Evaluating the Effectiveness of a Generative Pretrained Transformer-Based Dietary Recommendation System in Managing Potassium Intake for Hemodialysis Patients

OBJECTIVE

Despite adequate dialysis, the prevalence of hyperkalemia in Chinese hemodialysis (HD) patients remains elevated. This study aims to evaluate the effectiveness of a dietary recommendation system driven by generative pretrained transformers (GPTs) in managing potassium levels in HD patients.

METHODS

We implemented a bespoke dietary guidance tool utilizing GPT technology. Patients undergoing HD at our center were enrolled in the study from October 2023 to November 2023. The intervention comprised of two distinct phases. Initially, patients were provided with conventional dietary education focused on potassium management in HD. Subsequently, in the second phase, they were introduced to a novel GPT-based dietary guidance tool. This artificial intelligence (AI)-powered tool offered real-time insights into the potassium content of various foods and personalized dietary suggestions. The effectiveness of the AI tool was evaluated by assessing the precision of its dietary recommendations. Additionally, we compared predialysis serum potassium levels and the proportion of patients with hyperkalemia among patients before and after the implementation of the GPT-based dietary guidance system.

RESULTS

In our analysis of 324 food photographs uploaded by 88 HD patients, the GPTs system evaluated potassium content with an overall accuracy of 65%. Notably, the accuracy was higher for high-potassium foods at 85%, while it stood at 48% for low-potassium foods. Furthermore, the study examined the effect of GPT-based dietary advice on patients' serum potassium levels, revealing a significant reduction in those adhering to GPTs recommendations compared to recipients of traditional dietary guidance (4.57 ± 0.76 mmol/L vs. 4.84 ± 0.94 mmol/L, P = .004). Importantly, compared to traditional dietary education, dietary education based on the GPTs tool reduced the proportion of hyperkalemia in HD patients from 39.8% to 25% (P = .036).

CONCLUSION

These results underscore the promising role of AI in improving dietary management for HD patients. Nonetheless, the study also points out the need for enhanced accuracy in identifying low potassium foods. It paves the way for future research, suggesting the incorporation of extensive nutritional databases and the assessment of long-term outcomes. This could potentially lead to more refined and effective dietary management strategies in HD care.

Association between dietary carbohydrate intake percentage and epilepsy prevalence in the NHANES 2013-2018: a cross-sectional study

BACKGROUND

Epilepsy is a neurological disorder characterized by recurrent seizures. We aimed to investigate the association between the percentage of dietary carbohydrate intake (DCI) and epilepsy prevalence among American adults.

METHODS

We analyzed the data from 9,584 adults aged 20-80 years who participated in the National Health and Nutrition Examination Survey from 2013 to 2018. Logistic regression was applied to explore the association between the percentage of DCI and epilepsy prevalence.

RESULTS

A total of 146 (1.5%) individuals with epilepsy were enrolled in this study. The average age of the participants was 56.4 years, and 5,454 (56.9%) individuals were female. A high DCI was associated with an increased prevalence of epilepsy (odds ratio [OR], 4.56; 95% confidence interval [CI], 1.11-18.69; P = 0.035) after adjusting for age, sex, marital status, race/ethnicity, educational level, family income, body mass index, smoking status, drinking status, hypertension, diabetes, and cardiovascular disease. Stratified analyses indicated a positive correlation between DCI and epilepsy prevalence in adults with different characteristics. Compared with individuals in quartile 1 of DCI (<40.5%), those in quartile 4 (>55.4%) had an adjusted OR for epilepsy of 1.72 (95% CI, 1.09-2.73, P = 0.02, P for trend = 0.012).

CONCLUSIONS

A high percentage of DCI was associated with an increased prevalence of epilepsy. The risk of epilepsy increased 3.5-fold with a 1% increase in DCI. These results suggest an important role of DCI in the dietary management of epilepsy.

Food Intolerances, Food Allergies and IBS: Lights and Shadows

This narrative review delves into the intricate relationship between irritable bowel syndrome (IBS) and food intolerances. IBS, a chronic functional gastrointestinal disorder, is characterized by symptoms like abdominal pain and altered bowel habits. The prevalence of IBS has increased globally, especially among young adults. Food and dietary habits play a crucial role in IBS management. About 85-90% of IBS patients report symptom exacerbation linked to specific food consumption, highlighting the strong connection between food intolerances and IBS. Food intolerances often exhibit a dose-dependent pattern, posing a challenge in identifying trigger foods. This issue is further complicated by the complex nature of gastrointestinal physiology and varying food compositions. This review discusses various dietary patterns and their impact on IBS, including the low-FODMAP diet, gluten-free diet, and Mediterranean diet. It highlights the importance of a personalized approach in dietary management, considering individual symptom variability and dietary history. In conclusion, this review emphasizes the need for accurate diagnosis and holistic management of IBS, considering the complex interplay between dietary factors and gastrointestinal pathophysiology. It underlines the importance of patient education and adherence to treatment plans, acknowledging the challenges posed by the variability in dietary triggers and the psychological impact of dietary restrictions.

Development and validation of D-PATH website to improve hypertension management among hypertensive patients in Malaysia

Objective

This study aimed at developing and validating a web application on hypertension management called the D-PATH website.

Methods

The website development involved three stages: content analysis, web development, and validation. The model of Internet Intervention was used to guide the development of the website, in addition to other learning and multimedia theories. The content was developed based on literature reviews and clinical guidelines on hypertension. Then, thirteen experts evaluated the website using Fuzzy Delphi Technique.

Results

The website was successfully developed and contains six learning units. Thirteen experts rated the website based on content themes, presentation, interactivity, and instructional strategies. All experts reached a consensus that the web is acceptable to be used for nutrition education intervention.

Conclusion

D-PATH is a valid web-based educational tool ready to be used to help disseminate information on dietary and physical activity to manage hypertension. This web application was suitable for sharing information on dietary and physical activity recommendations for hypertension patients.

3-Day food record: efficacy in patients with type 2 diabetes mellitus

OBJECTIVES

This study aimed to assess the efficacy of the 3-day food records in monitoring and enhancing dietary habits among patients with type 2 diabetes mellitus.

METHODS

A total of 49 patients with type 2 diabetes mellitus were enrolled, with 38 completing the study. Participants were instructed to record their food intake over 3 consecutive days every 2 months. Key anthropometric and glycometabolic parameters, including body weight, abdominal circumference, glycated hemoglobin, and fasting blood sugar, were evaluated at baseline and after 6 months.

RESULTS

The introduction of the 3-day food records led to significant improvements in body weight, abdominal circumference, glycated hemoglobin, and fasting blood sugar. Additionally, there was a notable increase in the percentage of patients adhering to the LARN nutritional recommendations, especially concerning the intake of carbohydrates, simple sugars, proteins, fiber, and water. However, adherence to lipid and saturated fat recommendations remained a challenge.

CONCLUSIONS

The 3-day food records emerges as a valuable tool in the dietary management of patients with type 2 diabetes mellitus. By facilitating real-time monitoring and feedback, it holds promise in enhancing patient adherence to nutritional guidelines, thereby improving key health outcomes.

Characteristics of vitamin D deficiency hypocalcemia inpatient admissions at a single tertiary center

OBJECTIVES

Severe 25-hydroxyvitamin D (25(OH)D) deficiency can result in life-threatening presentations due to hypocalcemia leading to seizures and cardiac arrhythmias. vitamin D deficiency is a common cause of hypocalcemia and rickets in children; however, there are no recent studies on the burden of inpatient admissions in the United States. Our study aims to describe the clinical characteristics and risk factors of inpatient admissions due to severe hypocalcemia and 25(OH)D deficiency at a freestanding academic children's hospital.

METHODS

A descriptive retrospective chart review was completed on all inpatient admissions from 2016 to 2021 for children 0-18 years of age with corrected calcium <8 mg/dL and 25(OH)D <10 ng/mL during admission.

RESULTS

Thirty-eight patients met the inclusion criteria (74 % Black/African American). Neurological signs described in 49 %, bone abnormalities in 17 % and EKG abnormalities in 42 % of the patients. The mean calcium serum level was 6.0 mmol/L (range 5.0-7.9 mmol/L), the mean iCa 0.77 mmol/L (range 0.54-0.99 mmol/L). The mean level of 25(OH)D was 5.5 ng/mL (range 2.1-9.7 ng/mL). The median length of stay was 4.5 (range 1-59 days).

