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Lucendo A, Groetch M, Gonsalves N. Dietary Management of Eosinophilic Esophagitis. Immunol Allergy Clin North Am 2024; 44:223-244. [PMID: 38575220 DOI: 10.1016/j.iac.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Eosinophilic esophagitis (EoE) is a chronic immune-mediated food allergy-driven disease characterized by eosinophilic inflammation of the esophagus leading to symptoms of esophageal dysfunction. Prior studies have supported the key role of food allergen exposure as the main driver behind the etiopathogenesis showing that removal of food antigens can result in disease remission in both children and adults. These landmark studies serve as the basis for the rising interest and evolution of dietary therapy in EoE. This article will focus on the rationale for dietary therapy in EoE and provide helpful tools for the implementation of dietary therapy in practice.
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Affiliation(s)
- Alfredo Lucendo
- Department of Gastroenterology, Hospital General de Tomelloso, Tomelloso, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd); Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Tomelloso, Ciudad Real 13700, Spain
| | - Marion Groetch
- Department of Pediatric Allergy & Immunology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Nirmala Gonsalves
- Division of Gastroenterology and Hepatology, Northwestern University-Feinberg School of Medicine, 676 North St. Claire, Suite 1400, Chicago, IL 60611, USA.
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Tang M, Wang C, Xia Y, Tang J, Wang J, Shen L. Clostridiodes difficile infection in inflammatory bowel disease: a clinical review. Expert Rev Anti Infect Ther 2024. [PMID: 38676422 DOI: 10.1080/14787210.2024.2347955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/23/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Strong clinical data demonstrate that inflammatory bowel disease (IBD) is an independent risk factor for Clostridiodes difficile infection (CDI) and suggest a globally increased prevalence and severity of C. difficile coinfection in IBD patients (CDI-IBD). In addition to elderly individuals, children are also at higher risk of CDI-IBD. Rapid diagnosis is essential since the clinical manifestations of active IBD and CDI-IBD are indistinguishable. Antibiotics have been well established in the treatment of CDI-IBD, but they do not prevent recurrence. AREAS COVERED Herein, the authors focus on reviewing recent research advances on the new therapies of CDI-IBD. The novel therapies include gut microbiota restoration therapies (such as prebiotics, probiotics and FMT), immunotherapy (such as vaccines and monoclonal antibodies) and diet strategies (such as groningen anti-inflammatory diet and mediterranean diet). Future extensive prospective and placebo-controlled studies are required to evaluate their efficacy and long-term safety. EXPERT OPINION Available studies show that the prevalence of CDI-IBD is not optimistic. Currently, potential treatment options for CDI-IBD include a number of probiotics and novel antibiotics. This review updates the knowledge on the management of CDI in IBD patients, which is timely and important for GI doctors and scientists.
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Affiliation(s)
- Mengjun Tang
- Central Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
| | - Chunhua Wang
- Central Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
| | - Ying Xia
- Central Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
| | - Jian Tang
- Central Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
| | - Jiao Wang
- Central Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
- School of Basic Medicine, Hubei University of Arts and Science, China
| | - Liang Shen
- Central Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
- Department of Clinical Laboratory, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, China
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Tsuruta H, Sugahara S, Kume S. Nutrient quality in dietary therapy for diabetes and diabetic kidney disease. J Diabetes Investig 2024. [PMID: 38591876 DOI: 10.1111/jdi.14208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 03/17/2024] [Accepted: 03/21/2024] [Indexed: 04/10/2024] Open
Abstract
Dietary therapy is crucial for diabetes care with the aim of preventing the onset and progression of diabetes and its complications. The traditional approach to dietary therapy for diabetes has primarily focused on restricting the intake of the three major nutrients and rigorously controlling blood glucose levels. However, advancements in nutritional science have shown that within the three major nutrients - carbohydrates, proteins and lipids - there exist multiple types, each with distinct impacts on type 2 diabetes and its complications, sometimes even showing conflicting effects. In light of this, the present review shifts its focus from the quantity to the quality of the three major nutrients. It aims to provide an overview of how the differences in nutrient quality can influence onset and progression of type 2 diabetes and diabetic kidney disease, highlighting the diverse effects and, at times, contradictory impacts associated with each nutrient type.
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Affiliation(s)
- Hiroaki Tsuruta
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Sho Sugahara
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Shinji Kume
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
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Gkikas K, Svolos V, Hansen R, Russell RK, Gerasimidis K. Take-Home Messages from 20 Years of Progress in Dietary Therapy of Inflammatory Bowel Disease. Ann Nutr Metab 2023; 79:476-484. [PMID: 37944498 DOI: 10.1159/000535007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND A significant body of literature has interrogated the critical role of diet in the development and management of inflammatory bowel disease (IBD). SUMMARY This review provides a summary and critical appraisal of the literature in this area, focussing on four distinct themes: nutritional epidemiology, animal and in vitro experiments, enteral nutrition, and food-based dietary therapies. KEY MESSAGES Nutritional epidemiology and data from experiments in animals indicate that a western-type diet pattern is associated with increased risk of IBD onset. However, these findings have not been consistently replicated in the dietary management of IBD. Exclusive enteral nutrition (EEN) is the only dietary therapy with reproducible evidence of efficacy in the management of active Crohn's disease (CD). Use of EEN may also be useful for improving perioperative outcomes in CD, and as an adjuvant therapy to biologic therapy. Several dietary therapies for CD and ulcerative colitis have been proposed in the literature, but replication in well-controlled studies is needed before their routine use enters the clinical setting. Precision nutritional therapy might be an attractive therapeutic paradigm in a heterogenous disease like IBD. However, no recommendations for personalised dietary therapy can currently be made, and it is imperative we unravel the complex interplay between diet and gut inflammation before we are able to do so. Undoubtedly, diet is of critical importance in the development and management of IBD. However, the exact mechanism by which diet causes gut inflammation is still elusive, and dietary guidance is difficult to formulate.
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Affiliation(s)
| | - Vaios Svolos
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow, UK
| | - Richard Hansen
- Child Health, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Royal Hospital for Children and Young People, Edinburgh, UK
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Hotta A, Iwatani H. Efficacy of comprehensive group-based education in lowering body weight, uric acid levels, and diuretic use in patients with chronic kidney disease: a retrospective study. BMC Nephrol 2023; 24:272. [PMID: 37710146 PMCID: PMC10503079 DOI: 10.1186/s12882-023-03293-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Patient education for the management of chronic kidney disease (CKD) is attracting attention. Therefore, this study aimed to analyze changes in body weight, uric acid, and estimated-glomerular filtration rate (eGFR) in patients with CKD after a group-based education during admission. METHODS Overall, 157 patients with CKD, who were discharged from the nephrology department of our hospital between January 2015 and October 2019, received group-based education or individual-based education by nurses at admission. Deltas of body weight, uric acid, and eGFR, 6 months from baseline, were compared between group- and individual-based education using the Wilcoxon rank sum test. RESULTS In total, 60 patients receiving group-based education (G group, n =35) or individual-based education (I group, n =25) during admission were included in this retrospective study. The patient characteristics at baseline were as follows: age mean, 72 ± SD 9; 16 females and 44 males; body weight, 62 ± 17 kg; eGFR median, 21 (IQR: 14, 29) mL/min/1.73 m2; UA, 7 (6.1, 7.5) mg/dL; and estimated intake of salt 6.9 (6.2, 8.4) g/day. Delta eGFR (mL/min/1.73 m2) was -1 (-3, 3) for G group and -1 (-2.5, 2) for I group (p = 0.8039). Delta body weight (kg) was -0.4 (-1.6, 0) for G group and 0 (-0.45, 0.95) for I group (p = 0.0597). Delta uric acid (mg/dL) was -1.1 (-1.6, 0.1) for G group and -0.2 (-1.1, 0.5) for I group (p = 0.0567). In patients with higher sodium intake (≥ 117.4 mEq/day), delta body weight was significantly lower in the group-based education group than in the individual-based education group (p = 0.0398). CONCLUSIONS A comprehensive group-based education in patients with CKD may effectively suppress body weight and uric acid in 6 months along with less frequent diuretic use.
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Affiliation(s)
- Azumi Hotta
- Department of Nursing, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan
| | - Hirotsugu Iwatani
- Department of Nephrology, National Hospital Organization Osaka National Hospital, 2-1-14, Hoenzaka, Chuo-ku, Osaka, 540-0006, Japan.
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Lee HA, Moon H, Kim Y, Lee HA, Kim HY. Effect of 12-week intermittent calorie restriction compared to standard of care in patients with nonalcoholic fatty liver disease: a randomized controlled trial. Trials 2023; 24:490. [PMID: 37533096 PMCID: PMC10394920 DOI: 10.1186/s13063-023-07444-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 06/08/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. NAFLD can result in various complications. Owing to the lack of effective pharmacological therapies, lifestyle modifications are the cornerstone treatment for NAFLD. However, there has been no recommendation for a specific dietary therapy. Because no significant effects have been observed in previous studies. Intermittent calorie restriction (ICR) consists of alternating phases of extreme energy restriction and regular energy intake. Recent studies have demonstrated a significantly higher reduction in liver fat content in the ICR group than in the standard of care (SOC) or continuous calorie restriction groups in patients with NAFLD. However, critical weaknesses limit the broader application of ICR in clinical practice; those are a lack of appropriate assessment tools, different cutoffs of body mass index (BMI) used to define obesity, and different food portions. Thus, we report a protocol for a prospective, randomized controlled trial. The trial will evaluate the effect of 12-week ICR on improving liver fat content in NAFLD patients (Nonalcoholic Fatty Liver Disease-Intermittent Calorie Restriction [FLICR]). METHODS We will include adult (19-75 years) NAFLD patients. NAFLD will be diagnosed by histologic assessment or magnetic resonance imaging-proton density fat fraction (MRI-PDFF) ≥ 8%. A total of 72 patients will be classified according to BMI (obese group: BMI ≥ 25 kg/m2 [n = 36] and non-obese group: BMI < 25 kg/m2 [n = 36]). Participants will be followed up for 24 weeks. Participants will be randomly assigned to one of the two groups: the SOC or ICR group. The primary objective will be the change in liver fat content measured using MRI-PDFF from baseline to 12 weeks. DISCUSSION This FLICR study may provide clinical evidence on ICR in the treatment of NAFLD in both obese and non-obese patients. The use of ICR in patients with NAFLD will improve the clinical outcomes of patients facing a shortage of effective medical therapy. TRIAL REGISTRATION This trial was registered at the United States National Library of Medicine (NLM) at the National Institutes of Health. CLINICALTRIALS gov NCT05309642. Registered on April 4, 2022.
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Affiliation(s)
- Han Ah Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, 1071 Anyangcheon-Ro, Yangcheon-Gu, Seoul, 07985, Republic of Korea
| | - Hyeyoung Moon
- Nutritional Science and Food Management, Ewha Womans University, Seoul, Republic of Korea
| | - Yuri Kim
- Nutritional Science and Food Management, Ewha Womans University, Seoul, Republic of Korea
| | - Hye Ah Lee
- Clinical Trial Center, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea
| | - Hwi Young Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, 1071 Anyangcheon-Ro, Yangcheon-Gu, Seoul, 07985, Republic of Korea.
