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Hu H, Zhang P, Yin J, Wang L, Lu Y, Guo H. The effect of aspartame on accelerating caspase-dependent apoptosis of pancreatic islet via ZIPK/STAT3/caspase 3 signaling pathway. J Physiol Biochem 2024; 80:53-65. [PMID: 37906422 DOI: 10.1007/s13105-023-00980-2] [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: 12/30/2022] [Accepted: 08/08/2023] [Indexed: 11/02/2023]
Abstract
Aspartame (ASP) as an important sugar substitute is widely used in pharmaceutical and food processing. Here, we compared the effects of ASP and sucrose on mice pancreatic islet cells in vivo and observed that ASP with the condition of high concentration and long-term exposure (HASP) could cause insulin secretion (500 mg/kg for 1 month). Next, we conducted iTRAQ mass spectrometry to profile the global phosphoproteome and found that phosphorylation of zipper-interacting protein kinase (ZIPK) in murine pancreatic islet tissues were induced at Thr197, Thr242, Thr282, and Ser328 by high-sucrose (HS) treatment, but only induced at Thr197 and Ser328 by HASP treatment. Simultaneously, phosphorylation of STAT3 could be induced at Tyr705 and Ser727 by HS but not by HASP. Furthermore, presence of activated STAT3 accompanied with autophagy was observed in HS treatment. In turn, the inactivation of STAT3 as well as enhanced expression of caspase 3 was observed in HASP treatment. We generated Thr242APro and Thr282Pro on ZIPK using CRISPR-Cas9 in β-TC3 cells and found the weakened interaction with STAT3 as well as the reduced phosphorylation of STAT3 even under HS stimulation. Finally, we observed that ankyrin repeat domain containing 11 (ANKRD11) could interact with ZIPK and play an inhibitory role in the phosphorylation of Thr242APro and Thr282Pro of ZIPK. However, HASP can induce the retention of ANKRD11 in the cytoplasm by phenylpyruvic acid (the metabolite of ASP). Taken together, this study determined that ASP with high concentration and long-term exposure could lead to caspase-dependent apoptosis of pancreatic islet cells through ANKRD11/ZIPK/STAT3 inhibition. Our results give evidence of adverse effects of aspartame on islet cells in some extreme conditions, which might help people to reconsider the biosafety of non-nutritive sweeteners.
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Affiliation(s)
- Haiying Hu
- Department of Clinical Nutrition, The Second Affiliated Hospital of Zhejiang University, 88, Jiefang Road, Shangcheng District, Zhejiang, 310009, Hangzhou, China.
| | - Pianhong Zhang
- Department of Clinical Nutrition, The Second Affiliated Hospital of Zhejiang University, 88, Jiefang Road, Shangcheng District, Zhejiang, 310009, Hangzhou, China
| | - Junhua Yin
- Department of General Practice, The Second Affiliated Hospital of Zhejiang University, Zhejiang, Hangzhou, China
| | - Leilei Wang
- Department of Clinical Nutrition, The Second Affiliated Hospital of Zhejiang University, 88, Jiefang Road, Shangcheng District, Zhejiang, 310009, Hangzhou, China
| | - Yanyu Lu
- Department of Clinical Nutrition, The Second Affiliated Hospital of Zhejiang University, 88, Jiefang Road, Shangcheng District, Zhejiang, 310009, Hangzhou, China
| | - Huilan Guo
- Department of Clinical Nutrition, The Second Affiliated Hospital of Zhejiang University, 88, Jiefang Road, Shangcheng District, Zhejiang, 310009, Hangzhou, China
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Schorb S, Gleiss K, Wedekind R, Suonio E, Kull AK, Kuntz M, Walch SG, Lachenmeier DW. Assessment of Aspartame (E951) Occurrence in Selected Foods and Beverages on the German Market 2000-2022. Foods 2023; 12:2156. [PMID: 37297402 PMCID: PMC10252593 DOI: 10.3390/foods12112156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/12/2023] Open
Abstract
This study examines the occurrence of the artificial sweetener aspartame (E951) in foods and beverages sampled by food control authorities in Germany between 2000 and 2022. The dataset was obtained through the Consumer Information Act. Out of 53,116 samples analyzed, aspartame was present in 7331 samples (14%), of which 5703 samples (11%) in nine major food groups were further evaluated. The results showed that aspartame was most commonly found in powdered drink bases (84%), flavored milk drinks (78%), chewing gum (77%), and diet soft drinks (72%). In the solid food groups, the highest mean aspartame content was detected in chewing gum (1543 mg/kg, n = 241), followed by sports foods (1453 mg/kg, n = 125), fiber supplements (1248 mg/kg, n = 11), powdered drink bases (1068 mg/kg, n = 162), and candies (437 mg/kg, n = 339). Liquid products generally had the highest aspartame content in diet soft drinks (91 mg/L, n = 2021), followed by regular soft drinks (59 mg/L, n = 574), flavored milk drinks (48 mg/kg, n = 207), and mixed beer drinks (24 mg/L, n = 40). These results suggest that aspartame is commonly used in some foods and beverages in Germany. The levels of aspartame found were generally within the legal limits set by the European Union. These findings provide the first comprehensive overview of aspartame in the German food market and may be particularly useful in informing the forthcoming working groups of the WHO International Agency for Research on Cancer (IARC) and the WHO/FAO Joint Expert Committee on Food Additives (JECFA), which are in the process of evaluating the human health hazards and risks associated with the consumption of aspartame.