CONCLUSIONS

In this retrospective observational study, risk factors identified: (1) Black/African American race (2) age less than two years (3) lack of supplementation of vitamin D and (4) dietary restrictions. Inpatient admissions are preventable through the implementation of education at the community and healthcare levels.

Diabetes Management and the Role of the Community Nurse: a Holistic Perspective

Nearly 5 million people are now living with diabetes in the UK, with many receiving treatment and management in the community. With their unique and intimate insight into patients' lives, the community nurse is well-placed to offer support, education and advocacy to those who might be struggling to manage their condition. Francesca Ramadan explores the multiple ways in which a community nurse might facilitate a preventative, holistic and personalised approach to diabetes treatment and management.

Gluten-Free Diet Knowledge and Adherence in Adolescents with Celiac Disease: A Cross-Sectional Study

Objectives

This study examined the relationship between knowledge of, and adherence to, the gluten-free diet (GFD) in a local population of adolescents with celiac disease (CD). The secondary objectives were to identify information sources used to learn about the GFD and to compare adolescents' and parents' knowledge of the GFD.

Methods

Adolescents (12-17 years) with CD and their parents from pediatric gastroenterology clinics in Calgary, Alberta, completed an online survey containing a knowledge assessment (Gluten-Free Diet Quiz [GFD-Q]), an adherence scale, questions about GFD information sources, and demographic/clinical information. GFD-Q scores were deemed "sufficient knowledge" with correct identification of 3/3 gluten-containing foods, ≥4/7 gluten-free foods, and ≥ 4/7 foods that may contain gluten; otherwise, scores were termed "insufficient knowledge".

Results

Of the 40 adolescent-parent pairs, 15 of 40 adolescents (37%) had sufficient knowledge, and 25 of 40 adolescents (63%) had insufficient knowledge. Within the insufficient knowledge group, 14 of 25 (56%) did not correctly identify enough allowed gluten-free foods. Parents scored higher on the GFD-Q (67% had sufficient knowledge). Adolescents reported overall adherence to the GFD (88%), with adherence being similar between the sufficient and insufficient knowledge groups (80% versus 92%). The most helpful information sources included physicians, another person with CD, parent(s), and Google; apps were infrequently used.

Conclusion

Adolescents report good adherence; however, they struggle with GFD knowledge, particularly in identifying gluten-free foods. Further research is required to explore GFD educational tools, including mobile apps and dietician-led teaching sessions.

Clinical presentation and outcome of gastric impactions with or without concurrent intestinal lesions in horses

BACKGROUND

Gastric impactions (GI) have been identified as primary lesions (lone GI; LGI) or associated with other intestinal lesions (concurrent GI; CGI). Anecdotally, CGI resolve more rapidly with a better prognosis than LGI.

OBJECTIVES

To determine clinical, laboratory, and ultrasonographic findings, and short- and long-term survival in horses with GI. We hypothesized that LGI carries a worse prognosis than CGI.

ANIMALS

Seventy-one horses from 2 referral hospitals (2007-2022).

METHODS

Retrospective cohort study. Gastric impactions were defined as feed extending to the margo plicatus after ≥24 hours of fasting. Clinical, diagnostic and outcome findings were compared between LGI and CGI. Long-term survival was determined by a questionnaire.

RESULTS

Twenty-seven horses had LGI, 44 had CGI. Large intestinal lesions (32/44) were more common than small intestinal lesions (12/44). Concurrent gastric impactions resolved more slowly than LGI (LGI median 2 days, range 0-8; CGI median 4 days, range 1-10; P = .003). Short- (LGI 63%, 17/27; CGI 59%, 26/44; P = .75) and long-term survival (LGI 3.5 ± 1.9 years; CGI 2.3 ± 2.3 years; P = .42) were not significantly different. However, Lone gastric impactions were more likely to experience gastric rupture (LGI 29.6%, 8/27; CGI 11.4%, 5/44; P = .05). Lone gastric impactions were 8.7 times more likely to require dietary changes (LGI 72.7%, 8/11; CGI 25%, 4/16; 95% confidence interval [CI], 1.53-49.22; P = .01). Gastric impactions recurred in 21.7% (LGI, 6/20; CGI, 4/26; P = .23) of affected horses.

CONCLUSIONS AND CLINICAL IMPORTANCE

Lone gastric impactions and CGI present similarly with a comparable prognosis, but LGI are more likely to rupture. Long-term dietary changes are often necessary for horses with LGI.

Real-World Management of High Stool Output in Patients with Short Bowel Syndrome: An International Multicenter Survey

BACKGROUND

International practice guidelines for high-stool-output (HSO) management in short bowel syndrome (SBS) are available, but data on implementation are lacking. This study describes the approach used to manage HSO in SBS patients across different global regions.

METHODS

This is an international multicenter study evaluating medical management of HSO in SBS patients using a questionnaire survey. Thirty-three intestinal-failure centers were invited to complete the survey as one multidisciplinary team.

RESULTS

Survey response rate was 91%. Dietary recommendations varied based on anatomy and geographic region. For patients without colon-in-continuity (CiC), clinical practices were generally consistent with ESPEN guidelines, including separation of fluid from solid food (90%), a high-sodium diet (90%), and a low-simple-sugar diet (75%). For CiC patients, practices less closely followed guidelines, such as a low-fat diet (35%) or a high-sodium diet (50%). First-line antimotility and antisecretory medications were loperamide and proton-pump inhibitors. Other therapeutic agents (e.g., pancreatic enzymes and bile acid binders) were utilized in real-world practices, and usage varied based on intestinal anatomy.

CONCLUSION

Expert centers largely followed published HSO-management guidelines for SBS patients without CiC, but clinical practices deviated substantially for CiC patients. Determining the reasons for this discrepancy might inform future development of practice guidelines.

Mobile-based program improves healthy eating of ulcerative colitis patients: A pilot study

Background

Dietary management plays a crucial role in the treatment of patients with ulcerative colitis (UC). While various e-services provide dietary advice, the long-term dietary management requires continuous monitoring and dynamic adjustment to accommodate the evolving nature of the disease and meet the patients' nutritional needs. Consequently, the development of a novel dietary management tool that incorporates diet tracking, personalized nutritional feedback, and evidence-based advice becomes imperative. This study aims to address this need by developing a WeChat applet called "HealthyGut" specifically designed for the dietary management of UC patients, and evaluate its feasibility, acceptability, and preliminary efficacy.

Methods

A total of 134 UC patients were equally allocated into the intervention group (receiving a 12-week mobile-based dietary management via HealthyGut) and control group (receiving a paper-based food diary and routine advice). The feasibility outcomes were recruitment, retention, engagement, satisfaction, and acceptability in the intervention group. Dietary intakes were effective outcomes.

Results

Both groups had satisfactory retention rates (89.6% and 77.6%, respectively). The System Usability Scale in the intervention group yielded "good usability" with a mean score of 79.63 (SD 7.39), and all participants reported good user experiences and perceived benefits after using HealthyGut. At week 12, intervention responders reported significantly higher daily energy intake than control group (Z = -3.089, p = 0.002).

Conclusions and Implications

The results display that HealthyGut as a dietary management tool is feasible and accepted by UC patients, and it may help them make healthier food choices. Larger sample studies should be considered in the future.

Self-Reported Dietary Management Behaviors and Dietary Intake among Chinese Adults with Diabetes: A Population-Based Study

Few studies have analyzed the implementation of dietary management in Chinese adults with diabetes. Thus, we assessed and compared dietary intake and diet quality between diabetic patients with and without dietary management behaviors (DPDM vs. NDPDM), and evaluated the adherence to dietary guidelines in both groups of patients. The data were obtained from the 2002, 2010-2013, and 2015 China National Nutrition Survey. A total of 69,583, 67,177, and 96,631 subjects participated in the 2002, 2010-2013, and 2015 survey rounds, respectively. The dietary intake data were measured using 3-day 24 h dietary recalls and weighed records of household condiments. The China Healthy Diet Index (CHDI) was used to evaluate diet quality. The study included 6229 patients with diabetes, of which 78% had dietary management behaviors. The diabetic patients with dietary management behaviors showed higher percentages of energy from high-quality carbohydrates, animal protein, saturated fatty acids, and unsaturated fatty acids and lower percentages from low-quality carbohydrates and plant protein than NDPDM. The diabetic patients with dietary management behaviors also had lower intakes of cereals and tubers and higher intakes of vegetables than NDPDM. The total CHDI score of DPDM was higher than NDPDM (56.3 ± 12.7 vs. 54.1 ± 12.3). The proportion of DPDM meeting the recommended intake for different food items ranged from 3.3% to 42.8% and from 3.0% to 39.2% in NDPDM. The diabetic patients with dietary management behaviors showed better adherence to dietary guidelines and higher diet quality scores than NDPDM, while the overall adherence was poor in both groups of patients. Our findings suggested that measures are needed to promote and refine dietary management behaviors, which can help to improve disease management in diabetic patients.