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Paibool W, Schimpf S, Nordli DR, Phitsanuwong C. Modified Atkins diet in children with epilepsy with eyelid myoclonia (Jeavons syndrome). Epilepsy Behav 2023; 145:109347. [PMID: 37459720 DOI: 10.1016/j.yebeh.2023.109347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Epilepsy with eyelid myoclonia(EEM) or Jeavons syndrome is considered a genetic generalized epilepsy with a typical age of onset in childhood. Many types of seizures can be observed, including eyelid myoclonia, absence, generalized tonic-clonic, and myoclonic seizures. Seizures tend to be difficult to control requiring polypharmacy treatment or become drug-resistant. Dietary therapy, particularly with Modified Atkins Diet (MAD), as a treatment of seizures in this syndrome has rarely been studied. We report efficacy and tolerability of MAD in children with epilepsy with eyelid myoclonia. METHODS We reviewed medical records of children with EEM treated at the University of Chicago Ketogenic Diet program from 2017 to 2022. Patient's demography, seizure characteristics, EEG findings, response to treatment, and adverse effects were reviewed. RESULT Six patients with EEM were identified. Average age of seizure onset was 6 (2-11) years and an average age when the MAD started was 10.7 (6-15) years. All patients were started on MAD and completed at least 6 months on the diet at the time of report. An average of 4 (0-9) anti-seizure medications (ASM) had been tried prior to the MAD. All patients achieved ketosis with an average level of serum beta-hydroxybutyrate of 1.9 (1.03-3.61) mmol/L. At the 6-month follow-up visit, all patients (100%) experienced a greater than 50% seizure reduction, 3/6 patients (50%) had more than 90% seizure reduction, 1/6 patients (17%) became seizure-free. All seizure types demonstrated a greater than 80% reduction in frequency.Absence and myoclonic seizures showed the greatest reduction with 100% seizure reduction. Eyelid myoclonia and generalized tonic-clonic seizures showed more than 80% seizure reduction.Moreover, all patients reported improvement in alertness, mood, and concentration. Initial weight loss and mild gastrointestinal disturbances were reported in 2/6 patients (33%) and corrected with dietary adjustment. CONCLUSION The Modified Atkins Diet has shown to be effective and welltolerated for children with EEM in our study. Cognitive improvement has also been subjectively reported in all patients. Adverse effects are tolerable and correctable. The MAD, therefore, may be considered as a treatment option for patients with epilepsy with eyelid myoclonia.
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Affiliation(s)
- Watuhatai Paibool
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA; Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kean, Thailand.
| | - Stephanie Schimpf
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA
| | - Douglas R Nordli
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA
| | - Chalongchai Phitsanuwong
- Department of Pediatrics, The University of Chicago, The University of Chicago Medical Center, USA
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Zheng P, Lin Z, Ding Y, Duan S. Targeting the dynamics of cancer metabolism in the era of precision oncology. Metabolism 2023:155615. [PMID: 37286129 DOI: 10.1016/j.metabol.2023.155615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
Cancer metabolic reprogramming is a promising target for cancer therapy. The progression of tumors, including their growth, development, metastasis, and spread, is a dynamic process that varies over time and location. This means that the metabolic state of tumors also fluctuates. A recent study found that energy production efficiency is lower in solid tumors but increases significantly in tumor metastasis. Despite its importance for targeted tumor metabolism therapy, few studies have described the dynamic metabolic changes of tumors. In this commentary, we discuss the limitations of past targeted tumor metabolism therapy and the key findings of this study. We also summarize its immediate clinical implications for dietary intervention and explore future research directions for understanding the dynamic changes in tumor metabolic reprogramming.
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Affiliation(s)
- Peijie Zheng
- Department of Clinical Medicine, School of Medicine, Hangzhou City University, Hangzhou 310015, China.
| | - Zihao Lin
- Department of Clinical Medicine, School of Medicine, Hangzhou City University, Hangzhou 310015, China.
| | - Yuemin Ding
- Department of Clinical Medicine, School of Medicine, Hangzhou City University, Hangzhou 310015, China; Institute of Translational Medicine, Hangzhou City University, Hangzhou 310015, China; Key Laboratory of Novel Targets and Drug Study for Neural Repair of Zhejiang Province, Hangzhou City University, Hangzhou 310015, China.
| | - Shiwei Duan
- Department of Clinical Medicine, School of Medicine, Hangzhou City University, Hangzhou 310015, China; Institute of Translational Medicine, Hangzhou City University, Hangzhou 310015, China; Key Laboratory of Novel Targets and Drug Study for Neural Repair of Zhejiang Province, Hangzhou City University, Hangzhou 310015, China.
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Rettura F, Lambiase C, Grosso A, Rossi A, Tedeschi R, Ceccarelli L, Bellini M. Role of Low-FODMAP diet in functional dyspepsia: "Why", "When", and "to Whom". Best Pract Res Clin Gastroenterol 2023; 62-63:101831. [PMID: 37094910 DOI: 10.1016/j.bpg.2023.101831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 03/30/2023] [Indexed: 04/26/2023]
Abstract
Functional dyspepsia (FD) is a frequent disorder of gut-brain interaction, affecting 5-7% of people globally, with significant impairment in quality of life. The management of FD is challenging due to the lack of specific therapeutic approaches. Although food seems to play a role in symptom production, its pathophysiologic role in patients with FD is not fully understood. Most FD patients report that their symptoms are triggered by food, especially in the post-prandial distress syndrome (PDS) group, although evidence to support the use of dietary interventions are limited. FODMAPs can increase production of gas in the intestinal lumen, through fermentation by intestinal bacteria, can exert osmotic effects by increasing water volume and can cause an excessive production of short-chain fatty acids (propionate, butyrate, and acetate). Emerging scientific evidence, confirmed by recent clinical trials, suggest that FODMAPs could be involved in the pathogenesis of FD. Given the consolidated approach of the Low-FODMAP Diet (LFD) in irritable bowel syndrome (IBS) management and emerging scientific evidence regarding the LFD in FD, a therapeutic role of this diet may be hypothesized also in FD, either alone or in combination with other therapies.
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Affiliation(s)
- Francesco Rettura
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010, Pisa, Italy
| | - Christian Lambiase
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010, Pisa, Italy.
| | - Antonio Grosso
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010, Pisa, Italy
| | - Alessandra Rossi
- Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, 56100, Pisa, Italy
| | - Riccardo Tedeschi
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010, Pisa, Italy
| | - Linda Ceccarelli
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010, Pisa, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, 56010, Pisa, Italy
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Zhang Y, Wang O, Mi H, Yi J, Cai S. Rhus chinensis Mill. fruits prevent necrotizing enterocolitis in rat pups via regulating the expressions of key proteins involved in multiple signaling pathways. J Ethnopharmacol 2022; 290:115103. [PMID: 35157955 DOI: 10.1016/j.jep.2022.115103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/03/2022] [Accepted: 02/09/2022] [Indexed: 06/14/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Based on ancient records and previous studies, many parts of Rhus chinensis Mill., including the fruits, have good preventive and therapeutic effects on inflammation, malaria, diarrhea, and gastrointestinal diseases. Rhus plants and Galla chinensis produced from R. chinensis leaves can also prevent or cure intestinal diseases. However, the preventive effect and molecular mechanisms of R. chinensis fruits on necrotizing enterocolitis (NEC) have not been comprehensively studied. AIM OF THE STUDY This article aims to estimate the effect of the 80% ethanol extract of R. chinensis fruits (RM) on alleviating NEC in rat pups and illustrate the potential molecular mechanisms. MATERIALS AND METHODS Rat pups were subjected to formula feeding, intermittent hypoxic, and cold stresses to establish the NEC model. The preventive effects of RM on NEC were evaluated through survival rate; clinical sickness index; macroscopic conditions; histopathology; and expression levels of inflammatory markers (i.e., tumor necrosis factor-α [TNF-α], interleukin-6 [IL-6]), oxidative stress indicators (i.e., total antioxidant status [TAS], total oxidant status [TOS], superoxide dismutase [SOD], glutathione peroxidase [GSH-Px], myeloperoxidase [MPO], malondialdehyde [MDA]), and tight junction proteins (i.e., Zonula Occludens 1 [ZO-1], Occludin). Moreover, the expression levels of several key proteins involved in oxidative stress (i.e., nuclear factor erythroid 2-related factor 2 [Nrf2], NAD(P)H-quinone oxidoreductase-1 [NQO1]), inflammation (i.e., Toll-like receptor 4 [TLR4], phosphorylated-nuclear factor kappa-B [p-NF-κB], inducible nitric oxide synthase [iNOS]), and apoptosis (i.e., cleaved cysteinyl aspartate specific proteinase-3 [cleaved Caspase-3], Bcl-2-associated X [Bax], B-cell lymphoma-2 [Bcl-2]) in intestinal tissues were analyzed to clarify the molecular mechanisms. RESULTS The extract particularly high doses (400 mg RM/kg body weight) could remarkably reduce the mortality and clinical sickness score and improve the macroscopic condition and histopathological injury of the intestine in NEC pups. After RM administration, the levels of TOS, TNF-α, IL-6, MPO, and MDA in the bowel tissue decreased, whereas the levels of TAS, SOD, and GSH-Px were significantly enhanced. The expression levels of ZO-1 and Occludin proteins were dramatically augmented in RM-treated groups to maintain intestinal barrier integrity. Further analyses revealed that RM might prevent NEC pups by improving some pivotal proteins involved in oxidative stress, inflammation, and apoptosis of enterocytes, namely, by down-regulating the levels of TLR4, p-NF-κB, iNOS, cleaved Caspase-3, and Bax and up-regulating the levels of Bcl-2, NQO1, and Nrf2. CONCLUSIONS The RM prevented the intestinal inflammation and damage caused by NEC by regulating the expression of several pivotal proteins involved in oxidative stress, inflammation, and apoptosis. This study might provide a scientific basis for R. chinensis fruits as a traditional herbal medicine to prevent and/or alleviate NEC.
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Affiliation(s)
- Yi Zhang
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming, 650500, Yunnan Province, People's Republic of China
| | - Ou Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, Beijing, 100050, People's Republic of China
| | - Hongying Mi
- The First People's Hospital of Yunnan Province, Affiliated Hospital of Kunming University of Science and Technology, Kunming, 650032, Yunnan Province, People's Republic of China
| | - Junjie Yi
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming, 650500, Yunnan Province, People's Republic of China
| | - Shengbao Cai
- Faculty of Food Science and Engineering, Kunming University of Science and Technology, Kunming, 650500, Yunnan Province, People's Republic of China.
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Abstract
Ancient scholars across cultures have postulated that by being less potent versions of herbs, food plays a substantive role in the maintenance of health and treatment of disease. A commonality among these traditional medical systems is in relation to the 'heating' and 'cooling' properties of foods. In this chapter, 'hot' and 'cold' classifications of foods are explored, along with ways to optimize health and combat disease. Scientific evaluations of 'hot' and 'cold' properties are also reviewed in relation to chemical compositions and physiological impacts. A broad scoping Google Scholar search was conducted to identify relevant articles. Scientific evaluations were heterogeneous and of mixed quality. Nonetheless some evidence supported the traditional 'hot' and 'cold' classifications. Overall, 'heating' foods were associated with metabolism and sympathetic nervous system enhancement via increased proportions of caffeine, carbohydrate, protein, fat, and calories; as well as greater oxidation potential; vasodilatory and pro-inflammatory effects; and higher acidity and aromatic compound content. 'Cooling' foods were contrastly found to be higher in water, fiber, alkalinity, and aliphatic compounds; as well as associated with anti-inflammatory, and detoxification (elimination) processes. With the potential to specifically tailor diets to suit individual needs, further high-quality research to substantiate traditional food classifications is warranted.
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Affiliation(s)
- Simone Maree Ormsby
- NICM Health Research Institute, Western Sydney University, Locked Bag 1797, Penrith, NSW, 2751, Australia.