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Affiliation(s)
- Sydney Schorb
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany; (S.S.); (K.G.); (M.K.); (S.G.W.)
| | - Katharina Gleiss
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany; (S.S.); (K.G.); (M.K.); (S.G.W.)
| | - Roland Wedekind
- Evidence Synthesis and Classification Branch, International Agency for Research on Cancer, 25 Avenue Tony Garnier, 69366 Lyon, France; (R.W.); (E.S.)
| | - Eero Suonio
- Evidence Synthesis and Classification Branch, International Agency for Research on Cancer, 25 Avenue Tony Garnier, 69366 Lyon, France; (R.W.); (E.S.)
| | - Ann-Kathrin Kull
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany; (S.S.); (K.G.); (M.K.); (S.G.W.)
| | - Marcel Kuntz
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany; (S.S.); (K.G.); (M.K.); (S.G.W.)
| | - Stephan G. Walch
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany; (S.S.); (K.G.); (M.K.); (S.G.W.)
| | - Dirk W. Lachenmeier
- Chemisches und Veterinäruntersuchungsamt (CVUA) Karlsruhe, Weissenburger Strasse 3, 76187 Karlsruhe, Germany; (S.S.); (K.G.); (M.K.); (S.G.W.)
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Rondanelli M, Porta F, Gasparri C, Barrile GC, Cavioni A, Mansueto F, Mazzola G, Patelli Z, Peroni G, Pirola M, Razza C, Tartara A, Perna S. A food pyramid for adult patients with phenylketonuria and a systematic review on the current evidences regarding the optimal dietary treatment of adult patients with PKU. Clin Nutr 2023; 42:732-763. [PMID: 37001196 DOI: 10.1016/j.clnu.2023.03.007] [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: 09/02/2022] [Revised: 03/03/2023] [Accepted: 03/07/2023] [Indexed: 03/31/2023]
Abstract
Early dietary treatment is mind-saving in patients with phenylketonuria. A "diet-for-life" is advocated, aimed to prevent effects of chronic exposure to hyperphenylalaninemia. While adherence to diet is significant during childhood as patients are followed-up at specialized metabolic centers, during adolescence and adulthood percentage of patients discontinuing diet and/or lost at follow-up is still high. The process of passing skills and responsibilities from pediatric team to adult team is defined "transition". The goal of transition clinics is to set up specific multidisciplinary care pathways and guarantee continuity of care and compliance of patients to care. In 2017, "The complete European guidelines on phenylketonuria" were published. These guidelines, however, do not provide an easy way to illustrate to adult patients how to follow correct dietary approach. The purpose of this review is to evaluate current evidence on optimum dietary treatment of adults with phenylketonuria and to provide food pyramid for this population. The pyramid built shows that carbohydrates should be consumed every day (3 portions), together with fruits and vegetables (5 portions), extra virgin olive oil, and calcium water (almost 1 L/day); weekly portions can include 150 g potatoes walnuts and hazelnuts (20 g). At top of pyramid, there are two pennants. The green means that, based on individual metabolic phenotype and daily phenylalanine tolerance, patients need personalized supplementation (specific phenylalanine free amino acid mixtures, vitamins and omega 3 fatty acids); the one red indicates foods that are banned from diet (aspartame and protein foods exceeding individual dietary phenylalanine tolerance).
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Affiliation(s)
- Mariangela Rondanelli
- IRCCS Mondino Foundation, 27100 Pavia, Italy; Unit of Human and Clinical Nutrition, Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy.
| | - Francesco Porta
- Department of Pediatrics, Città Della Salute e Della Scienza University Hospital, University of Torino, Piazza Polonia 94, 10126, Turin, Italy.
| | - Clara Gasparri
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Gaetan Claude Barrile
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Alessandro Cavioni
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Francesca Mansueto
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Giuseppe Mazzola
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Zaira Patelli
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Gabriella Peroni
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Martina Pirola
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Claudia Razza
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Alice Tartara
- Endocrinology and Nutrition Unit, Azienda di Servizi Alla Persona ''Istituto Santa Margherita'', University of Pavia, 27100 Pavia, Italy.
| | - Simone Perna
- Division of Human Nutrition, Department of Food, Environmental and Nutritional Sciences (DeFENS), Università Degli Studi di Milano, 20122 Milano, Italy.