Knowledge, perceptions and behaviours regarding dietary management of adults living with phenylketonuria

BACKGROUND

Lifelong dietary treatment remains the mainstay for many with phenylketonuria (PKU); however, adherence is known to reduce with age. It remains unclear whether knowledge and perceptions of the PKU diet amongst adults with PKU influence dietary behaviours.

METHODS

A nationwide questionnaire survey was performed to investigate the knowledge and perceptions, and associated diet behaviours of adults with PKU in the UK. The survey was sent to adults with PKU under the care of the host hospital and members of the National Society of PKU.

RESULTS

One hundred and thirty-seven respondents (n = 78 females, 56.9%) completed the survey with a mean age of 34 years and 4 months (16-65 years). Sixty (43.8%) respondents had always followed a PKU diet, 39 (28.5%) returned to diet and 35 (25.5%) were off diet. Overall mean ± SD knowledge score was 75.2% ± 13.4%, with significantly higher scores for knowledge of PKU (80.7% ± 16.2%) compared to knowledge specifically of the PKU diet (72.6% ± 14.5%, p < 0.001). Knowledge was associated with dietary adherence. Respondents who always followed a PKU diet had similar knowledge to those who returned to diet, whereas respondents off diet had significantly lower scores. Perception of the diet was not a predictor of dietary adherence, with the exception of whether patients had concerns for their long-term health when on diet or felt well when not following a diet.

CONCLUSIONS

The present study highlights the importance of ongoing dietetic input in building knowledge and skills for dietary management. Further research is needed to understand the motivators and beliefs that influence dietary adherence.

Proper Dietary and Supplementation Patterns as a COVID-19 Protective Factor (Cross-Sectional Study-Silesia, Poland)

BACKGROUND

The COVID-19 pandemic has become a challenge for the world today, so it is very important to create healthy eating habits in society to support immunity and raise awareness of the benefits of supplementation.

OBJECTIVE

The purpose of this study is to evaluate diet and dietary supplementation, since previous studies indicate the protective nature of these in building immunity during the pandemic and post-pandemic period (COVID-19). The hypothesis of the study is whether the dietary regimen presented by the COVID-19 respondents can be considered protective in building immunity against SARS-CoV-2.

MATERIAL AND METHODS

The study included 304 subjects, with an average age of 39.04 ± 23.59. The main criteria for inclusion in the study were that the respondent was ≥18 years old and participated voluntarily. The study was conducted using an original questionnaire.

RESULTS

In the study group, no change was noticed in the previous diet during the COVID-19 pandemic, while the level of physical activity among the respondents decreased. Too low a percentage of people regularly consumed, among other foods. legume seeds-only 10.5% of respondents consumed them several times a week-and citrus fruits-the largest number of respondents, as many as 39.8%, only consumed them several times a month. The largest percentage of respondents with mild/scanty COVID-19 disease regularly took vitamin C-containing preparations (n = 61; 59.80%). Statistical analysis showed that there was a correlation between the incidence of mild/scanty COVID-19 and the regularity of taking vitamin C-containing preparations (T = 11.374; r = 0.611; p = 0.04603). A statistical significance level was also obtained for the regularity of supplementation of multivitamin preparations, which were taken by 68% (34) of respondents affected by mild/scanty COVID-19 (T = 13.456; r = 0.711; p = 0.02191).

CONCLUSIONS

The study's hypothesis was supported. Respondents characterized by a normal dietary pattern and taking supplements commonly recognized as immune "boosters" were more likely to mildly survive COVID-19. Moreover, it was shown that the pandemic in most of the respondents did not significantly affect their dietary strategy. It is reasonable to conclude that the dietary patterns adopted may be a common way to prevent SARS-CoV-2 infections and their possible complications.

Medium-chain Acyl-COA dehydrogenase deficiency: Pathogenesis, diagnosis, and treatment

INTRODUCTION

Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) is the most common inherited metabolic disorder of β-oxidation. Patients with MCADD present with hypoketotic hypoglycemia, which may quickly progress to lethargy, coma, and death. Prognosis for MCADD patients is highly promising once a diagnosis has been established, though management strategies may vary depending on the severity of illness and the presence of comorbidities.

METHODS AND RESULTS

Given the rapid developments in the world of gene therapy and implementation of newborn screening for inherited metabolic disorders, the provision of concise and contemporary knowledge of MCADD is essential for clinicians to effectively manage patients. Thus, this review aims to consolidate current information for physicians on the pathogenesis, diagnostic tools, and treatment options for MCADD patients.

CONCLUSION

MCADD is a commonly inherited metabolic disease with serious implications for health outcomes, particularly in children, that may be successfully managed with proper intervention.

Orthorexia nervosa is a concern in gastroenterology: A scoping review

There is concern that use of restrictive therapeutic diets, such as those used in disorders of the gut-brain interaction (DGBI), may increase disordered eating. In this issue of Neurogastroenterology and Motility, Burton Murray et al. and Peters et al. both demonstrate a high prevalence of disordered eating in patients with gastrointestinal conditions, particularly those with DGBI. Given these findings, it is likely that orthorexia is common in this patient group, although this was not directly examined in these studies. Orthorexia nervosa is described as an obsessive and unsafe focus on eating foods perceived as healthy. This mini-review therefore focuses on orthorexia by conducting a scoping review, as per the PRISMA extension for scoping reviews, aimed to assess the prevalence of orthorexia, and associations between orthorexia and restrictive eating practices. While a wide range of orthorexia prevalence has been reported (0%-97%) across the 57 studies included, no studies assessed prevalence specifically in gastrointestinal conditions. Four of eight studies describing diseases associated with specific dietary patterns suggested that participants who followed a diet for "digestive issues" or "food intolerances" were at higher orthorexia risk. These results suggest that dietary modifications may be a factor contributing to orthorexia. Additionally, we provide a commentary on the clinical implications of the findings for gastrointestinal conditions including a clinical flow chart. Clinicians should consider if a restrictive diet is appropriate for individuals with DGBI and include screening for disordered eating prior to implementation of dietary modifications. Future prospective studies should evaluate orthorexia within this patient group.

Evaluation of Dietary Management Using Artificial Intelligence and Human Interventions: Nonrandomized Controlled Trial

Background

There has been an increase in personal health records with the increased use of wearable devices and smartphone apps to improve health. Traditional health promotion programs by human professionals have limitations in terms of cost and reach. Due to labor shortages and to save costs, there has been a growing emphasis in the medical field on building health guidance systems using artificial intelligence (AI). AI will replace advanced human tasks to some extent in the future. However, it is difficult to sustain behavioral change through technology alone at present.

Objective

This study investigates whether AI alone can effectively encourage healthy behaviors or whether human interventions are needed to achieve and sustain health-related behavioral change. We examined the effectiveness of AI and human interventions to encourage dietary management behaviors. In addition, we elucidated the conditions for maximizing the effect of AI on health improvement. We hypothesized that the combination of AI and human interventions will maximize their effectiveness.

Methods

We conducted a 3-month experiment by recruiting participants who were users of a smartphone diet management app. We recruited 102 participants and divided them into 3 groups. Treatment group I received text messages using the standard features of the app (AI-based text message intervention). Treatment group II received video messages from a companion, in addition to the text messages (combined text message and human video message intervention by AI). The control group used the app to keep a dietary record, but no feedback was provided (no intervention). We examine the participants’ continuity and the effects on physical indicators.

Results

Combined AI and video messaging (treatment group II) led to a lower dropout rate from the program compared to the control group, and the Cox proportional-hazards model estimate showed a hazard ratio (HR) of 0.078, which was statistically significant at the 5% level. Further, human intervention with AI and video messaging significantly reduced the body fat percentage (BFP) of participants after 3 months compared to the control group, and the rate of reduction was greater in the group with more individualized intervention. The AI-based text messages affected the BMI but had no significant effect on the BFP.