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Shumakova AA, Shipelin VA, Leontyeva EV, Gmoshinski IV. Effect of Resveratrol, L-Carnitine, and Aromatic Amino Acid Supplements on the Trace Element Content in the Organs of Mice with Dietary-Induced Obesity. Biol Trace Elem Res 2022; 200:281-297. [PMID: 33624220 DOI: 10.1007/s12011-021-02642-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/14/2021] [Indexed: 11/30/2022]
Abstract
Given environmental contamination with toxic metals, diets that promote the elimination of these metals from the body of individuals, including those suffering from obesity, are urgently needed. The aim of this study was to determine the effects of supplementation with resveratrol (Res), L-carnitine (L-Car), tyrosine (Tyr), and tryptophan (Trp) on the content of trace elements in the organs of mice. DBA/2J mice and DBCB tetrahybrid mice received diets high in carbohydrate and fat supplemented with Res, L-Car, Tyr, or Trp for 65 days. In the liver, kidneys, and brain, the contents of 18 elements, including Al, As, Cu, Fe, Mn, Pb, Se, and Zn, were determined by inductively coupled plasma mass spectrometry. Res, L-Car, Tyr, and Trp had minimal or no effect on the essential elements (Fe, Mg, Cu, Zn, Se) in all organs studied. The Mn content notably increased in the organs of mice consuming L-Car and Trp. Mn accumulation was stimulated by Res in organs exclusively in DBCB mice and by Tyr exclusively in livers and brains of DBA/2J mice. Al levels were significantly reduced by L-Car and Trp in all organs of the mice, by Res in only DBCB mice, and by Tyr in only kidneys and livers of DBA/2J mice. In addition, L-Car and Trp decreased Pb accumulation in most organs of mice. Res and Tyr also inhibited Pb accumulation in some cases. Thus, the studied supplements affected the metabolism of trace elements, which may contribute to dietary treatments for obese individuals.
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Affiliation(s)
- Antonina A Shumakova
- Federal Research Centre of Nutrition, Biotechnology and Food Safety, Ust'insky proezd 2/14, Moscow, 109240, Russia
| | - Vladimir A Shipelin
- Federal Research Centre of Nutrition, Biotechnology and Food Safety, Ust'insky proezd 2/14, Moscow, 109240, Russia
- Plekhanov Russian University of Economics, Moscow, 115093, Russia
| | - E V Leontyeva
- Federal Research Centre of Nutrition, Biotechnology and Food Safety, Ust'insky proezd 2/14, Moscow, 109240, Russia
| | - Ivan V Gmoshinski
- Federal Research Centre of Nutrition, Biotechnology and Food Safety, Ust'insky proezd 2/14, Moscow, 109240, Russia.
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13
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Barta AG, Becsei D, Kiss E, Sumánszki C, Simonová E, Reismann P. The Impact of Phenylketonuria on Body Composition in Adults. Ann Nutr Metab 2021; 78:98-105. [PMID: 34872082 DOI: 10.1159/000520047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 10/02/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with phenylketonuria (PKU) must follow a lifelong phenylalanine (Phe)-restricted diet with additional amino acid supplementations, and this may put them at risk for nutritional disturbances. However, the body composition and nutritional status of adult patients with PKU has only been partially explored. The current study aims to assess the body composition of adult patients with PKU using multifrequency bioimpedance analysis (MF-BIA) and to reveal potential correlations between therapy adherence and body composition. Additionally, we compared body composition of patients with healthy controls. METHODS Fifty adult patients with early-treated PKU (27 female and 23 male) and 40 healthy, age- and gender-matched controls were included in this single-center, cross-sectional study. MF-BIA was performed on all subjects. Additionally, we determined serum nutritional markers for all patients. In the PKU patient group, correlation analyses were performed between body composition parameters and therapy adherence. We compared body composition of patients with PKU and controls using BIA. RESULTS The proportion of overweight was 56% among all patients with PKU. Female patients with PKU had significantly higher body fat percentage compared with controls. In parallel with higher fat content, we observed lower muscle mass, protein, and mineral content among female patients with PKU compared to controls. Such findings were not observed in male patients. Female patients with PKU had decreased therapy adherence and had significantly lower prealbumin levels compared with males. There was no significant correlation observed between body composition parameters and therapy adherence over the last 10 years in the PKU patient group. CONCLUSION Although female patients had less optimal therapy adherence over the last 10 years compared with male patients, our results suggest that this does not influence body composition fundamentally. Our results suggest that obesity is an important comorbidity in young adult patients with PKU, especially in females. We advocate that nutritional assessments and weight management should be additional objectives of PKU management to provide optimal care.
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Affiliation(s)
- András Gellért Barta
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary,
| | - Dóra Becsei
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Erika Kiss
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Csaba Sumánszki
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Erika Simonová
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Péter Reismann
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
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14
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Abstract
The esophagus plays a crucial role in oral nutrition and digestive pathophysiology. In addition, diet is now considered an important primary or augmentative therapy in several esophageal disease states. This review highlights common dietary therapies used in treating diseases of the esophagus as well as the underlying data that support such practices. Specially, diet and its relationship to swallowing dysfunction, motility disorders, malignancies, and inflammatory mucosal diseases such as gastroesophageal reflux disease and eosinophilic esophagitis is explored.
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Affiliation(s)
- Carolyn Newberry
- Division of Gastroenterology, Weill Cornell Medical Center, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Kristle Lynch
- Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Boulevard, 7th Floor, South Tower, Philadelphia, PA 19104, USA.
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15
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Sarlo GL, Holton KF. Caregiver perspectives on dietary therapies for epilepsy. Epilepsy Res 2021; 178:106803. [PMID: 34753070 DOI: 10.1016/j.eplepsyres.2021.106803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/06/2021] [Accepted: 10/25/2021] [Indexed: 11/21/2022]
Abstract
The objective of this research was to identify caregiver perspectives on dietary therapies for epilepsy, as well as provide future directions for improving caregiver support. A Qualtrics survey was distributed via social media platforms. The survey was aimed towards caregivers with children who are currently using or have previously used dietary therapy for epilepsy. A total of 192 respondents were included, though the number of respondents varied by question. Caregivers reported dietary therapy as 'somewhat to very challenging' with 76% of children and 99% of caregivers reporting at least one difficulty. Eighty percent of caregivers' children experienced at least one type of adverse event, with the most common event being constipation. Finally, caregivers reported high scores for quality of life, happiness with the diet, and feeling supported during treatment. Recommendations for how to improve the experience of families included increased clinic support, support group offerings, meal resources, educational resources, access to diet related equipment, financial assistance/relief, therapy/transition assistance, respect for the caregivers' concerns/thoughts, and restaurant options. In short, most caregivers are pleased with dietary therapy; however, there are specific changes that would significantly help caregivers during treatment. This information could be used by clinics to better support caregivers during treatment.
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16
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Sharawat IK, Panda PK, Sihag RK, Panda P, Dawman L. Efficacy and safety of corpus callosotomy and ketogenic diet in children with Lennox Gastaut syndrome: a systematic review and meta-analysis. Childs Nerv Syst 2021; 37:2557-2566. [PMID: 33871716 DOI: 10.1007/s00381-021-05174-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Both corpus callosotomy (CC) and the ketogenic diet (KD) are commonly used in patients with Lennox Gastaut syndrome (LGS), as a significant proportion of these patients develop pharmacoresistant epilepsy. But no systematic review has yet compared the efficacy and safety of these two measures. METHODS We conducted a systematic search on various databases to collating all available literature until 30th November 2020 with a primary objective to compare the efficacy of KD and CC in terms of the proportion of patients with complete seizure freedom, at least 75% and 50% reduction in seizure frequency at various time points after the institution of these modalities. We also attempted to compare the proportion and nature of adverse effects, impact on EEG, cognition, and behavior with these modalities. We only included original articles enrolling at least 10 patients with CC or KD for quantitative synthesis to determine a pooled estimate. We used a fixed or random effects model, depending on the degree of heterogeneity. RESULTS We selected 23 and 7 articles describing the efficacy of CC and KD in 436 and 185 LGS patients out of 217 search items, but none of the studies compared directly these two entities. The indirect comparison between the pooled estimate of all patients with individual modalities revealed more patients with CC had seizure freedom, at least 75% and 50% reduction in seizure frequency (p=0.0001, 0.01, and 0.04 respectively). The proportion of patients with adverse effects was also higher for CC patients (p=0.01), although the proportion with serious adverse effects was not significantly different between the two modalities. Patients selected for CC were older, had higher seizure burden, more lag time after the onset of seizures, and received more number of antiseizure medications previously. Due to the availability of limited data, a firm conclusion could not be determined regarding the effect on EEG, cognition, and behavior with CC and KD. CONCLUSION CC is more efficacious than KD in reducing seizure frequency in patients with LGS, although it has relatively more adverse effects during the immediate perioperative period.
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Affiliation(s)
- Indar Kumar Sharawat
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Prateek Kumar Panda
- Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
| | - Rakesh Kumar Sihag
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Pragnya Panda
- Department of Neurology, King George Medical University, Lucknow, 226003, India
| | - Lesa Dawman
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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17
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Fedak Romanowski E, Yeshidinber Weldetsadik A. Barriers to Implementation of Dietary Therapy for Pediatric Epilepsy in Resource-Limited Countries: Ethiopian Experience. Pediatr Neurol 2021; 117:1-3. [PMID: 33548834 DOI: 10.1016/j.pediatrneurol.2020.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/11/2020] [Accepted: 11/14/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Erin Fedak Romanowski
- Division of Pediatric Neurology, Department of Pediatrics, Michigan Medicine, Ann Arbor, Michigan.
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18
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Lakshminarayanan K, Agarawal A, Panda PK, Sinha R, Tripathi M, Pandey RM, Gulati S. Efficacy of low glycemic index diet therapy (LGIT) in children aged 2-8 years with drug-resistant epilepsy: A randomized controlled trial. Epilepsy Res 2021; 171:106574. [PMID: 33582533 DOI: 10.1016/j.eplepsyres.2021.106574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND A classic ketogenic diet, even though effective in children with drug-resistant epilepsy is not tolerated well by them and cumbersome to prepare. Low glycemic index therapy (LGIT), the least restrictive with minimal adverse effects among ketogenic dietary therapies has been proven effective in uncontrolled trials, but a placebo-controlled trial in this regard is still lacking. METHODS In this open-label randomized controlled study, we randomized children above age two years with drug-resistant epilepsy into two groups (LGIT and control groups). Patients in the LGIT group received an add-on low glycemic index diet for 3 months along with the ongoing antiepileptic drugs and the patients in the control group did not receive any dietary intervention. Seizure frequency was assessed from the seizure diary maintained by the parents. Diet compliance was assessed using the diet diary that was maintained by the parents for three days just before the scheduled monthly visits of the patients. RESULTS Forty children with drug-refractory epilepsy (20 in each group) were enrolled. While 6/20 children in the LGIT arm have >50 % reduction in seizure frequency, none achieved this in the control arm (p = 0.02). The overall compliance with the low glycemic diet in the intervention group was 88.5 %. Out of six responders to LGIT, one child achieved seizure freedom and one achieved >90 % seizure reduction. Five continued LGIT further for a median duration of 8 months (range-4-12 months) successfully. The number needed to treat for more than 50 % seizure reduction was 3 and for more than 90 % seizure reduction was 10. The mean frequency of seizures for the intervention and control groups at three months of follow-up was not significantly different (p = 0.16), but the change in seizure frequency as compared to baseline was better in the intervention arm (p = 0.01). Three patients in the LGIT arm had non-serious adverse events (lethargy in two, vomiting in one). CONCLUSION In children aged 2-8 years with drug-refractory epilepsy, the administration of LGIT along with ongoing anti-seizure medications (ASM) is more efficacious in reducing seizure frequency as compared to ASM alone.