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Soyseven M, Sezgin B, Acar E, Arli G. Green, Rapid, Robust Determination of Aspartame in Beverages by High-Performance Liquid Chromatography-Evaporative Light Scattering Detection (HPLC-ELSD): Method Development and Validation. ANAL LETT 2022. [DOI: 10.1080/00032719.2022.2146129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Murat Soyseven
- Department of Medical Services and Techniques, Yunus Emre Vocational School of Health Services, Department of Medical Services and Techniques, Anadolu University, Eskişehir, Turkey
| | - Burcu Sezgin
- Department of Environmental Protection Technologies, Eskişehir Vocational School, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Ebrar Acar
- Department of Analytical Chemistry, Faculty of Pharmacy, Anadolu University, Eskişehir, Turkey
| | - Göksel Arli
- Department of Medical Services and Techniques, Yunus Emre Vocational School of Health Services, Department of Medical Services and Techniques, Anadolu University, Eskişehir, Turkey
- Department of Analytical Chemistry, Faculty of Pharmacy, Anadolu University, Eskişehir, Turkey
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Savin M, Vrkatić A, Dedić D, Vlaški T, Vorgučin I, Bjelanović J, Jevtic M. Additives in Children's Nutrition-A Review of Current Events. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13452. [PMID: 36294032 PMCID: PMC9603407 DOI: 10.3390/ijerph192013452] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Additives are defined as substances added to food with the aim of preserving and improving safety, freshness, taste, texture, or appearance. While indirect additives can be found in traces in food and come from materials used for packaging, storage, and technological processing of food, direct additives are added to food with a special purpose (canning). The use of additives is justified if it is in accordance with legal regulations and does not pose a health or danger to consumers in the prescribed concentration. However, due to the specificity of the child's metabolic system, there is a greater risk that the negative effects of the additive will manifest. Considering the importance of the potential negative impact of additives on children's health and the increased interest in the control and monitoring of additives in food for children, we have reviewed the latest available literature available through PubMed, Scopus, and Google Scholar. Expert data were taken from publicly available documents published from January 2010 to April 2022 by internationally recognized professional organizations. It was found that the most frequently present additives in the food consumed by children are bisphenols, phthalates, perfluoroalkyl chemicals, perchlorates, pesticides, nitrates and nitrites, artificial food colors, monosodium glutamate, and aspartame. Increasing literacy about the presence and potential risk through continuous education of parents and young people as well as active monitoring of newly registered additives and harmonization of existing legal regulations by competent authorities can significantly prevent the unwanted effects of additives on children's health.
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Affiliation(s)
- Marijana Savin
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
- Institute for Child and Youth Health Care of Vojvodina, Hajduk Veljkova 10, 21000 Novi Sad, Serbia
| | - Aleksandra Vrkatić
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
| | - Danijela Dedić
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
- Emergency Service, Community Health Center Šid, Alekse Šantića 1, 22239 Šid, Serbia
| | - Tomislav Vlaški
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
| | - Ivana Vorgučin
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
- Institute for Child and Youth Health Care of Vojvodina, Hajduk Veljkova 10, 21000 Novi Sad, Serbia
| | - Jelena Bjelanović
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
- Institute of Public Health of Vojvodina, Futoška 121, 21000 Novi Sad, Serbia
| | - Marija Jevtic
- Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000 Novi Sad, Serbia
- Institute of Public Health of Vojvodina, Futoška 121, 21000 Novi Sad, Serbia
- Research Center on Environmental Health and Occupational Health, School of Public Health, Université Libre de Bruxelles (ULB), 1050 Bruxelles, Belgium
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Newbould E, Pinto A, Evans S, Ford S, O’Driscoll M, Ashmore C, Daly A, MacDonald A. Accidental Consumption of Aspartame in Phenylketonuria: Patient Experiences. Nutrients 2021; 13:nu13020707. [PMID: 33672234 PMCID: PMC7926728 DOI: 10.3390/nu13020707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/04/2022] Open
Abstract