Conclusions

This experiment shows that it is challenging to sustain participants' healthy behavior with AI intervention alone. The results also suggest that even if the health information conveyed is the same, the information conveyed by humans and AI is more effective in improving health than the information sent by AI alone. The support received from the companion in the form of video messages may have promoted voluntary health behaviors. It is noteworthy that companions were competent, even though they were nonexperts. This means that person-to-person communication is crucial for health interventions.

Epidemiology of Phenylketonuria Disease in Jordan: Medical and Nutritional Challenges

Background: Phenylketonuria (PKU) is the most frequent inborn error in amino acid metabolism caused by a deficiency of the phenylalanine hydroxylase enzyme (PAH). If PKU is left untreated, high concentrations of phenylalanine (Phe) accumulate in the blood, leading to severe brain dysfunction, neurodevelopmental, behavioral and psychological problems. Data concerning the epidemiology of PKU in Jordan are limited. The main objectives of our study were to determine the prevalence of PKU in Jordan, analyze the PKU phenotypes, and identify major challenges in providing dietary management to PKU patients. Methods: Data were collected utilizing the medical records of PKU patients attending the PKU clinic at the Ministry of Health in Amman, Jordan, between 2008 and 2021. Results: The total number of patients diagnosed with PKU was 294. The prevalence of PKU was estimated to be 1/5263. Most patients were Jordanians (90.8%), and 9.2% were non-Jordanians. More than half of the patients (56%) were diagnosed through the national newborn screening (NBS) program. Regarding the phenotypes of PKU, 46.6% had moderate PKU, whereas 42.9% had the classic type of PKU and only 8 (2.7%) had cofactor Tetrahydrobiopterin (BH4) deficiency (atypical PKU). According to the age of diagnosis, 66% of patients were diagnosed more than 30 days post-birth. Consanguinity was found in 87.4% of patients, and the majority of patients, 218 (74.2%), had first-degree consanguinity. The most common complication was mental retardation (31%). Most patients were committed to dietary management (83%) and developed fewer complications. Conclusion: In our study, we demonstrated the importance of the NBS program in the early identification and diagnosis of new PKU cases which allows the initiation of treatment and dietary management to prevent severe complications of PKU in Jordan.

Dietetic Management of Adults with Phenylketonuria (PKU) in the UK: A Care Consensus Document

There is an increasing number of adults and elderly patients with phenylketonuria (PKU) who are either early, late treated, or untreated. The principal treatment is a phenylalanine-restricted diet. There is no established UK training for dietitians who work with adults within the specialty of Inherited Metabolic Disorders (IMDs), including PKU. To address this, a group of experienced dietitians specializing in IMDs created a standard operating procedure (SOP) on the dietetic management of adults with PKU to promote equity of care in IMD dietetic services and to support service provision across the UK. The group met virtually over a period of 12 months until they reached 100% consensus on the SOP content. Areas of limited evidence included optimal blood phenylalanine reporting times to patients, protein requirements in older adults, management of weight and obesity, and management of disordered eating and eating disorders. The SOP does not include guidance on maternal PKU management. The SOP can be used as a tool for training dietitians new to the specialty and to raise the standard of education and care for patients with PKU in the UK.

Effectiveness and Usability of Digital Tools to Support Dietary Self-Management of Gestational Diabetes Mellitus: A Systematic Review

Advice on dietary intake is an essential first line intervention for the management of gestational diabetes mellitus (GDM). Digital tools such as web-based and smartphone apps have been suggested to provide a novel way of providing information on diet for optimal glucose regulation in women with GDM. This systematic review explores the effectiveness and usability of digital tools designed to support dietary self-management of GDM. A systematic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, and Scopus using key search terms identified 1476 papers reporting research studies, of which 16 met the specified inclusion criteria. The quality of the included studies was assessed using the ErasmusAGE Quality Score or the Mixed Methods Appraisal Tool (MMAT) version 2018. The findings show that the adoption of digital tools may be an effective approach to support self-management relating to healthy diet, health behaviour, and adherence to therapy in women with GDM as a usable intervention. However, there is a lack of evidence concerning the effectiveness of tools to support the dietary management of GDM. Consideration for ethnic specific dietary advice and evidence-based frameworks in the development of effective digital tools for dietary management of GDM should be considered as these aspects have been limited in the studies reviewed.

The Effect of a Fat-Restricted Diet in Four Patients with Familial Chylomicronemia Syndrome: A Long-Term Follow-Up Study

(1) Background: Familial chylomicronemia syndrome (FCS) is a very rare autosomal recessive disorder characterized by severely elevated triglycerides and clinical symptoms in early childhood mainly presenting with abdominal pain, acute pancreatitis and hepatosplenomegaly. Primary treatment is a lifelong very strict low-fat diet, which might be challenging in pediatric patients. So far, data about children with FCS are rare. The aim of this study was to show the familial chylomicronemia syndrome traffic light table for pediatric patients and to assess the dietary fat intake and impact on triglycerides in children with FCS. (2) Methods: We performed a retrospective analysis in four children (50% male) affected by FCS from the Department of Pediatrics and Adolescent Medicine, Medical University of Vienna between January 2002 and September 2020. (3) Results: The four patients presented with classical FCS symptoms and showed baseline triglycerides (TG) exceeding 30,000 mg/dL in two patients, 10,000 mg/dL and 2400 mg/dL in one patient each. After diagnosis, fat percentage of total daily caloric intake was decreased and resulted immediately in triglyceride reduction. In all patients, FCS was genetically confirmed by mutations in genes encoding lipoprotein lipase. Acute pancreatitis and hepatosplenomegaly disappeared under the fat-restricted diet. A FCS traffic light table was developed as a dietary tool for affected families. (4) Conclusions: A restriction of dietary fat between 10% to 26% of the total daily caloric intake was feasible and effective in the long-term treatment of genetically confirmed FCS in children and could reduce the risk for acute pancreatitis. The dietary tool, the pediatric FCS traffic light table and the age-appropriate portion sizes for patients between 1 to 18 years, supports children and their parents to achieve and adhere to the lifelong strict low-fat diet.

Prophylactic effects of dietary ascorbic acid on oxidative stress indices, physiological and behavioural responses of domestic pigeons exposed to road transport stress

Transport disturbs birds' welfare and health status which lead to oxidative stress and dietary ascorbic acid mitigates the adverse effects of transport stress. The present study was aimed to evaluate the impacts of ascorbic acid administration on oxidative stress indices, cortisol, H/L ratio, tonic immobility reaction and rectal temperature of pigeons exposed to road transport. A total of 80 clinically healthy pigeons were selected and randomly divided to eight equal groups as follow: (1) Ctrl- : fed by basal diet and no subjected to transport stress; (2) Ctrl+: fed by the basal diet and subjected to transport stress; (3, 4) 1DBS10 and 1DBS16: received ascorbic acid from 1 day before transport stress at doses of 10 g/100 L and 16 g/100 L of drinking water, respectively; (5, 6) 3DBS10 and 3DBS16: treated with ascorbic acid from 3 consecutive days before transport stress at doses of 10 g/100 L and 16 g/100 L, respectively and (7, 8) 7DBS10 and 7DBS16: received ascorbic acid from 7 consecutive days before the transport at doses 10 g/100 L and 16 g/100 L, respectively. Birds were transported for 3 h over a distance of about 200 km. The total antioxidant capacity, malondialdehyde and cortisol were measured before transport and at 6, 24 and 72 h post-transportation. The rectal temperature and tunic immobility reactions were recorded. Dietary ascorbic acid led to a decrease in tonic immobility response, hetrophil to lymphocyte ratio, circulating cortisol and total antioxidant capacity, and an increase in circulating malondialdehyde in pigeons exposed to transport stress compare to Ctrl+ group. In conclusion, ascorbic acid administration at dose 16 g/100 L of drinking water from 3 and 7 days before exposure to stress helps attenuate undesirable effects of oxidative stress in pigeons.

Extremely low birthweight neonates with phenylketonuria require special dietary management

AIM

Extremely low birthweight (ELBW) neonates require a high protein intake, but this can be challenging in the very rare cases when they also have phenylketonuria (PKU). This is due to a lack of suitable parenteral nutrition or enteral formula. Our aim was to analyse tolerance to phenylalanine in these infants.