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Affiliation(s)
- Kannan Lakshminarayanan
- Paediatric Neurologist and Epileptologist, Gleneagles Global Hospital, Chennai, Tamilnadu, India
| | - Anuja Agarawal
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Prateek Kumar Panda
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India; Pediatric Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Rahul Sinha
- DM Pediatric Neurology, Department of Pediatrics, Command Hospital, Chandigarh, India
| | - Manjari Tripathi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ravindra M Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sheffali Gulati
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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19
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Liu C, Wu H, Fan H. Progress in understanding of mechanism of dietary therapy for ulcerative colitis with regard to intestinal microbiota. Shijie Huaren Xiaohua Zazhi 2021; 29:146-151. [DOI: 10.11569/wcjd.v29.i3.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The pathogenesis of ulcerative colitis is closely related to the complex interaction between heredity, environment, and intestinal microbiota. Intestinal dysbiosis is not only the cause of ulcerative colitis, but also the pathological result of ulcerative colitis. Dietary therapies have been found to modulate the microbiota to alter the effects of environmental factors on ulcerative colitis. Dietary pattern is related to the pathogenesis, development, and prognosis of ulcerative colitis, and the role of diet in ulcerative colitis has attracted more and more attention. This article reviews the mechanisms by which dietary therapy treats ulcerative colitis with regard to regulating the brain-gut functional axis, regulating the immune function, and protecting the intestinal mucosal barrier by modulating intestinal microbiota.
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Affiliation(s)
- Chang Liu
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Hui Wu
- Department of Integrated Traditional Chinese and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
| | - Heng Fan
- Department of Integrated Traditional Chinese and Western Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei Province, China
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20
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Sarlo GL, Kao A, Holton KF. Optimizing data collection in dietary therapy clinics for epilepsy: A recommendation for standardized data collection forms. Epilepsy Res 2020; 168:106488. [PMID: 33161311 DOI: 10.1016/j.eplepsyres.2020.106488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/22/2020] [Accepted: 10/20/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The objectives of this study were to 1) examine medical records from one medium-sized dietary clinic as an example of data being collected clinically, 2) identify data limitations, and then 3) create standardized data collection forms with the long-term goals of improving clinical care and facilitating multicenter data analysis. METHODS A retrospective chart review was conducted at the Dietary Therapies for Epilepsy Clinic at Children's National Medical Center (CNMC) in Washington, D.C. Patients who initiated dietary therapy between 2015 and 2018 were assessed. Categorical variables were examined via Chi Square or Fisher's Exact tests and continuous variables were assessed via an independent t-test or Mann-Whitney U test, depending on normality. RESULTS Forty-two patients underwent dietary therapy initiation during this time period, but only 26 had follow-up visit data. Of these patients, 54% reported non-seizure symptom improvement(s), and only 16 had quantitative seizure frequency information available, with 63% being clinical responders. No significant associations were observed between patient or diet characteristics and seizure or non-seizure improvement. Some variables, such as seizure duration, seizure severity, beta-hydroxybutyrate, and dietary compliance were not typically included in the records and therefore could not be evaluated statistically. Variations in seizure type(s), etiology, and clinical diagnoses/syndromes also made it unfeasible to evaluate differences in improvement based on these variables. Standardized data collection forms were created to address these limitations and are included as appendices. SIGNIFICANCE The results suggest limitations with the clinical data currently being collected. Medium-sized clinics may not see enough patients to study specific epilepsy populations. Standardized patient forms could target these issues, thereby improving clinical care and expanding research opportunities. Future research can test these forms for clinical use and as a collection tool for larger scale research across clinics.
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Affiliation(s)
- Gabrielle L Sarlo
- Behavior, Cognition and Neuroscience Program, American University, Washington DC, United States
| | - Amy Kao
- Division of Neurophysiology, Epilepsy, and Critical Care, Center for Neuroscience and Behavioral Medicine, Children's National Medical Center, Washington DC, United States
| | - Kathleen F Holton
- Department of Health Studies, American University, Washington DC, United States; Center for Behavioral Neuroscience, American University, Washington DC, United States.
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21
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Abstract
PURPOSE OF REVIEW Despite the increase in the number of novel antiseizure medications over the past 20 years, approximately one-third of patients will not have adequate seizure control on medications. For these patients, additional options need to be considered, including dietary, device, and surgical treatments. In addition, many complementary therapies can be considered as adjunctive treatment, with the intent of improving quality of life for persons with epilepsy and potentially allowing for improvement in seizure control. RECENT FINDINGS This review outlines established and developing treatments for drug-resistant epilepsy. Surgical treatments, including resective surgery and vagus nerve stimulation, have been routine care for several decades. In the last several years, new neurostimulation options have been approved (responsive neurostimulation and deep brain stimulation) or are under development (continuous subthreshold cortical stimulation). For patients with lesion or well-defined seizure-onset zones, less invasive options including laser ablation and ultrasound therapy provide the potential for faster recovery times and less morbidity. Not all therapies are in the pharmacological or surgical arenas. This review also explores the evidence for complementary treatments, including relaxation and meditation techniques, and art and music therapy. Despite the range of antiseizure medications available, they still provide inadequate for a large number of patients with epilepsy, either due to ongoing seizures or intolerable side effects. Complementary therapies, including diet, meditation techniques, and music therapy, provide compelling treatment options to improve quality of life while potentially improving seizure control. In appropriate patients, stimulation devices or surgical resection can offer options for significant seizure reduction or even cure. The full range of therapeutics should be considered for each patient with epilepsy when they are struggling with inadequate seizure control or side effects with traditional pharmacological treatment.
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22
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Panyod S, Ho CT, Sheen LY. Dietary therapy and herbal medicine for COVID-19 prevention: A review and perspective. J Tradit Complement Med 2020; 10:420-427. [PMID: 32691006 PMCID: PMC7260602 DOI: 10.1016/j.jtcme.2020.05.004] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 12/14/2022] Open
Abstract
A novel coronavirus disease (COVID-19), transmitted from humans to humans, has rapidly become the pandemic responsible for the current global health crisis. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which is said to be of zoonotic origin. This review describes the etiology and signs and symptoms as well as the current allopathic therapy for COVID-19. Additionally, findings of previous studies on the immunomodulatory effects and antiviral activities of particular foods and herbs on influenza virus and coronaviruses have been collated, with the aim of promoting the use of dietary therapy and herbal medicine as COVID-19 preventive therapies, while specific drugs and vaccines are yet to be discovered or are still under development. The volume of existing reports is irrefutable evidence that foods and herbs possess a potential antiviral ability against SARS-CoV-2 and can prevent COVID-19. Foods and herbs could be used as dietary or complementary therapy to prevent infection and strengthen immunity, as antiviral agents for masks, as disinfectants to curb aerosol transmission, or as sanitizing agents to disinfect surfaces. However, these hypotheses need to be experimentally verified for SARS-CoV-2 and COVID-19 patients.
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Affiliation(s)
- Suraphan Panyod
- Institute of Food Science and Technology, National Taiwan University, Taipei, Taiwan
| | - Chi-Tang Ho
- Department of Food Science, Rutgers University, New Brunswick, NJ, United States
| | - Lee-Yan Sheen
- Institute of Food Science and Technology, National Taiwan University, Taipei, Taiwan
- Center for Food and Biomolecules, National Taiwan University, Taipei, Taiwan
- National Center for Food Safety Education and Research, National Taiwan University, Taipei, Taiwan
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23
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Chidambaram SB, Bhat A, Mahalakshmi AM, Ray B, Tuladhar S, Sushmitha BS, Saravanan B, Thamilarasan M, Thenmozhi AJ, Essa MM, Guillemin GJ, Qoronfleh MW. Protein Nutrition in Autism. Adv Neurobiol 2020; 24:573-586. [PMID: 32006374 DOI: 10.1007/978-3-030-30402-7_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Autism is a developmental disorder that affects communication and behavior. Although autism can be diagnosed at any age, it is said to be a "developmental disorder" because symptoms generally appear in the first 2 years of life. The primary cause of autism is still not clear and therapy is currently restricted to controlling behavioral abnormalities. However, emerging studies have shown a link between mitochondrial dysfunction and autism. Dietary supplements that promote mitochondrial biogenesis and inhibit the production of oxidative stress have been used to treat autism patients. Dietary adjustments in treating autism is a novel approach to suppress autistic symptoms. Supplementation with antioxidants has been found to not only inhibit cognitive decline but also improve behavioral symptoms in autism. Dietary supplements fortified with vitamins should only be given under the supervision of a physician. A wide range of nutraceuticals are under clinical trials to understand whether they physiologically target mitochondrial pathways and improve the quality of life in autism.
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Affiliation(s)
- Saravana Babu Chidambaram
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, India. .,Central Animal Facility, JSS Academy of Higher Education & Research, Mysuru, India.
| | - Abid Bhat
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, India.,Central Animal Facility, JSS Academy of Higher Education & Research, Mysuru, India
| | | | - Bipul Ray
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, India.,Central Animal Facility, JSS Academy of Higher Education & Research, Mysuru, India
| | - Sunanda Tuladhar
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, India.,Central Animal Facility, JSS Academy of Higher Education & Research, Mysuru, India
| | - B S Sushmitha
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, India
| | - B Saravanan
- Department of Pharmacology, JSS College of Pharmacy, JSS Academy of Higher Education & Research, Mysuru, India
| | - Manivasagam Thamilarasan
- Department of Biochemistry and Biotechnology, Annamalai University, Chidambaram, Tamil Nadu, India
| | | | - Musthafa Mohamed Essa
- Department of Food Science and Nutrition, CAMS, Sultan Qaboos University, Muscat, Oman.,Ageing and Dementia Research Group, Sultan Qaboos University, Muscat, Oman
| | - Gilles J Guillemin
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - M Walid Qoronfleh
- Research & Policy Department, World Innovation Summit for Health (WISH), Qatar Foundation, Doha, Qatar
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24
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Wang S, Martins R, Sullivan MC, Friedman ES, Misic AM, El-Fahmawi A, De Martinis ECP, O'Brien K, Chen Y, Bradley C, Zhang G, Berry ASF, Hunter CA, Baldassano RN, Rondeau MP, Beiting DP. Diet-induced remission in chronic enteropathy is associated with altered microbial community structure and synthesis of secondary bile acids. Microbiome 2019; 7:126. [PMID: 31472697 PMCID: PMC6717631 DOI: 10.1186/s40168-019-0740-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 08/19/2019] [Indexed: 05/10/2023]
Abstract
BACKGROUND The microbiome has been implicated in the initiation and persistence of inflammatory bowel disease. Despite the fact that diet is one of the most potent modulators of microbiome composition and function and that dietary intervention is the first-line therapy for treating pediatric Crohn's disease, the relationships between diet-induced remission, enteropathy, and microbiome are poorly understood. Here, we leverage a naturally-occurring canine model of chronic inflammatory enteropathy that exhibits robust remission following nutritional therapy, to perform a longitudinal study that integrates clinical monitoring, 16S rRNA gene amplicon sequencing, metagenomic sequencing, metabolomic profiling, and whole genome sequencing to investigate the relationship between therapeutic diet, microbiome, and disease. RESULTS We show that remission induced by a hydrolyzed protein diet is accompanied by alterations in microbial community structure marked by decreased abundance of pathobionts (e.g., Escherichia coli and Clostridium perfringens), reduced severity of dysbiosis, and increased levels of the secondary bile acids, lithocholic and deoxycholic acid. Physiologic levels of these bile acids inhibited the growth of E. coli and C. perfringens isolates, in vitro. Metagenomic analysis and whole genome sequencing identified the bile acid producer Clostridium hiranonis as elevated after dietary therapy and a likely source of secondary bile acids during remission. When C. hiranonis was administered to mice, levels of deoxycholic acid were preserved and pathology associated with DSS colitis was ameliorated. Finally, a closely related bile acid producer, Clostridium scindens, was associated with diet-induced remission in human pediatric Crohn's disease. CONCLUSIONS These data highlight that remission induced by a hydrolyzed protein diet is associated with improved microbiota structure, an expansion of bile acid-producing clostridia, and increased levels of secondary bile acids. Our observations from clinical studies of exclusive enteral nutrition in human Crohn's disease, along with our in vitro inhibition assays and in vivo studies in mice, suggest that this may be a conserved response to diet therapy with the potential to ameliorate disease. These findings provide insight into diet-induced remission of gastrointestinal disease and could help guide the rational design of more effective therapeutic diets.