Aspartame is a phenylalanine containing sweetener, added to foods and drinks, which is avoided in phenylketonuria (PKU). However, the amount of phenylalanine provided by aspartame is unidentifiable from food and drinks labels. We performed a cross-sectional online survey aiming to examine the accidental aspartame consumption in PKU. 206 questionnaires (58% female) were completed. 55% of respondents (n = 114) were adults with PKU or their parent/carers and 45% (n = 92) were parents/carers of children with PKU. 74% (n = 152/206) had consumed food/drinks containing aspartame. Repeated accidental aspartame consumption was common and more frequent in children (p < 0.0001). The aspartame containing food/drinks accidentally consumed were fizzy drinks (68%, n = 103/152), fruit squash (40%, n = 61/152), chewing gum (30%, n = 46/152), flavoured water (25%, n = 38/152), ready to drink fruit squash cartons (23%, n = 35/152) and sports drinks (21%, n = 32/152). The main reasons described for accidental consumption, were manufacturers’ changing recipes (81%, n = 123/152), inability to check the ingredients in pubs/restaurants/vending machines (59%, n = 89/152) or forgetting to check the label (32%, n = 49/152). 23% (n= 48/206) had been prescribed medicines containing aspartame and 75% (n = 36/48) said that medicines were not checked by medics when prescribed. 85% (n = 164/192) considered the sugar tax made accidental aspartame consumption more likely. Some of the difficulties for patients were aspartame identification in drinks consumed in restaurants, pubs, vending machines (77%, n = 158/206); similarities in appearance of aspartame and non-aspartame products (62%, n = 127/206); time consuming shopping/checking labels (56%, n = 115/206); and unclear labelling (55%, n = 114/206). These issues caused anxiety for the person with PKU (52%, n = 106/206), anxiety for parent/caregivers (46%, n = 95/206), guilt for parent/carers (42%, n = 87/206) and social isolation (42%, n = 87/206). It is important to understand the impact of aspartame and legislation such as the sugar tax on people with PKU. Policy makers and industry should ensure that the quality of life of people with rare conditions such as PKU is not compromised through their action.
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Affiliation(s)
- Ella Newbould
- Faculty of Health, Education & Life Sciences, Birmingham City University: City South Campus, Westbourne Road, Edgbaston, Birmingham B15 3TN, UK;
| | - Alex Pinto
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Sharon Evans
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Suzanne Ford
- National Society for Phenylketonuria, Purley CR8 9DD, UK;
| | - Mike O’Driscoll
- School of Health and Education, Middlesex University, Room WG41A (Williams Building), The Burroughs Hendon, London NW4 4BT, UK;
| | - Catherine Ashmore
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Anne Daly
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
| | - Anita MacDonald
- Birmingham Women’s and Children’s NHS Foundation Trust, Steelhouse Lane, Birmingham B4 6NH, UK; (A.P.); (S.E.); (C.A.); (A.D.)
- Correspondence:
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Daly A, Evans S, Pinto A, Ashmore C, Rocha JC, MacDonald A. A 3 Year Longitudinal Prospective Review Examining the Dietary Profile and Contribution Made by Special Low Protein Foods to Energy and Macronutrient Intake in Children with Phenylketonuria. Nutrients 2020; 12:E3153. [PMID: 33076399 PMCID: PMC7602523 DOI: 10.3390/nu12103153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 12/18/2022] Open
Abstract
The nutritional composition of special low protein foods (SLPFs) is controlled under EU legislation for 'Foods for Special Medical Purposes (FSMP)'. They are designed to meet the energy needs of patients unable to eat a normal protein containing diet. In phenylketonuria (PKU), the macronutrient contribution of SLPFs has been inadequately examined. AIM A 3-year longitudinal prospective study investigating the contribution of SLPFs to the macronutrient intake of children with early treated PKU. METHODS 48 children (27 boys) with a mean recruitment age of 9.3 y were studied. Semi-quantitative dietary assessments and food frequency questionnaires (FFQ) were collected three to four times/year for 3 years. RESULTS The mean energy intake provided by SLPFs was 33% (SD ± 8), and this figure was 42% (SD ± 13) for normal food and 21% (SD ± 5) for protein substitutes (PS). SLPFs supplied a mean intake of 40% carbohydrate (SD ± 10), 51% starch (SD ± 18), 21% sugar (SD ± 8), and 38% fat (SD ± 13). Fibre intake met 83% of the Scientific Advisory Committee on Nutrition (SACN) reference value, with 50% coming from SLPFs with added gums and hydrocolloids. Low protein bread, pasta and milk provided the highest energy contribution, and the intake of sweet SLPFs (e.g., biscuits, cakes, and chocolate) was minimal. Children averaged three portions fruit/vegetable daily, and children aged ≥ 12 y had irregular meal patterns. CONCLUSION SLPFs provide essential energy in phenylalanine restricted diets. Optimising the nutritional quality of SLPFs deserves more attention.
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Affiliation(s)
- Anne Daly
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Sharon Evans
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Alex Pinto
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Catherine Ashmore
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
| | - Júlio César Rocha
- Nutrition and Metabolism, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Centre for Health Technology and Services Research (CINTESIS), 4200-450 Porto, Portugal
| | - Anita MacDonald
- Dietetic Department, Birmingham Children’s Hospital, Steelhouse Lane, Birmingham B4 6NH, UK; (S.E.); (A.P.); (C.A.); (A.M.)
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