MATERIAL

There are approximately 110 000 children born in the Czech Republic each year. A neonatal screening programme from 2005 to 2020 found that 320 neonates had PKU, including 30 premature neonates with a birth weight of less than 2500 g.

RESULTS

This study focused on three neonates who were born with ELBWs of 720, 740 and 950 g, respectively. Phenylalanine levels normalised in ELBW neonates with PKU within 1 week of the introduction of low-phenylalanine parenteral or enteral nutrition. The tolerance to phenylalanine was very high (70-110 mg/kg) in the first months of life, due to a rapid weight gain, but significantly decreased during infancy.

CONCLUSION

Extremely low birthweight neonates with PKU need special dietary management. Regular assessments of phenylalanine are necessary during the first weeks of life to allow prompt dietary adjustments that reflect rapid weight gain and transitory high tolerance to phenylalanine.

Dietary Management for Faecal Microbiota Transplant: An International Survey of Clinical and Research Practice, Knowledge and Attitudes

Faecal microbiota transplantation (FMT) involves homogenisation and infusion of stool from a healthy, highly screened individual into the bowel of an unwell recipient. Dietary intake is an important modulator of the gut microbiota. Currently there are no clinical practice recommendations available to provide patients or stool donors with dietary advice for FMT. This study aimed to conduct an international survey to examine health professionals and researchers' attitudes, knowledge and current practice recommendations for diet in patients undergoing FMT. An online, cross-sectional, international survey comprising of health professionals and researchers managing patients undergoing treatment with FMT was conducted between July-October 2020. Purposeful and snowball sampling techniques were employed to identify eligible participants who were sent an email invitation and two email reminders with a link to participate in the electronic survey. The survey comprised 21 questions covering demographics, current practice, beliefs and future directions regarding FMT and diet. Closed responses were calculated as proportions of total responses. Open-ended responses were systematically categorised. Common themes were identified from recurring categories. Fifty-eight (M 60%) participants from 14 countries completed the survey. Participants were gastroenterologists (55%), with 1-5 years' experience working in FMT (48%) and treating up to ten patients with FMT per month (74%). Participants agreed that diet was an important consideration for FMT recipients and stool donors (both 71%), and that it would affect the outcomes of FMT. However, they did not feel confident in providing dietary advice to patients, nor that there was sufficient evidence to provide dietary advice and this was reflected in their practice. Future research must collect information on the dietary intake of patients and donors to better understand the relationship between diet and FMT outcomes. In clinical practice, promotion of healthy eating guidelines aligns with current practice and literature.

The effect of individualized exercise prescriptions combined with dietary management on blood glucose in the second-and-third trimester of gestational diabetes mellitus

OBJECTIVE

To explore the effect of individualized exercise prescriptions plus dietary management on blood glucose in the second-and-third trimester of gestational diabetes mellitus (GDM).

METHODS

We collected and reviewed the clinical data of 106 patients in their second-and-third trimester who had GDM in our hospital from September 2017 to September 2018. They were equally divided into a test group and a control group with a random number table method. All patients took oral metformin tablets, and the control group received routine clinical care. The test group received individualized exercise prescriptions plus dietary management. Then we compared the intervention effects between the two groups.

RESULTS

After the intervention, the FBG, 2-h PBG, and IR indexes in the test group were considerably lower than those in the control group (P<0.001). After the intervention, both groups had lower HbA1c values than before, and those in the test group were obviously lower than the control group (P<0.001). There was no clear difference in BMI between the two groups before and after intervention (P>0.05). The BMI had clearly increased after intervention in both groups, and the increment in the test group was significantly lower than the control group (all P<0.05). The medication compliance and nursing satisfaction were significantly higher than in the control group (all P<0.05). The self-efficacy and the self-management ability scores in the test group were significantly higher than the control group (P<0.05).

CONCLUSION

In the second-and-third trimester of pregnancy with GDM, individualized exercise prescriptions plus dietary management can effectively control the blood glucose and keep BMI within a healthy range, thus improving the compliance and the clinical satisfaction of maternal care, fulfilling self-management, and reducing the risks of childbirth. It is worth promoting because of its enormous efficacy.

The Effects of High-Protein Diet and Resistance Training on Glucose Control and Inflammatory Profile of Visceral Adipose Tissue in Rats

High-protein diets (HPDs) are widely accepted as a way to stimulate muscle protein synthesis when combined with resistance training (RT). However, the effects of HPDs on adipose tissue plasticity and local inflammation are yet to be determined. This study investigated the impact of HPDs on glucose control, adipocyte size, and epididymal adipose inflammatory biomarkers in resistance-trained rats. Eighteen Wistar rats were randomly assigned to four groups: normal-protein (NPD; 17% protein total dietary intake) and HPD (26.1% protein) without RT and NPD and HPD with RT. Trained groups received RT for 12 weeks with weights secured to their tails. Glucose and insulin tolerance tests, adipocyte size, and an array of cytokines were determined. While HPD without RT induced glucose intolerance, enlarged adipocytes, and increased TNF-α, MCP-1, and IL1-β levels in epididymal adipose tissue (p < 0.05), RT diminished these deleterious effects, with the HPD + RT group displaying improved blood glucose control without inflammatory cytokine increases in epididymal adipose tissue (p < 0.05). Furthermore, RT increased glutathione expression independent of diet (p < 0.05). RT may offer protection against adipocyte hypertrophy, pro-inflammatory states, and glucose intolerance during HPDs. The results highlight the potential protective effects of RT to mitigate the maladaptive effects of HPDs.

Higher intake of microbiota-accessible carbohydrates and improved cardiometabolic risk factors: a meta-analysis and umbrella review of dietary management in patients with type 2 diabetes

BACKGROUND

Microbiota-accessible carbohydrates (MACs) are critical substrates for intestinal microbes; the subsequent production of SCFAs may have some potential benefits for patients with type 2 diabetes mellitus (T2DM).

OBJECTIVES

We conducted a meta-analysis of randomized controlled trials (RCTs) to assess the effects of higher compared with lower MAC intakes on cardiovascular risk factors in T2DM patients and performed an umbrella review of RCTs to evaluate the evidence quality concerning existing dietary T2DM interventions.

METHODS

Publications were identified by searching MEDLINE, EMBASE, and CINAHL. In the meta-analysis, random-effects models were used to calculate pooled estimates, and sensitivity analyses, meta-regression, subgroup analyses, and Egger's test were performed. For the umbrella review, we summarized pooled estimates, 95% CIs, heterogeneity, and publication bias. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and modified NutriGrade were used to assess the quality of evidence in the meta-analysis and umbrella review, respectively.

RESULTS

Forty-five RCTs with 1995 participants were included in the meta-analysis. High MAC intake significantly reduced glycated hemoglobin (HbA1c) (weighted mean difference [WMD] -0.436% [-0.556, -0.315]), fasting glucose (WMD -0.835 mmol/L [-1.048, -0.622]), total cholesterol (WMD -0.293 mmol/L [-0.397, -0.190]), triglycerides (WMD -0.118 mmol/L [-0.308, -0.058]), BMI (WMD -0.476 [-0.641, -0.312]), and systolic blood pressure (WMD -3.066 mmHg [-5.653, -0.478]), with a moderate-to-high quality of evidence, compared with low intake. Region, dose, and MAC type were key variables. The umbrella review of all dietary interventions for cardiovascular risk factors in patients with T2DM included 26 meta-analyses with 158 pooled estimates. The evidence quality of MACs, dietary fiber, high-protein diet, ω-3 (n-3), viscous fiber, vitamin D, and vitamin E intake was moderate to high.

CONCLUSIONS

When compared with lower intake, increased MAC intake improved glycemic control, blood lipid, body weight, and inflammatory markers for people with T2DM. This trial was registered at PROSPERO (https://www.crd.york.ac.uk/PROSPERO/#recordDetails) as CRD42019120531.