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Affiliation(s)
- Shuai Wang
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rene Martins
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Megan C Sullivan
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Elliot S Friedman
- Division of Gastroenterology, School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ana M Misic
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ayah El-Fahmawi
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | | | - Kevin O'Brien
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ying Chen
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Charles Bradley
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Grace Zhang
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alexander S F Berry
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Christopher A Hunter
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Robert N Baldassano
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
| | - Mark P Rondeau
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Daniel P Beiting
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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Shah LM, Turner Z, Bessone SK, Winesett SP, Stanfield A, Kossoff EH. How often is antiseizure drug-free ketogenic diet therapy achieved? Epilepsy Behav 2019; 93:29-31. [PMID: 30831398 DOI: 10.1016/j.yebeh.2019.01.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/28/2019] [Indexed: 11/29/2022]
Abstract
The ketogenic diet (KD) is often started not only for seizure reduction but also to potentially wean antiseizure drugs (ASDs) in children with epilepsy. Although there have been several publications regarding ASD reduction on the KD, it is unknown how often complete medication withdrawal occurs. We reviewed the charts of all children started on the KD at Johns Hopkins Hospital and Johns Hopkins All Children's Hospital from 1/11 to 4/18. Children were defined as achieving drug-free diet (DFD) status if they started the KD on at least 1 ASD and achieved a period of time where they were on the KD alone. Over the time period, 232 children were evaluated; DFD status occurred in 43 (18.5%), of which 32 (13.8% of the full cohort) remained off ASDs for the remainder of their KD treatment course. Eleven children restarted ASD after a mean of 7 months. Children achieving DFD therapy were more likely to be younger, have fewer ASDs at KD onset, have Glut1 deficiency or epilepsy with myoclonic-atonic seizures, but were less likely to have Lennox-Gastaut syndrome or a gastrostomy tube.
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Affiliation(s)
- Lochan M Shah
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Zahava Turner
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD, USA; Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Stacey K Bessone
- Neuroscience Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - S Parrish Winesett
- Neuroscience Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Anthony Stanfield
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Eric H Kossoff
- Department of Pediatrics, The Johns Hopkins Hospital, Baltimore, MD, USA; Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD, USA.
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Yamanaka M, Sakuma M, Matsushita A, Tanaka S, Yamamoto Y, Asai T, Arai H. The Effects of Long-Term Dietary Therapy on Patients with Hypertriglyceridemia. J Atheroscler Thromb 2018; 26:39-49. [PMID: 29794409 PMCID: PMC6308261 DOI: 10.5551/jat.42440] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Aim: This study aimed to evaluate the effect of diet on serum lipids and to assess the effectiveness of long-term dietary therapy for hypertriglyceridemia. Methods: Seventy-nine patients (34 males and 45 females) with hypertriglyceridemia were enrolled and underwent dietary counseling for 12 months based on the following three recommendations: (1) reduce carbohydrate intake, (2) increase n-3 polyunsaturated fatty acid (PUFA) intake, and (3) limit alcohol drinking. We examined the effect of dietary therapy for 6 months on serum triglyceride (TG) levels and also compared the effectiveness of dietary and combined drug therapies on preventing arteriosclerotic disease from 7 to 12 months. Results: We observed that serum TG levels of the patients receiving dietary counseling were decreased compared with baseline at 6 months. Body weight and serum TG levels were decreased, and serum high-density lipoprotein levels were increased in the dietary therapy alone group, whereas BW, body mass index, and abdominal circumference were decreased in the combined drug treatment group compared with baselines at 6 and 12 months. Furthermore, the dietary therapy alone group demonstrated reductions in intake of total energy, carbohydrate, and saturated fatty acids, as well as n-6/n-3 PUFA ratio compared with baselines, but only n-6/n-3 PUFA ratio was decreased in the combined drug treatment group. Conclusion: This study demonstrated a decrease in serum TG level after 12 months of dietary therapy similar to drug therapy, which suggests that it is an effective treatment for hypertriglyceridemia, and heightened awareness should be made to encourage its use. The clinical trial registration number: UMIN000028860.
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Affiliation(s)
- Mizuki Yamanaka
- Laboratory of Clinical Nutrition and Management, School of Food and Nutritional Sciences, The University of Shizuoka
| | - Masae Sakuma
- Laboratory of Clinical Nutrition and Management, School of Food and Nutritional Sciences, The University of Shizuoka
| | - Asami Matsushita
- Laboratory of Clinical Nutrition and Management, School of Food and Nutritional Sciences, The University of Shizuoka
| | - Satomi Tanaka
- Laboratory of Clinical Nutrition and Management, School of Food and Nutritional Sciences, The University of Shizuoka
| | | | | | - Hidekazu Arai
- Laboratory of Clinical Nutrition and Management, School of Food and Nutritional Sciences, The University of Shizuoka
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27
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Jung KW, Seo M, Cho YH, Park YO, Yoon SY, Lee J, Yang DH, Yoon IJ, Seo SY, Lee HJ, Park SH, Kim KJ, Ye BD, Byeon JS, Jung HY, Yang SK, Kim JH, Myung SJ. Prevalence of Fructose Malabsorption in Patients With Irritable Bowel Syndrome After Excluding Small Intestinal Bacterial Overgrowth. J Neurogastroenterol Motil 2018; 24:307-316. [PMID: 29433301 PMCID: PMC5885730 DOI: 10.5056/jnm17044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 09/07/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Fructose malabsorption (FM) mimics symptoms of irritable bowel syndrome (IBS), and its prevalence has increased. Diagnosing FM in IBS is challenging because of its overlap with small intestinal bacterial overgrowth (SIBO). We assessed the prevalence of FM by comparing patients with IBS with asymptomatic control individuals after excluding SIBO using the glucose hydrogen breath test (HBT). Methods Patients diagnosed with IBS and asymptomatic control individuals were enrolled prospectively. Dietary habits were assessed with the Food Frequency Questionnaire. After excluding SIBO, participants underwent HBTs with both 15 g and 25 g of fructose. Results Thirty-five patients with IBS and 35 age- and sex-matched asymptomatic control individuals were enrolled. The 15-g fructose HBT yielded positive results in 7 of the 35 (20.0%) patients with IBS and in 2 of 35 (5.7%) controls (P = 0.070). The 25-g fructose HBT was positive in 16 of the 35 (45.7%) patients with IBS and in 8 of the 35 (22.9%) controls (P = 0.040). Analysis of the Food Frequency Questionnaire responses showed no significant differences between the 2 groups in dietary intake, although patients with IBS showed a significantly higher mean fiber intake than controls (21.24 ± 11.35 g vs 15.87 ± 7.07 g, respectively, P = 0.040). Conclusions The 25-g fructose HBT identified FM in a significantly higher percentage of SIBO-negative patients with IBS than in asymptomatic control individuals, suggesting that FM may correlate with IBS. Education regarding dietary control of foods containing fructose may be useful for the management of patients with IBS.
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Affiliation(s)
- Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myeognsook Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hwan Cho
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Ok Park
- Department of Clinical Nutrition, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So-Yoon Yoon
- Department of Clinical Nutrition, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jungbok Lee
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ja Yoon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - So Young Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyo Jeong Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Jo Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
Clinical suspicion of urolithiasis should be evaluated with low-dose computed tomography as the first-line imaging modality for nonpregnant, adult patients. A period of observation may be appropriate for ureteral stones less than 10 mm, and medical expulsive therapy may be beneficial for facilitating passage of distal ureteral stones. Regardless of stone type, patients should adhere to a low-sodium diet and attempt to achieve a urine volume of more than 2.5 L daily. Individuals with calcium stones should maintain a normal calcium diet, and if stones persist, citrate therapy or thiazide diuretics in the setting of hypercalciuria may be indicated.
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Affiliation(s)
- Wesley W Ludwig
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Marburg 134, Baltimore, MD 21287, USA.
| | - Brian R Matlaga
- Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Marburg 134, Baltimore, MD 21287, USA
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Gambello MJ, Li H. Current strategies for the treatment of inborn errors of metabolism. J Genet Genomics 2018; 45:61-70. [PMID: 29500085 DOI: 10.1016/j.jgg.2018.02.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 11/14/2017] [Accepted: 02/11/2018] [Indexed: 12/23/2022]
Abstract
Inborn errors of metabolism (IEMs) are a large group of inherited disorders characterized by disruption of metabolic pathways due to deficient enzymes, cofactors, or transporters. The rapid advances in the understanding of the molecular pathophysiology of many IEMs, have led to significant progress in the development of many new treatments. The institution and continued expansion of newborn screening provide the opportunity for early treatment, leading to reduced morbidity and mortality. This review provides an overview of the diverse therapeutic approaches and recent advances in the treatment of IEMs that focus on the basic principles of reducing substrate accumulation, replacing or enhancing absent or reduced enzyme or cofactor, and supplementing product deficiency. In addition, the challenges and obstacles of current treatment modalities and future treatment perspectives are reviewed and discussed.
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Affiliation(s)
- Michael J Gambello
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Hong Li
- Department of Human Genetics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Abstract
Eosinophilic esophagitis is characterized by dense mucosal eosinophilia with symptoms of esophageal dysfunction. Because the incidence and prevalence are increasing, understanding the available treatments is imperative. This article highlights evolution and advancements in dietary treatment, supports the notion that food antigens drive this disease, and discusses the advantages, limitations, and future of dietary therapy. Medical and dietary therapies are effective treatments and the optimal approach should be individualized based on patient goals and available local resources. Dietary therapy has been effective and further studies will help identify optimal approaches to dietary therapy.
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Abstract
PURPOSE OF REVIEW Esophageal diseases represent a wide variety of conditions affecting esophageal anatomy, physiology, and motility. Therapy focuses on pharmacotherapy and endoscopic or surgical management. Dietary therapy can be considered in management algorithms for specific esophageal diseases. This review focuses on outlining the literature related to dietary therapy in gastroesophageal reflux disease, eosinophilic esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. RECENT FINDINGS Currently, data are strongest for dietary manipulation in eosinophilic esophagitis, specifically the six-food elimination diet. Dietary effects on gastroesophageal reflux disease are less clear, though newer research indicates that increased fiber with reduction in simple sugar intake may improve symptoms. In terms of Barrett's esophagus and esophageal adenocarcinoma, antioxidant intake may affect carcinogenesis, though to an unknown degree. Outcomes data regarding dietary manipulation for the management of esophageal diseases is heterogeneous. Given the rising interest in non-pharmacological treatment options for these patients, continued research is warranted.
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Lane ER, Lee D, Suskind DL. Dietary Therapies in Pediatric Inflammatory Bowel Disease: An Evolving Inflammatory Bowel Disease Paradigm. Gastroenterol Clin North Am 2017; 46:731-44. [PMID: 29173518 DOI: 10.1016/j.gtc.2017.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Nutrition has long been recognized as a critical component in the treatment of pediatric inflammatory bowel disease (IBD). Formerly, nutritional interventions have focused on targeting improved weight gain and linear growth, as well as correction of micronutrient deficiencies. Recently, there has been growing interest and study of dietary interventions for induction and maintenance of remission. In addition to exclusive enteral nutrition, successes have been achieved with specific exclusion diets. This article evaluates current literature regarding the role of diet and nutrition in pathogenesis of disease, as well as the role of diet as primary therapy for pediatric IBD.
