reviewed recent evidence and aimed to harmonise treatment protocols in Europe. The objective of this study was to appraise the EPG acceptance and implementation in Portuguese treatment centres. Methods An electronic questionnaire was prepared and the link was sent to 135 SPDM members. It outlined the 10 EPG key recommendations and compared each statement with the consensus recommendations published by SPDM. Responses were recorded and descriptive analyses were performed. Results Twenty-five professionals completed the questionnaire, and over half (56%) were nutritionists/dieticians. At least one questionnaire from each of the 10 national treatment centres was returned. In general, responders accepted most of the recommendations. However, only the recommendation about target phenylalanine (Phe) concentrations between 120 and 360 μmol/L for patients <12 years received 100% consensus with a further seven recommendations gaining over 70% consensus. Almost half of the professionals (48%, n = 12) required further discussion about the EPG-safe upper target blood Phe concentration (600 μmol/L) suggested for patients aged ≥12 years. Almost one third (32%, n = 8) failed to agree with the recommendation in the EPG-proposed classification of Phe hydroxylase (PAH) deficiency. Conclusions The EPG received overall good acceptance, but there was divided opinion about some recommendations which require further discussion before implementation by the Portuguese treatment centres.
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Affiliation(s)
- Cátia Sousa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Manuela Ferreira Almeida
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | - Catarina Sousa Barbosa
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Faculdade de Ciências da Nutrição e Alimentação da Universidade do Porto, Porto, Portugal
| | - Esmeralda Martins
- Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Unit for Multidisciplinary Research in Biomedicine, Abel Salazar Institute of Biomedical Sciences, University of Porto-UMIB/ICBAS/UP, Porto, Portugal
| | - Patrícia Janeiro
- Reference Centre for the Treatment of Inborn Errors of Metabolism, CHULN, Lisbon, Portugal
| | | | | | - Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Referência na área de Doenças Hereditárias do Metabolismo, Centro Hospitalar Universitário do Porto - CHUP, Porto, Portugal.,Centro de Genética Médica, Doutor Jacinto de Magalhães, CHUP, EPE, Praça Pedro Nunes 88, 4099-028 Porto, Portugal.,Center for Health Technology and Services Research [CINTESIS], Porto, Portugal
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Dobrowolski SF, Tourkova IL, Robinson LJ, Secunda C, Spridik K, Blair HC. A bone mineralization defect in the Pah enu2 model of classical phenylketonuria involves compromised mesenchymal stem cell differentiation. Mol Genet Metab 2018; 125:193-199. [PMID: 30201326 PMCID: PMC6542264 DOI: 10.1016/j.ymgme.2018.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/29/2022]
Abstract
Osteopenia is observed in some patients affected by phenylalanine hydroxylase (PAH) deficient phenylketonuria (PKU). Bone density studies, in diverse PKU patient cohorts, have demonstrated bone disease is neither fully penetrant nor uniform in bone density loss. Biochemical assessment has generated a muddled perspective regarding mechanisms of the PKU bone phenotype where the participation of hyperphenylalaninemia remains unresolved. Osteopenia is realized in the Pahenu2 mouse model of classical PKU; although, characterization is incomplete. We characterized the Pahenu2 bone phenotype and assessed the effect of hyperphenylalaninemia on bone differentiation. Employing Pahenu2 and control animals, cytology, static and dynamic histomorphometry, and biochemistry were applied to further characterize the bone phenotype. These investigations demonstrate Pahenu2 bone density is decreased 33% relative to C57BL/6; bone volume/total volume was similarly decreased; trabecular thickness was unchanged while increased trabecular spacing was observed. Dynamic histomorphometry demonstrated a 25% decrease in mineral apposition. Biochemically, control and PKU animals have similar plasma cortisol, adrenocorticotropic hormone, and 25-hydroxyvitamin D. PKU animals show moderately increased plasma parathyroid hormone while plasma calcium and phosphate are reduced. These data are consistent with a mineralization defect. The effect of hyperphenylalaninemia on bone maturation was assessed in vitro employing bone-derived mesenchymal stem cells (MSCs) and their differentiation into bone. Using standard culture conditions, PAH deficient MSCs differentiate into bone as assessed by in situ alkaline phosphatase activity and mineral staining. However, PAH deficient MSCs cultured in 1200 μM PHE (metric defining classical PKU) show significantly reduced mineralization. These data are the first biological evidence demonstrating a negative impact of hyperphenylalaninemia upon bone maturation. In PAH deficient MSCs, expression of Col1A1 and Rankl are suppressed by hyperphenylalaninemia consistent with reduced bone formation and bone turnover. Osteopenia is intrinsic to PKU pathology in untreated Pahenu2 animals and our data suggests PHE toxicity participates by inhibiting mineralization in the course of MSC bone differentiation.
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Affiliation(s)
- Steven F Dobrowolski
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.
| | - Irina L Tourkova
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lisa J Robinson
- Department of Pathology, Ruby Memorial Hospital, West Virginia University, Morgantown, WV, United States
| | - Cassandra Secunda
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kayla Spridik
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Harry C Blair
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States; Veteran's Affairs Medical Center, Pittsburgh, PA, United States
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Rocha JC, MacDonald A. Treatment options and dietary supplements for patients with phenylketonuria. Expert Opin Orphan Drugs 2018. [DOI: 10.1080/21678707.2018.1536541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Júlio César Rocha
- Centro de Genética Médica, Centro Hospitalar do Porto - CHP, Porto, Portugal
- Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Porto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
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Evers RAF, van Wegberg AMJ, van Dam E, de Vries MC, Janssen MCH, van Spronsen FJ. Anthropomorphic measurements and nutritional biomarkers after 5 years of BH 4 treatment in phenylketonuria patients. Mol Genet Metab 2018; 124:238-242. [PMID: 30078395 DOI: 10.1016/j.ymgme.2018.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 06/17/2018] [Accepted: 06/17/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Roeland A F Evers
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Annemiek M J van Wegberg
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands; Radboud University Medical Center Nijmegen, Department of Gastroenterology and Hepatology-Dietetics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Esther van Dam
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands
| | - Maaike C de Vries
- Radboud University Medical Center Nijmegen, Department of Pediatrics, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Mirian C H Janssen
- Radboud University Medical Center, Department of Internal Medicine, PO box 9101, 6500 HB Nijmegen, The Netherlands
| | - Francjan J van Spronsen
- University of Groningen, University Medical Center Groningen, Division of Metabolic Diseases, PO box 30.001, 9700 RB Groningen, The Netherlands.
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Vitamins, Amino Acids and Drugs and Formulations Used in Nutrition. SIDE EFFECTS OF DRUGS ANNUAL 2017. [DOI: 10.1016/bs.seda.2017.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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