Dietary Management of Eosinophilic Esophagitis: Tailoring the Approach

Eosinophilic esophagitis (EoE) is a unique form of non-immunoglobulin E-mediated food allergy, restricted to the esophagus, characterized by esophageal eosinophil-predominant inflammation and dysfunction. The diagnosis requires an esophago-gastroduodenoscopy with esophageal biopsies demonstrating active eosinophilic inflammation with 15 or more eosinophils/high-power field, following the exclusion of alternative causes of eosinophilia. Food allergens trigger the disease, withdairy/milk, wheat/gluten, egg, soy/legumes, and seafood the most common. Therapeutic strategies comprise dietary restrictions, proton pump inhibitors, topical corticosteroids, biologic agents, and esophageal dilation when strictures are present. However, avoidance of trigger foods remains the only option targeting the cause, and not the effect, of the disease. Because EoE relapses when treatment is withdrawn, dietary therapy offers a long-term, drug-free alternative to patients who wish to remain off drugs and still be in remission. There are currently multiple dietary management strategies to choose from, each having its specific efficacy, advantages, and disadvantages that both clinicians and patients should acknowledge. In addition, dietary regimens should be tailored around each individual patient to increase the chance of tolerability and long-term adherence. In general, liquid elemental diets devoid of antigens and elimination diets restricting causative foods are valuable options. Designing diets on the basis of food allergy skin tests results is not reliable and should be avoided. This review summarizes the most recent knowledge regarding the clinical use of dietary measures in EoE. We discussed endpoints, rationale, advantages and disadvantages, and tailoring of diets, as well as currently available dietary regimens for EoE.

Dietary Management in Pediatric Patients with Crohn's Disease

It has been widely endorsed that a multifactorial etiology, including interaction between genetic and environmental factors, can contribute to Crohn's Disease (CD) pathogenesis. More specifically, diet has proven to be able to shape gut microbiota composition and thus is suspected to play a significant role in inflammatory bowel disease (IBD) pathogenesis. Moreover, poor nutritional status and growth retardation, arising from several factors such as reduced dietary intake or nutrient leakage from the gastrointestinal tract, represent the hallmarks of pediatric CD. For these reasons, multiple research lines have recently focused on the utilization of dietary therapies for the management of CD, aiming to target concurrently mucosal inflammation, intestinal dysbiosis and optimization of nutritional status. The forerunner of such interventions is represented by exclusive enteral nutrition (EEN), a robustly supported nutritional therapy; however, it is burdened by monotony and low tolerance in the long term. Novel dietary interventions, such as Crohn's Disease Exclusion Diet or Crohn's Disease treatment with eating, have shown their efficacy in the induction of remission in pediatric patients with CD. The aim of the present narrative review is to provide a synopsis of the available nutritional strategies in the management of pediatric CD and to discuss their application in the dietary management of these patients.

Evaluation of E-Health Applications for Paediatric Patients with Refractory Epilepsy and Maintained on Ketogenic Diet

E-health technologies improve healthcare quality and disease management. The aim of this study was to develop a ketogenic diet management app as well as a website about this dietary treatment and to evaluate the benefits of giving caregivers access to various web materials designed for paediatric patients with refractory epilepsy. Forty families participated in the questionnaire survey, from January 2016 to March 2016. All caregivers were exposed to paper-based materials about the ketogenic diet, whereas only 22 received the app, called KetApp, and videos produced by dieticians. Caregivers with free access to web materials were more satisfied than the others with the informative material provided by the centre (p ≤ 0.001, Mann–Whitney test). Indeed, they showed a better attitude towards treatment, and they became more aware of dietary management in comparison to the control group (p ≤ 0.001). Moreover, caregivers provided with web materials were stimulated to pursue the treatment (p = 0.002) and to introduce it to their children and other people (p = 0.001). Additionally, caregivers supplied with web materials were more willing to help other families in choosing the ketogenic diet (p = 0.004). Overall, these findings indicate that web materials are beneficial for caregivers of paediatric patients with refractory epilepsy in our centres. Thus, the use of e-health applications could be a promising tool in the daily aspects of ketogenic diet management, and it is especially of value in the attempt to start or maintain the diet during the ongoing COVID-19 pandemic crisis.

Mechanisms of Food-Induced Symptom Induction and Dietary Management in Functional Dyspepsia

Functional dyspepsia (FD) is a common disorder of gut-brain interaction, characterised by upper gastrointestinal symptom profiles that differentiate FD from the irritable bowel syndrome (IBS), although the two conditions often co-exist. Despite food and eating being implicated in FD symptom induction, evidence-based guidance for dietetic management of FD is limited. The aim of this narrative review is to collate the possible mechanisms for eating-induced and food-related symptoms of FD for stratification of dietetic management. Specific carbohydrates, proteins and fats, or foods high in these macronutrients have all been reported as influencing FD symptom induction, with removal of 'trigger' foods or nutrients shown to alleviate symptoms. Food additives and natural food chemicals have also been implicated, but there is a lack of convincing evidence. Emerging evidence suggests the gastrointestinal microbiota is the primary interface between food and symptom induction in FD, and is therefore a research direction that warrants substantial attention. Objective markers of FD, along with more sensitive and specific dietary assessment tools will contribute to progressing towards evidence-based dietetic management of FD.

Clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care: A systematic review

BACKGROUND

Dietary management of type 2 diabetes is considered as a key remission and management strategy. This review explored clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care.

METHODS

MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA were searched from 1980 to 26 June 2020.

RESULTS

Of 2021 records, 14 studies met the inclusion criteria, describing the 14 domains of the refined Theoretical Domains Framework. The data synthesised to the domains of environmental context and resources, intentions and beliefs about capabilities were considered most trustworthy, closely followed by knowledge, behavioural regulation and beliefs about consequences. Two-thirds of studies cited time for staff training or patient education as major constraints to type 2 diabetes management. Clinicians also identified lack of patient engagement and poor dietary adherence as issues. Despite this, clinician confidence about giving dietary advice to patients was high. With further exploration, knowledge gaps were apparent and feelings of despondency as a result of poor outcomes were visible.

CONCLUSIONS

This review revealed four clinician behaviours: (2) the perception of the dietitian; (2) the definition of a clinician qualified to give dietary advice; (3) clinician belief in dietary management as a treatment; and (4) clinician belief in a patient's capability to change dietary behaviour. These behaviours, if challenged and changed, have the potential to improve dietary management and outcomes for people with type 2 diabetes in primary care.

Dietary Management of Type 2 Diabetes in the MENA Region: A Review of the Evidence

The alarmingly rising trend of type 2 diabetes constitutes a major global public health challenge particularly in the Middle Eastern and North African (MENA) region where the prevalence is among the highest in the world with a projection to increase by 96% by 2045. The economic boom in the MENA region over the past decades has brought exceptionally rapid shifts in eating habits characterized by divergence from the traditional Mediterranean diet towards a more westernized unhealthy dietary pattern, thought to be leading to the dramatic rises in obesity and non-communicable diseases. Research efforts have brought a greater understanding of the different pathways through which diet and obesity may affect diabetes clinical outcomes, emphasizing the crucial role of dietary interventions and weight loss in the prevention and management of diabetes. The purpose of this review is to explore the mechanistic pathways linking obesity with diabetes and to summarize the most recent evidence on the association of the intake of different macronutrients and food groups with the risk of type 2 diabetes. We also summarize the most recent evidence on the effectiveness of different macronutrient manipulations in the prevention and management of diabetes while highlighting the possible underlying mechanisms of action and latest evidence-based recommendations. We finally discuss the need to adequately integrate dietetic services in diabetes care specific to the MENA region and conclude with recommendations to improve dietetic care for diabetes in the region.

Scientific and technical guidance on foods for special medical purposes in the context of Article 3 of Regulation (EU) No 609/2013

[Table: see text] Following a request from the European Commission in 2014, the EFSA Panel on Dietetic products, Nutrition and Allergies (NDA) was asked to provide scientific and technical guidance on foods for special medical purposes (FSMP) in the context of Article 3 of Regulation (EU) No 609/2013. The guidance presented in this document is to assist in the preparation and presentation of well-structured dossiers. It presents a common format for the organisation of the information and outlines the information and scientific data which could be included in the dossier, as well as the key issues which should be addressed in the dossier in order to assess the extent to which a food product notified as FSMP falls under the scope of Regulation (EU) No 609/2013, under the proposed use. It is intended that the guidance will be kept under review and will be further amended and updated as appropriate in the light of experience gained from the evaluation of dossiers for specific food products notified as FSMP, and in the light of future Community guidelines and legislation. The scope of this guidance is limited to FSMPs in the context of Article 3 of Regulation (EU) No 609/2013. Out of the scope of this guidance are: a) other categories of food falling under Regulation (EU) No 609/2013, such as infant formula and follow-on formula, processed cereal-based food and baby food, and total diet replacement for weight control; b) meal replacements for weight control; c) "gluten-free" and "lactose-free" foods. Upon request from the European Commission in 2020, this guidance has been revised to inform applicants of new provisions in the pre-submission phase and submission application procedure set out in Regulation (EC) No 178/2002, as amended by Regulation (EU) 2019/1381 on the transparency and sustainability of the EU risk assessment in the food chain, that are applicable to all applications submitted as of 27 March 2021.