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33
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Groetch M, Venter C, Skypala I, Vlieg-Boerstra B, Grimshaw K, Durban R, Cassin A, Henry M, Kliewer K, Kabbash L, Atkins D, Nowak-Węgrzyn A, Holbreich M, Chehade M. Dietary Therapy and Nutrition Management of Eosinophilic Esophagitis: A Work Group Report of the American Academy of Allergy, Asthma, and Immunology. J Allergy Clin Immunol Pract 2017; 5:312-324.e29. [PMID: 28283156 DOI: 10.1016/j.jaip.2016.12.026] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/21/2016] [Indexed: 12/16/2022]
Abstract
Eosinophilic esophagitis (EoE) is a chronic/immune-antigen-mediated disease characterized clinically by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation. Dietary elimination therapy has been shown to be an effective, drug-free prescription for the treatment of EoE. A range of different dietary elimination therapies have been used. Regardless of the elimination diet chosen, dietary therapy requires in-depth nutrition assessment and management. Elimination diets are not without risk and may impact nutritional status, eating pleasure, and overall quality of life. With adequate guidance, dietary therapy can be effective and nutritionally balanced, and the adverse impact on lifestyle can be minimized. This work group report addresses the potential challenges of implementing an elimination diet for the management of EoE and provides instructions and tools for physicians, dietitians, and other allied health professionals to help guide them in planning elimination diets for both children and adults.
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Affiliation(s)
- Marion Groetch
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Carina Venter
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Isabel Skypala
- Allergy Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK; Department of Paediatrics, Imperial College, London, UK
| | - Berber Vlieg-Boerstra
- Onze lieve Vrouwe Gasthuis (OLVG), Department of Paediatrics, Amsterdam, The Netherlands
| | - Kate Grimshaw
- Department of Nutrition and Dietetics, Southampton's Children's Hospital, Southampton, UK; Clinical and Experimental Sciences and Human Development in Health Academic Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Raquel Durban
- Division of Food Allergy, Asthma and Allergy Specialists, PA, Charlotte, NC
| | - Alison Cassin
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michelle Henry
- Department of Medical Affairs, Fresenius Kabi USA, LLC, Lake Zurich, Ill
| | - Kara Kliewer
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynda Kabbash
- Department of Internal Medicine, Harvard Medical School, Boston, Mass; Department of Internal Medicine, New England Baptist Hospital, Boston, Mass
| | - Dan Atkins
- Gastrointestinal Eosinophilic Diseases Program and Allergy & Immunology Section, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Anna Nowak-Węgrzyn
- Division of Allergy and Immunology, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Mirna Chehade
- Departments of Pediatrics and Medicine, Mount Sinai Center for Eosinophilic Disorders, Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Mathisen TF, Rosenvinge JH, Pettersen G, Friborg O, Vrabel K, Bratland-Sanda S, Svendsen M, Stensrud T, Bakland M, Wynn R, Sundgot-Borgen J. The PED-t trial protocol: The effect of physical exercise -and dietary therapy compared with cognitive behavior therapy in treatment of bulimia nervosa and binge eating disorder. BMC Psychiatry 2017; 17:180. [PMID: 28494809 PMCID: PMC5427572 DOI: 10.1186/s12888-017-1312-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Accepted: 04/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sufferers from bulimia nervosa (BN) and binge eating disorder (BED) underestimate the severity risk of their illness and, therefore, postpone seeking professional help for years. Moreover, less than one in five actually seek professional help and only 50% respond to current treatments, such as cognitive behavioral therapy (CBT). The impetus for the present trial is to explore a novel combination treatment approach adapted from physical exercise- and dietary therapy (PED-t). The therapeutic underpinnings of these separate treatment components are well-known, but their combination to treat BN and BED have never been previously tested. The purpose of this paper is to provide the rationale for this new treatment approach and to outline the specific methods and procedures. METHODS The PED-t trial uses a prospective randomized controlled design. It allocates women between 18 and 40 years (BMI range 17.5-35.0) to groups consisting of 5-8 members who receive either CBT or PED-t for 16 weeks. Excess participants are allocated to a waiting list control group condition. All participants are assessed at baseline, post-treatment, 6, 12 and 24 months' post-follow-up, respectively, and monitored for changes in biological, psychological and therapy process variables. The primary outcome relates to the ED symptom severity, while secondary outcomes relates to treatment effects on physical health, treatment satisfaction, therapeutic alliance, and cost-effectiveness. We aim to disseminate the results in high-impact journals, preferable open access, and at international conferences. DISCUSSION We expect that the new treatment will perform equal to CBT in terms of behavioral and psychological symptoms, but better in terms of reducing somatic symptoms and complications. We also expect that the new treatment will improve physical fitness and thereby, quality of life. Hence, the new treatment will add to the portfolio of evidence-based therapies and thereby provide a good treatment alternative for females with BN and BED. TRIAL REGISTRATION Prospectively registered in REC the 16th of December 2013 with the identifier number 2013/1871 , and in Clinical Trials the 17th of February 2014 with the identifier number NCT02079935 .
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Affiliation(s)
| | - Jan H. Rosenvinge
- 0000000122595234grid.10919.30Department of Psychology, UiT -The Arctic University of Norway, Faculty of Health Sciences, 9037 Tromsø, Norway
| | - Gunn Pettersen
- 0000000122595234grid.10919.30Department of Health and Caring Sciences, UiT -The Arctic University of Norway, Faculty of Health Sciences, 9073 Tromsø, Norway
| | - Oddgeir Friborg
- 0000000122595234grid.10919.30Department of Psychology, UiT -The Arctic University of Norway, Faculty of Health Sciences, 9037 Tromsø, Norway
| | - KariAnne Vrabel
- Research Institute of Modum Bad, Badeveien 287, 3370 Vikersund, Norway
| | - Solfrid Bratland-Sanda
- grid.463530.7University College of Southeast Norway, Bø Postboks 235, 3603 Kongsberg, Norway
| | - Mette Svendsen
- 0000 0004 0389 8485grid.55325.34Department of Preventive Medicine, Oslo University Hospital, Kirkeveien 166, 0407 Oslo, Norway
| | - Trine Stensrud
- 0000 0000 8567 2092grid.412285.8Department of Sports Medicine, Norwegian School of Sport Sciences, Sognsvegen 220, 0806 Oslo, Norway
| | - Maria Bakland
- 0000000122595234grid.10919.30Department of Health and Caring Sciences, UiT -The Arctic University of Norway, Faculty of Health Sciences, 9073 Tromsø, Norway
| | - Rolf Wynn
- 0000000122595234grid.10919.30Department of Clinical Medicine, UiT -The Arctic University of Norway, Faculty of Health Sciences, 9037 Tromsø, Norway
| | - Jorunn Sundgot-Borgen
- 0000 0000 8567 2092grid.412285.8Department of Sports Medicine, Norwegian School of Sport Sciences, Sognsvegen 220, 0806 Oslo, Norway
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Svolos V, Gerasimidis K, Buchanan E, Curtis L, Garrick V, Hay J, Laird S, Munro J, Gaya DR, Russell RK, Hansen R. Dietary treatment of Crohn's disease: perceptions of families with children treated by exclusive enteral nutrition, a questionnaire survey. BMC Gastroenterol 2017; 17:14. [PMID: 28103809 PMCID: PMC5247812 DOI: 10.1186/s12876-016-0564-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/22/2016] [Indexed: 01/13/2023] Open
Abstract
Background Diet is strongly associated with the aetiology of Crohn’s Disease (CD) and exclusive enteral nutrition (EEN) is the primary induction treatment in paediatric CD. This study explored opinions around the use of EEN and alternative novel, solid food-based diets (SFDs) expressed by paediatric patients with CD, previously treated with EEN and their parents. Methods This anonymous questionnaire surveyed families of CD patients treated with EEN over 1 year. Two questionnaire forms were completed; one asking the patients’ opinions and another referring to their main carer. This questionnaire explored participants’ demographic characteristics; acceptability of a repeat EEN course to treat a future flare (EEN repeat); their opinion on how difficult EEN would be compared to an example SFD; and their intention to participate in a future clinical trial assessing the therapeutic efficacy of an SFD in CD. Results Forty-one families of CD patients were approached with 29 sending replies (71%). Most of our participants were positive on completing another EEN course, however the majority would choose an SFD alternative (Patients:66, Parents:72%). Both patients and their parents rated EEN to be more difficult to adhere to compared to an example SFD (p < 0.05), and their ratings were strongly correlated (EEN:r = 0.83, SFD:r = 0.75, p < 0.001). The majority of our respondents would agree to participate in a clinical trial assessing an SFD’s effectiveness (Patients:79, Parents:72%) for the management of active CD. Conclusions While patients with CD and their families would accept an EEN repeat, the majority would prefer an SFD alternative. CD families surveyed are supportive of the development of solid food-based dietary treatments. Electronic supplementary material The online version of this article (doi:10.1186/s12876-016-0564-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vaios Svolos
- Human Nutrition, School of Medicine, Dentistry & Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Konstantinos Gerasimidis
- Human Nutrition, School of Medicine, Dentistry & Nursing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
| | - Elaine Buchanan
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Lee Curtis
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Vikki Garrick
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Jacqueline Hay
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Susan Laird
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Joanna Munro
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Daniel R Gaya
- Department of Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | - Richard K Russell
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Richard Hansen
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children, Glasgow, UK.
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Witters P, Debbold E, Crivelly K, Vande Kerckhove K, Corthouts K, Debbold B, Andersson H, Vannieuwenborg L, Geuens S, Baumgartner M, Kozicz T, Settles L, Morava E. Autism in patients with propionic acidemia. Mol Genet Metab 2016; 119:317-321. [PMID: 27825584 DOI: 10.1016/j.ymgme.2016.10.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 10/29/2016] [Accepted: 10/29/2016] [Indexed: 12/29/2022]
Abstract
Certain inborn errors of metabolism have been suggested to increase the risk of autistic behavior. In an animal model, propionic acid ingestion triggered abnormal behavior resembling autism. So far only a few cases were reported with propionic acidemia and autistic features. From a series of twelve consecutively diagnosed cases with propionic acidemia, we report on eight patients with autistic features. The patients were followed 2-4 times a year and underwent regular clinical, dietary and laboratory investigations. Psychological evaluation was performed every second to fourth year. All patients were compliant with the standard diet and carnitine supplementation. None of the patients had frequent metabolic decompensations. From the metabolic factors known to impact neuropsychological outcome we detected chronically decreased valine levels and altered valine to leucine ratios in five out of the eight patients. Recurrent lactic acid elevations were present in six out of the eight patients. Five of the eight patients were diagnosed with Autism Spectrum Disorder, four of them had pathogenic variants in PCCB. Disorder according to DSM-IV and/or DSM-5 criteria. One of the patients diagnosed with propionic acidemia by newborn screening had the most significant behavioral features and another was diagnosed with Autism Spectrum Disorder prior to propionic acidemia. We hypothesize that chronic suboptimal intracellular metabolic balance may be responsible for the increased risk for autistic features in propionic acidemia. We propose that patients diagnosed with propionic acidemia should be screened for Autism Spectrum Disorder.