Dietary Management of Obesity: A Review of the Evidence

Obesity is a multi-factorial disease and its prevention and management require knowledge of the complex interactions underlying it and adopting a whole system approach that addresses obesogenic environments within country specific contexts. The pathophysiology behind obesity involves a myriad of genetic, epigenetic, physiological, and macroenvironmental factors that drive food intake and appetite and increase the obesity risk for susceptible individuals. Metabolically, food intake and appetite are regulated via intricate processes and feedback systems between the brain, gastrointestinal system, adipose and endocrine tissues that aim to maintain body weight and energy homeostasis but are also responsive to environmental cues that may trigger overconsumption of food beyond homeostatic needs. Under restricted caloric intake conditions such as dieting, these processes elicit compensatory metabolic mechanisms that promote energy intake and weight regain, posing great challenges to diet adherence and weight loss attempts. To mitigate these responses and enhance diet adherence and weight loss, different dietary strategies have been suggested in the literature based on their differential effects on satiety and metabolism. In this review article, we offer an overview of the literature on obesity and its underlying pathological mechanisms, and we present an evidence based comparative analysis of the effects of different popular dietary strategies on weight loss, metabolic responses and diet adherence in obesity.

Medical Nutritional Therapy for Patients with Chronic Kidney Disease not on Dialysis: The Low Protein Diet as a Medication

The 2020 Kidney Disease Outcome Quality Initiative (KDOQI) Clinical Practice Guideline for Nutrition in chronic kidney disease (CKD) recommends protein restriction to patients affected by CKD in stages 3 to 5 (not on dialysis), provided that they are metabolically stable, with the goal to delay kidney failure (graded as evidence level 1A) and improve quality of life (graded as evidence level 2C). Despite these strong statements, low protein diets (LPDs) are not prescribed by many nephrologists worldwide. In this review, we challenge the view of protein restriction as an “option” in the management of patients with CKD, and defend it as a core element of care. We argue that LPDs need to be tailored and patient-centered to ensure adherence, efficacy, and safety. Nephrologists, aligned with renal dietitians, may approach the implementation of LPDs similarly to a drug prescription, considering its indications, contra-indications, mechanism of action, dosages, unwanted side effects, and special warnings. Following this framework, we discuss herein the benefits and potential harms of LPDs as a cornerstone in CKD management.

Dietary Management, Clinical Status and Outcome of Patients with Citrin Deficiency in the UK

Background: Little is known about the optimal dietary treatment for citrin deficiency. Our aim is to describe the management of UK citrin deficiency patients. Methods: A longitudinal retrospective review was performed. Data were collected from medical records on presenting signs and symptoms, dietary management and clinical outcome. Results: data were collected on 32 patients from 21 families. 50% were females (16/32). Median age at diagnosis was 4 y (5 days–35 y) with 12 patients diagnosed in the neonatal period with neonatal intrahepatic cholestasis (NICCD), eight later in childhood (FTTDCD) and 12 by family screening based on index cases from five families. No patient had adult-onset type II citrullinemia. The patient age at the time of data collection was a median of 11 y (1–44 y). 91% (29/32) of patients had normal physical and neurological development, 47% (15/32) experienced recurrent unexplained abdominal pain and 9% (3/32) episodes of hypoglycaemia. Siblings had different phenotypes (5 families had > 1 affected patient). Most patients preferred high protein foods, limiting sugar-containing foods. Only 41% (13/32) were prescribed a low CHO, high protein, high fat diet (restriction varied) and two used medium chain triglyceride (MCT) supplements. No patient was prescribed drug therapy. Twenty-five per cent (8/32) of patients were underweight and 41% (13/32) had height <−1 z-scores. Conclusions: patients presented with various phenotypes, symptoms and suboptimal growth. Symptoms and biochemical markers improved with age, but height remained low in some. More research is necessary to assess the effectiveness of dietary approaches in improving clinical outcomes and symptoms in citrin deficiency.

Phytobezoar-induced small bowel obstruction in an elderly patient undergoing dialysis: a case report

A phytobezoar is defined as an accumulation of poorly digested fruit and vegetable fibers in the gastrointestinal tract. Phytobezoar-induced small bowel obstruction is an uncommon entity and is usually removed surgically. We herein describe an elderly man undergoing dialysis who developed a phytobezoar because of excessive consumption of high-fiber fruits and inappropriate chewing. His potential predisposing factors were dialysis-related lifestyle changes, reduced activity levels, fluid restriction, and gastrointestinal motility dysfunction; however, he had no history of gastric surgery. The patient’s clinical history and characteristic imaging features aided in the diagnosis. He underwent medical treatment, and his recovery was uneventful. This case highlights the importance of an awareness of phytobezoar-induced small bowel obstruction in patients at increased risk of developing bezoars and demonstrates that this condition can occur in the absence of previous gastric surgery. We believe that elderly patients undergoing dialysis are at increased risk of developing bezoars. Excessive consumption of a strictly fibrous diet and insufficient chewing exacerbate the risk. A detailed dietary history and imaging features can aid in early diagnosis, leading to appropriate medical or surgical care. Surgical treatment is not inevitable in all cases. Individualized dietary suggestions in these patients are important for effective preventive control.

Long Term Follow-Up of Polish Patients with Isovaleric Aciduria. Clinical and Molecular Delineation of Isovaleric Aciduria

Isovaleric acidemia (IVA) is an autosomal recessive leucine inborn error of metabolism caused by isovaleryl-CoA dehydrogenase deficiency. The disease has various courses, from severe ones manifesting in newborns to the intermittent form with first manifestation in children and adults. The aim of this study was to analyze clinical and neurological outcomes in Polish patients with IVA. Ten patients diagnosed and treated in The Children's Memorial Health Institute were included in the study. The diagnosis was based on tandem MS (increased level of C5 acylcarnitine) and urine GCMS (increased isovalerylglycine, and 3-hydroxyisovaleric acid). Molecular analysis was performed in seven patients (70%) leading to the detection of pathogenic variants in the IVD gene in all of them. A retrospective analysis of patients' medical records included: demographics, symptoms at diagnosis, medical management, and biochemical and clinical outcomes following therapy. The median follow-up time (median; Q1-Q2) was 2.5 years (1.5-9.0) for newborn screening (NBS) and family screening (FS) children, and 17 years (5.0-20) for symptomatic patients. Five patients were in a good clinical state, four children presented mild neurological symptoms, and one-severely delayed child. In the IVD gene, five known and two novel variants (p.466C>G, c.1132G>A) were identified. Molecular analysis was performed in seven patients leading to identification of biallelic pathogenic variants in the IVD gene in all of them. We can conclude that long-term clinical and neurological outcomes of patients with IVA were satisfactory as a result of an early diagnosis and proper management. Although early treatment did not prevent decompensations, they were milder in these patients.

Proteomic Strategies to Evaluate the Impact of Farming Conditions on Food Quality and Safety in Aquaculture Products

This review presents the primary applications of various proteomic strategies to evaluate the impact of farming conditions on food quality and safety in aquaculture products. Aquaculture is a quickly growing sector that represents 47% of total fish production. Food quality, dietary management, fish welfare, the stress response, food safety, and antibiotic resistance, which are covered by this review, are among the primary topics in which proteomic techniques and strategies are being successfully applied. The review concludes by outlining future directions and potential perspectives.