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Affiliation(s)
- Peter Witters
- Department of Pediatrics, Metabolic Center, University Hospitals Leuven, Leuven, Belgium
| | - Eric Debbold
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Kea Crivelly
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Karen Corthouts
- Department of Pediatrics, Metabolic Center, University Hospitals Leuven, Leuven, Belgium
| | - Brett Debbold
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Hans Andersson
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA
| | - Lena Vannieuwenborg
- Department of Psychology, Metabolic Center, University Hospitals Leuven, Leuven, Belgium
| | - Sam Geuens
- Department of Psychology, Metabolic Center, University Hospitals Leuven, Leuven, Belgium
| | - Matthias Baumgartner
- Division of Metabolism, Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Tamas Kozicz
- Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA; Donders Institute for Brain, Neuroscience, Radboudumc, Nijmegen, The Netherlands
| | - Lisa Settles
- Department of Psychiatry, Tulane University School of Medicine, New Orleans, LA, USA
| | - Eva Morava
- Department of Pediatrics, Metabolic Center, University Hospitals Leuven, Leuven, Belgium; Hayward Genetics Center, Tulane University School of Medicine, New Orleans, LA, USA.
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Abstract
Obesity is a common disorder with complex causes. The epidemic has spurred significant advances in the understanding of nutritional approaches to treating obesity. Although the primary challenge is to introduce a dietary intake that creates an energy deficit, clinicians should also consider targeted risk factor modification with manipulation of the nutrient profile of the weight-reducing diet. These strategies produce significant weight loss and improvements in cardiometabolic risk factors. Future research is needed to better understand how to personalize nutrient prescriptions further to promote optimal risk modification and maintenance of long-term energy balance in the weight-reduced state.
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Affiliation(s)
- Jamy D Ard
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston Salem, NC, USA.
| | - Gary Miller
- Department of Health and Exercise Science, Wake Forest University, Winston Salem, NC, USA
| | - Scott Kahan
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
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Pasca L, De Giorgis V, Macasaet JA, Trentani C, Tagliabue A, Veggiotti P. The changing face of dietary therapy for epilepsy. Eur J Pediatr 2016; 175:1267-76. [PMID: 27586246 DOI: 10.1007/s00431-016-2765-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 08/07/2016] [Accepted: 08/19/2016] [Indexed: 01/01/2023]
Abstract
UNLABELLED Ketogenic diet is an established and effective non-pharmacologic treatment for drug-resistant epilepsy. Ketogenic diet represents the treatment of choice for GLUT-1 deficiency syndrome and pyruvate dehydrogenase complex deficiency. Infantile spasms, Dravet syndrome and myoclonic-astatic epilepsy are epilepsy syndromes for which ketogenic diet should be considered early in the therapeutic pathway. Recently, clinical indications for ketogenic diet have been increasing, as there is emerging evidence regarding safety and effectiveness. Specifically, ketogenic diet response has been investigated in refractory status epilepticus and encephalopathy with status epilepticus during sleep. New targets in neuropharmacology, such as mitochondrial permeability transition, are being studied and might lead to using it effectively in other neurological diseases. But, inefficient connectivity and impaired ketogenic diet proposal limit ideal availability of this therapeutic option. Ketogenic diet in Italy is not yet considered as standard of care, not even as a therapeutic option for many child neurologists and epileptologists. CONCLUSIONS The aim of this review is to revisit ketogenic diet effectiveness and safety in order to highlight its importance in drug-resistant epilepsy and other neurological disorders. WHAT IS KNOWN • Ketogenic diet efficacy is now described in large case series, with adequate diet compliance and side effects control. • Ketogenic diet is far from being attempted as a first line therapy. Its availability varies worldwide. What is New: • New pharmacological targets such as mitochondrial permeability transition and new epileptic syndromes and etiologies responding to the diet such as refractory status epilepticus are being pointed out. • Ketogenic diet can function at its best when used as a tailor-made therapy. Fine tuning is crucial.
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Affiliation(s)
- Ludovica Pasca
- Department of Child Neurology and Psychiatry, IRCCS "C. Mondino" National Neurological Institute, Pavia, Italy
| | - Valentina De Giorgis
- Department of Child Neurology and Psychiatry, IRCCS "C. Mondino" National Neurological Institute, Pavia, Italy.,Brain and Behaviour Department, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | | | - Claudia Trentani
- Human nutrition and eating disorder center, department of public health, experimental and forensic medicine, University of Pavia, Pavia, Italy
| | - Anna Tagliabue
- Human nutrition and eating disorder center, department of public health, experimental and forensic medicine, University of Pavia, Pavia, Italy
| | - Pierangelo Veggiotti
- Department of Child Neurology and Psychiatry, IRCCS "C. Mondino" National Neurological Institute, Pavia, Italy. .,Brain and Behaviour Department, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy.
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Asher Wolf W, Huang KZ, Durban R, Iqbal ZJ, Robey BS, Khalid FJ, Dellon ES. The Six-Food Elimination Diet for Eosinophilic Esophagitis Increases Grocery Shopping Cost and Complexity. Dysphagia 2016; 31:765-70. [PMID: 27503565 DOI: 10.1007/s00455-016-9739-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/28/2016] [Indexed: 02/07/2023]
Abstract
The six-food elimination diet (SFED), where dairy, wheat, eggs, soy, nuts, and seafood are avoided, is an effective treatment for eosinophilic esophagitis (EoE). Patient-related costs of this approach, however, are unknown. We aimed to assess the cost of and ease of shopping for an SFED compared to an unrestricted diet. A dietitian with expertise in EoE generated menus meeting dietary requirements for a week's worth of meals for the SFED and an unrestricted diet. We compared prices and the number of missing items for both diets at standard and specialty grocery stores. The average weekly price of the SFED at a standard supermarket was $92.54 compared to $79.84 for an unrestricted diet (p = 0.0001). A patient shopping at a standard grocery store needed a higher proportion of items from a second store compared to an unrestricted diet (32 vs. 3 %, p = 0.0001). The prices of the SFED and unrestricted diet using a specialty supermarket were comparable ($106.47 vs. $105.96, p = 0.81), as was the percentage of items requiring a trip to a second store (6 vs. 2 % items, p = 0.03). Shopping at a specialty grocery store increased weekly grocery costs by $13.93 (p = 0.04) for the SFED and $26.12 (p = 0.03) for the unrestricted diet. In conclusion, for patients shopping at standard grocery stores, the cost of an SFED is higher, and an SFED requires more items from a second store. These differences disappear at specialty grocery stores, but costs were significantly higher. This cost and logistical burden can inform patients when selecting dietary therapy.
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Yuzyuk T, Thomas A, Viau K, Liu A, De Biase I, Botto LD, Pasquali M, Longo N. Effect of dietary lysine restriction and arginine supplementation in two patients with pyridoxine-dependent epilepsy. Mol Genet Metab 2016; 118:167-172. [PMID: 27324284 DOI: 10.1016/j.ymgme.2016.04.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 12/27/2022]
Abstract
Pyridoxine-Dependent Epilepsy (PDE) is a recessive disorder caused by deficiency of α-aminoadipic semialdehyde dehydrogenase in the catabolic pathway of lysine. It is characterized by intractable seizures controlled by the administration of pharmacological doses of vitamin B6. Despite seizure control with pyridoxine, intellectual disability and developmental delays are still observed in some patients with PDE, likely due to the accumulation of toxic intermediates in the lysine catabolic pathway: alpha-aminoadipic semialdehyde (AASA), delta-1-piperideine-6-carboxylate (P6C), and pipecolic acid. Here we evaluate biochemical and clinical parameters in two PDE patients treated with a lysine-restricted diet and arginine supplementation (100-150mg/kg), aimed at reducing the levels of PDE biomarkers. Lysine restriction resulted in decreased accumulation of PDE biomarkers and improved development. Plasma lysine but not plasma arginine, directly correlated with plasma levels of AASA-P6C (p<0.001, r(2)=0.640) and pipecolic acid (p<0.01, r(2)=0.484). In addition, plasma threonine strongly correlated with the levels of AASA-P6C (p<0.0001, r(2)=0.732) and pipecolic acid (p<0.005, r(2)=0.527), suggesting extreme sensitivity of threonine catabolism to pyridoxine availability. Our results further support the use of dietary therapies in combination with pyridoxine for the treatment of PDE.
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Affiliation(s)
- Tatiana Yuzyuk
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA.
| | - Amanda Thomas
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA
| | - Krista Viau
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Aiping Liu
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Irene De Biase
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Lorenzo D Botto
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Marzia Pasquali
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA; Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Nicola Longo
- Department of Pathology, University of Utah, Salt Lake City, UT, USA; ARUP Laboratories, Salt Lake City, UT, USA; ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA; Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Mehta R, Goel S, Sharma S, Jain P, Mukherjee SB, Aneja S. Efficacy and tolerability of the modified Atkins diet in young children with refractory epilepsy: Indian experience. Ann Indian Acad Neurol 2016; 19:523-527. [PMID: 27994368 PMCID: PMC5144480 DOI: 10.4103/0972-2327.194463] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: The modified Atkins diet (MAD) has been used predominantly in older children, adolescents, and adults. There is a paucity of data on the use of the MAD in refractory epilepsy in young children. Objectives: This study was planned to evaluate the efficacy and tolerability of the MAD in refractory epilepsy in young children. Methods: This study recruited children aged 9 months to 3 years with refractory seizures. Children received MAD for 6-month with the on-going anticonvulsant medications being continued unchanged. Reduction in seizure frequency was the primary outcome measure. Adverse effects were also studied. Results: Thirty-one children with daily seizures were studied with a median age of 18-month (range 9–30 months). West syndrome was the most common epilepsy syndrome (26, 86.6%). Twenty-one children remained on diet at 3 months and 13 at 6 months. The children who achieved >50% seizure reduction were 17 (54.8%) at 3 months and 9 (29%) at 6 months. Refusal to eat was a significant problem seen in eight children. Three children discontinued the diet due to adverse effects. Conclusion: The MAD was found to be feasible, effective, and well-tolerated.
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Affiliation(s)
- Ranju Mehta
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Shaiphali Goel
- Department of Pediatrics, Division of Pediatric Neurology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Suvasini Sharma
- Department of Pediatrics, Division of Pediatric Neurology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Puneet Jain
- Department of Neonatal, Pediatric and Adolescent Medicine, Division of Pediatric Neurology, BL Kapur Super Speciality Hospital, New Delhi, India
| | - Sharmila B Mukherjee
- Department of Pediatrics, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
| | - Satinder Aneja
- Department of Pediatrics, Division of Pediatric Neurology, Lady Hardinge Medical College and Associated Kalawati Saran Children's Hospital, New Delhi, India
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Obih C, Wahbeh G, Lee D, Braly K, Giefer M, Shaffer ML, Nielson H, Suskind DL. Specific carbohydrate diet for pediatric inflammatory bowel disease in clinical practice within an academic IBD center. Nutrition 2015; 32:418-25. [PMID: 26655069 DOI: 10.1016/j.nut.2015.08.025] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Despite dietary factors being implicated in the pathogenesis of inflammatory bowel disease (IBD), nutritional therapy, outside of exclusive enteral nutrition (EEN), has not had a defined role within the treatment paradigm of pediatric IBD within IBD centers. Based on emerging data, Seattle Children's Hospital IBD Center has developed an integrated dietary program incorporating the specific carbohydrate diet (SCD) into its treatment paradigm. This treatment paradigm uses the SCD as primary therapy as well as adjunctive therapy for the treatment of IBD. The aim of this study was to evaluate the potential effects of the SCD on clinical outcomes and laboratory studies of pediatric patients with Crohn's disease (CD) and ulcerative colitis (UC). METHODS In this retrospective study, we reviewed the medical records of patients with IBD on SCD. RESULTS We analyzed 26 children on the SCD: 20 with CD and 6 with UC. Duration of the dietary therapy ranged from 3 to 48 mo. In patients with active CD (Pediatric Crohn's Disease activity index [PCDAI] >10), PCDAI dropped from 32.8 ± 13.2 at baseline to 20.8 ± 16.6 by 4 ± 2 wk, and to 8.8 ± 8.5 by 6 mo. The mean Pediatric Ulcerative Colitis Activity Index for patients with active UC decreased from a baseline of 28.3 ± 10.3 to 20.0 ± 17.3 at 4 ± 2 wk, to 18.3 ± 31.7 at 6 mo. CONCLUSION This retrospective review provides evidence that the SCD can be integrated into a tertiary care center and may improve clinical and laboratory parameters for pediatric patients with nonstructuring, nonpenetrating CD as well as UC. Further prospective studies are needed to fully assess the safety and efficacy of the SCD in pediatric patients with IBD.
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Affiliation(s)
- Chinonyelum Obih
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Ghassan Wahbeh
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Dale Lee
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Kim Braly
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Matthew Giefer
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Michele L Shaffer
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA; Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, WA, USA
| | - Heather Nielson
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - David L Suskind
- Department of Pediatrics, Seattle Children's Hospital and University of Washington, Seattle, WA, USA.
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43
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Abstract
A 73-year-old female of Asian origin was diagnosed with ulcerative colitis (UC) after initial gastrointestinal symptoms of abdominal pain and bloody diarrhea. She had a relatively benign course over the subsequent 12 years. In 2009, she had increased left-sided abdominal pain, bloody diarrhea and progressive weight loss, due to a severe exacerbation. In spite of a variety of standard treatments, her condition continued to decline with a significant impact on normal life and functioning. In December of 2010, repeat colonoscopy and microscopy confirmed pancolitis, without diverticulitis. The Specific Carbohydrate Diet (SCD) was initiated due to failure of conventional therapies. Following this highly restricted diet, within a period of 3–6 months, improvement was noted, and within a year, no abdominal pain or diarrhea were present, and she returned to her baseline functioning and career. Two years later, repeat colonoscopy showed resolution of the pancolitis, confirmed with microscopic evaluation. Successful use of the SCD in children with UC has been documented. We describe previously unreported, highly beneficial results with both symptomatic and clinical improvement and complete remission of UC in an adult female with the SCD.
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Affiliation(s)
- Birgit N Khandalavala
- Department of Family Medicine, University of Nebraska Medical Center, Omaha, Nebr., USA
| | - Maya C Nirmalraj
- Department of Family Medicine, University of Nebraska Medical Center, Omaha, Nebr., USA
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44
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Colson D, Kalach N, Soulaines P, Vannerom Y, Campeotto F, Talbotec C, Chatenoud L, Hankard R, Dupont C. The impact of dietary therapy on clinical and biologic parameters of pediatric patients with eosinophilic esophagitis. J Allergy Clin Immunol Pract 2015; 2:587-93. [PMID: 25213053 DOI: 10.1016/j.jaip.2014.05.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 04/29/2014] [Accepted: 05/23/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is a clinicopathologic disease that presents with a massive infiltration of the esophagus by eosinophils triggered by food antigen(s). OBJECTIVE To determine the impact of dietary therapy on nutritional parameters in patients who present with EoE. METHODS A convenience retrospective study analyzed patients with EoE after a 2-month dietary therapy (6-food elimination diet, avoidance of the 6 most common allergenic foods, plus avoidance of those eliciting positive skin testing, plus amino-acid formula as replacement for dairy products). Pre- and postdiet allergic and nutritional status were evaluated. RESULTS Of 111 eligible patients, 59 patients, with a median age of 77.7 months (range, 9-189 months) were enrolled. Dietary therapy significantly increased the return to normal endoscopic appearance (47.4%, P < .0009) and led to complete remission (<5 eosinophils/esophageal HPF and disappearance of symptoms) in 59.3%. All symptoms improved, digestive (98.3%), cutaneous (80%), and respiratory (92.8%). The prediet median weight-for-height (WFH) z score was -0.75 (-3.00 to 5.69), and the postdiet WFH did not significantly differ, -0.51 (-3.09 to 5.00). The prediet WFH z score was less than -2 (moderate malnutrition) in 10.1%. Postdiet blood eosinophils counts decreased in absolute numbers and in counts ≥ 500 × 10(6)/L (P < .0001). Evaluation after 1 year of progressive reintroduction of eliminated foods was available in 33 children: the median WFH z score did not significantly improve, from -0.89 (range, -3.00 to 0.67) at enrollment to -0.59 (range, -3.66 to 2.24). CONCLUSION The nutritional status of children with EoE was mildly affected and not worsened by the 2-month dietary therapy.
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Affiliation(s)
- Diana Colson
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France; Nutricia Nutrition Clinique, Saint-Ouen, France
| | - Nicolas Kalach
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France; Clinique Pédiatrique Saint Antoine, Hôpital Saint Vincent de Paul, Groupement des Hôpitaux de l'Institut Catholique de Lille, France
| | - Pascale Soulaines
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | | | - Florence Campeotto
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Cecile Talbotec
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France
| | - Lucienne Chatenoud
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France; Laboratoire d'Immunologie Biologie, Hôpital Necker - Enfants Malades, Paris, France
| | - Régis Hankard
- INSERM 1069, CHRU Tours, F-37000, Tours; Univ. F. Rabelais, Tours. France
| | - Christophe Dupont
- Hôpital Necker - Enfants Malades, Université Paris Descartes, Paris, France; Clinique Pédiatrique Saint Antoine, Hôpital Saint Vincent de Paul, Groupement des Hôpitaux de l'Institut Catholique de Lille, France.
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Sasakabe T, Haimoto H, Umegaki H, Wakai K. Association of decrease in carbohydrate intake with reduction in abdominal fat during 3-month moderate low-carbohydrate diet among non-obese Japanese patients with type 2 diabetes. Metabolism 2015; 64:618-25. [PMID: 25682064 DOI: 10.1016/j.metabol.2015.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 01/08/2015] [Accepted: 01/23/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The effectiveness of a moderate low-carbohydrate diet (M-LCD) has been demonstrated in terms of glycemic control, body weight and serum lipid profiles. We investigated the effect of a 3-month M-LCD on visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT), and examined an association between decrease in carbohydrate intake and reduction in abdominal fat among patients with Type 2 diabetes mellitus (T2DM). METHODS Seventy-six patients (45 men and 31 women; mean age ± SD: 59.5 ± 11.1 years) with T2DM were instructed to follow an M-LCD for 3 months. We assessed abdominal fat distribution using computed tomography and macronutrient intakes from 3-day dietary records at baseline and after 3 months. RESULTS The patients complied well with the M-LCD - %carbohydrate: %fat: %protein at baseline and after 3 months were 51:27:15 and 41:33:18 in men and 54:27:16 and 42:37:19 in women, respectively. VAT and SAT significantly decreased during the 3 months (P for time < 0.001 for both). Decrease in carbohydrate intake (g/day) and %carbohydrate were correlated with decrease (%) in VAT. The correlations were significant in men (Spearman correlation coefficient r = 0.469 for carbohydrate intake (g) and r = 0.402 for %carbohydrate) but not in women (r = 0.269 and 0.278, respectively). The correlations in men remained significant in multiple regression analysis adjusted for age and changes in energy intake. CONCLUSIONS In men, decrease in carbohydrate intake was significantly correlated with VAT loss during a 3-month M-LCD, independently of reduction in energy intake.
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Affiliation(s)
- Tae Sasakabe
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan.
| | - Hajime Haimoto
- Department of Internal Medicine, Haimoto Clinic, 1-80 Yayoi-cho, Kasugai, Aichi 486-0838, Japan
| | - Hiroyuki Umegaki
- Department of Geriatrics, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
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Abstract
Vitiligo is a common pigmentary skin condition with a profound impact. Despite a number of therapeutic modalities, few have been demonstrated to result in significant repigmentation within a brief period of time. Reported dietary interventions are sparse. Following exclusion of gluten in the diet, early and extensive repigmentation of facial lesions were noted in a young female adult of Asian ethnicity with acrofacial vitiligo. The majority of the benefits occurred within the first month and stabilized at 4 months. Previous topical and phototherapy had not been found to be effective. The patient was maintained on the previously prescribed dapsone therapy. Dietary elimination can potentially be a disease-modifying intervention for vitiligo and should be considered even in patients without concomitant celiac disease.
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Affiliation(s)
- Birgit N Khandalavala
- Department of Family Medicine, University of Nebraska Medical Center, Omaha, Nebr., USA
| | - Maya C Nirmalraj
- Department of Family Medicine, University of Nebraska Medical Center, Omaha, Nebr., USA
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Rassbach W, Rubenstein JH, Elkins M, DeMatos V, Greenson JK, Greenhawt M. Age-based differences in the diagnosis and management of esophageal eosinophilia. J Allergy Clin Immunol Pract 2014; 3:81-87.e1. [PMID: 25577623 DOI: 10.1016/j.jaip.2014.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 06/03/2014] [Accepted: 06/14/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eosinophilic esophagitis (EoE) is hallmarked by esophageal eosinophilia, >15 eosinophils(eos)/high-powered field (hpf), unresponsive to acid inhibition, and varied symptomatology. EoE consensus guidelines do not discriminate based on age for initiating treatment. OBJECTIVE To evaluate if age-related differences exist in managing esophageal eosinophilia and EoE within a university population. METHODS In a retrospective cohort study from a referral center, the medical records of 426 pediatric and adult patients with at least 1 presenting symptom of esophagitis, reflux, or upper gastrointestinal dysfunction, who underwent esophageal biopsy between 2009 and 2011 were analyzed for age-based differences in care in diagnosing and managing esophageal eosinophilia. RESULTS For these patients, 79.6% (336/426) had ≥15 eos/hpf in biopsy specimens, which was not associated with age. Significantly fewer adults than children with ≥15 eos/hpf were diagnosed with EoE (P < .001), referred for allergy evaluation (P < .001), started on swallowed steroid therapy (P < .001), or underwent repeated biopsy (P < .001). Increasing age, atopy, and increasing biopsy peak eos count moderated these effects, but the adjusted predicted probabilities for these outcomes were significantly lower among adults. Restriction for an 8-week prebiopsy proton-pump inhibitor trial did not alter the age-based relationships for an allergy referral or repeated biopsy. CONCLUSIONS Numerous age-based differences in the management of symptomatic patients with esophageal eosinophilia existed in this cohort. Adults were significantly less likely than children to receive a clinical diagnosis of EoE, allergy referral, or steroid treatment, or to have a repeated biopsy. Even when stratified for an 8-week prebiopsy proton-pump inhibitor trial, advancing age was associated with lower odds of referral or repeated biopsy. Further study is necessary to better understand why discrepancies exist and their potential ramifications.
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Affiliation(s)
- Whitney Rassbach
- Division of Allergy and Clinical Immunology, The Ichan School of Medicine at Mount Sinai, New York, NY; Department of Medicine and Pediatrics, The University of Michigan Health System, Ann Arbor, Mich
| | - Joel H Rubenstein
- Division of Gastroenterology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Mich
| | - Matthew Elkins
- Department of Pathology, SUNY Upstate Medical University, Syracuse, NY; Department of Pathology, The University of Michigan Medical School, Ann Arbor, Mich
| | - Vera DeMatos
- Division of Gastroenterology, Department of Pediatrics, The University of Michigan Medical School, Ann Arbor, Mich
| | - Joel K Greenson
- Department of Pathology, The University of Michigan Medical School, Ann Arbor, Mich
| | - Matthew Greenhawt
- The University of Michigan Food Allergy Center; Ann Arbor, Mich; Division of Allergy and Clinical Immunology, Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor, Mich; Department of Pediatrics, Child Health Evaluation and Research Unit, The University of Michigan Medical School, Ann Arbor, Mich.
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