Amino Acid Plasma Profiles from a Prolonged-Release Protein Substitute for Phenylketonuria: A Randomized, Single-Dose, Four-Way Crossover Trial in Healthy Volunteers

Several disorders of amino acid (AA) metabolism are treated with a protein-restricted diet supplemented with specific AA mixtures. Delivery kinetics impacts AA absorption and plasma concentration profiles. We assessed plasma profiles after ingestion of an AA mixture engineered to prolong AA absorption with Physiomimic Technology^TM (Test) in a randomized, single-dose, four-way crossover trial in healthy volunteers (Trial Registration: ISRCTN11016729). In a two-step hypothesis, the primary endpoints were (i) significant reduction in peak plasma concentrations (C_max) of essential amino acids (EAAs) while (ii) maintaining EAA bioavailability (AUC_{0-300 min}) compared to a free AA mixture (Reference). Secondary endpoints included effects on plasma profiles of other AA groups and effects on several metabolic markers. Thirty subjects completed the study. Both co-primary endpoints were met: C_max for EAAs was 27% lower with the Test product compared to the Reference product (ratio, 0.726, p < 0.0001); overall plasma EAA levels from the two AA mixtures was within the pre-specified bioequivalence range (AUC_0-300min ratio, 0.890 (95% CI: 0.865, 0.915)). These findings were supported by the results of secondary endpoints. Prolongation of AA absorption was associated with modulation of several metabolic markers. It will be important to understand whether this can improve the long-term management of disorders of AA metabolism.

Dietary Management of the Glycogen Storage Diseases: Evolution of Treatment and Ongoing Controversies

The hepatic glycogen storage diseases (GSDs) are a group of disorders where abnormal storage or release of glycogen leads to potentially life-threatening hypoglycemia and metabolic disturbances. Dietary interventions have markedly improved the outcome for these disorders, from a previously fatal condition to one where people can do well with proper care. This article chronicles the evolution of dietary management and treatment of the hepatic GSDs (types 0, I, III, VI, IX, and XI). We examine historic and current approaches for preventing hypoglycemia associated with GSDs. There is a lack of consensus on the optimal dietary management of GSDs despite decades of research, and the ongoing controversies are discussed.

The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence

Even though irritable bowel syndrome (IBS) has been known for more than 150 years, it still remains one of the research challenges of the 21st century. According to the current diagnostic Rome IV criteria, IBS is characterized by abdominal pain associated with defecation and/or a change in bowel habit, in the absence of detectable organic causes. Symptoms interfere with the daily life of patients, reduce health-related quality of life and lower the work productivity. Despite the high prevalence of approximately 10%, its pathophysiology is only partly understood and seems multifactorial. However, many patients report symptoms to be meal-related and certain ingested foods may generate an exaggerated gastrointestinal response. Patients tend to avoid and even exclude certain food products to relieve their symptoms, which could affect nutritional quality. We performed a narrative paper review of the existing and emerging evidence regarding dietary management of IBS patients, with the aim to enhance our understanding of how to move towards an individualized dietary approach for IBS patients in the near future.

Current Management of Patients With Acquired Solitary Kidney

Persons with acquired solitary kidney, including those who have had a unilateral nephrectomy for living kidney donation, renal malignancies, or trauma, have decreased renal mass that leads to increased intraglomerular pressure and glomerular hyperfiltration. These physiologic adaptations of solitary kidney may exacerbate other preexisting and genetic conditions that could create a predisposition to or worsen glomerular pathologies, leading to unfavorable renal outcomes. Hence, these persons may benefit from special care and lifestyle modifications, including nutritional interventions. There is a lack of consensus and evidence for proper surveillance and management after nephrectomy, and misconceptions in both directions of having a “normal” versus “abnormal” kidney status may cause confusion among patients and healthcare providers pertaining to long-term kidney health monitoring and management. We have reviewed available data on the impact of lifestyle modifications, particularly nutritional measures, and pharmacologic interventions, on short- and long-term outcomes after nephrectomy. We recommend avoidance of excessively high dietary protein intake (>1 g/kg per day) and high dietary sodium intake (>4 grams/d), adequate dietary fiber intake from plant-based foods, a target body mass index of <30 kg/m² (in non-athletes and non-bodybuilders), and judicious management of risk factors of progressive chronic kidney disease (CKD), and future studies should help to better determine optimal care practices for these persons.

Irritable Bowel Syndrome and Dietary Interventions

Irritable bowel syndrome (IBS) is the most prevalent functional gastrointestinal disorder, affecting approximately 14% of the global population. Symptoms of IBS are some of the most common reasons that primary care providers refer patients to gastroenterologists. IBS has a significant economic impact on the health care system and greatly reduces patients' quality of life. The precise cause of IBS remains unknown, but likely involves a variety of factors, such as infection, inflammation, medication, and stress, in a genetically predisposed individual. Physicians can diagnose patients with IBS by obtaining a careful history and physical examination, performing limited testing, and applying the Rome IV criteria. Treating IBS symptoms can be challenging, as no medication cures the disorder. Thus, treatment focuses on improving symptoms and quality of life. Many patients report that symptoms develop from, or are exacerbated by, food. A number of physiologic and biochemical processes can occur with food ingestion that may produce heightened symptoms of IBS. Therefore, dietary interventions to improve IBS symptoms appear to be a reasonable treatment approach. This article discusses the evidence supporting dietary interventions for the treatment of IBS.

Evidence- and consensus-based recommendations for the use of pegvaliase in adults with phenylketonuria

Purpose

Phenylketonuria (PKU) is a rare metabolic disorder that requires life-long management to reduce phenylalanine (Phe) concentrations within the recommended range. The availability of pegvaliase (PALYNZIQ™, an enzyme that can metabolize Phe) as a new therapy necessitates the provision of guidance for its use.

Methods

A Steering Committee comprising 17 health-care professionals with experience in using pegvaliase through the clinical development program drafted guidance statements during a series of face-to-face meetings. A modified Delphi methodology was used to demonstrate consensus among a wider group of health-care professionals with experience in using pegvaliase.

Results

Guidance statements were developed for four categories: (1) treatment goals and considerations prior to initiating therapy, (2) dosing considerations, (3) considerations for dietary management, and (4) best approaches to optimize medical management. A total of 34 guidance statements were included in the modified Delphi voting and consensus was reached on all after two rounds of voting.

Conclusion

Here we describe evidence- and consensus-based recommendations for the use of pegvaliase in adults with PKU. The manuscript was evaluated against the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument and is intended for use by health-care professionals who will prescribe pegvaliase and those who will treat patients receiving pegvaliase.

Application of Behavior Change Techniques in a Personalized Nutrition Electronic Health Intervention Study: Protocol for the Web-Based Food4Me Randomized Controlled Trial

BACKGROUND

To determine the efficacy of behavior change techniques applied in dietary and physical activity intervention studies, it is first necessary to record and describe techniques that have been used during such interventions. Published frameworks used in dietary and smoking cessation interventions undergo continuous development, and most are not adapted for Web-based delivery. The Food4Me study (N=1607) provided the opportunity to use existing frameworks to describe standardized Web-based techniques employed in a large-scale, internet-based intervention to change dietary behavior and physical activity.

OBJECTIVE

The aims of this study were (1) to describe techniques embedded in the Food4Me study design and explain the selection rationale and (2) to demonstrate the use of behavior change technique taxonomies, develop standard operating procedures for training, and identify strengths and limitations of the Food4Me framework that will inform its use in future studies.

METHODS

The 6-month randomized controlled trial took place simultaneously in seven European countries, with participants receiving one of four levels of personalized advice (generalized, intake-based, intake+phenotype-based, and intake+phenotype+gene-based). A three-phase approach was taken: (1) existing taxonomies were reviewed and techniques were identified a priori for possible inclusion in the Food4Me study, (2) a standard operating procedure was developed to maintain consistency in the use of methods and techniques across research centers, and (3) the Food4Me behavior change technique framework was reviewed and updated post intervention. An analysis of excluded techniques was also conducted.

RESULTS

Of 46 techniques identified a priori as being applicable to Food4Me, 17 were embedded in the intervention design; 11 were from a dietary taxonomy, and 6 from a smoking cessation taxonomy. In addition, the four-category smoking cessation framework structure was adopted for clarity of communication. Smoking cessation texts were adapted for dietary use where necessary. A posteriori, a further 9 techniques were included. Examination of excluded items highlighted the distinction between techniques considered appropriate for face-to-face versus internet-based delivery.

CONCLUSIONS

The use of existing taxonomies facilitated the description and standardization of techniques used in Food4Me. We recommend that for complex studies of this nature, technique analysis should be conducted a priori to develop standardized procedures and training and reviewed a posteriori to audit the techniques actually adopted. The present framework description makes a valuable contribution to future systematic reviews and meta-analyses that explore technique efficacy and underlying psychological constructs. This was a novel application of the behavior change taxonomies and was the first internet-based personalized nutrition intervention to use such a framework remotely.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01530139; https://clinicaltrials.gov/ct2/show/NCT01530139 (Archived by WebCite at http://www.webcitation.org/6y8XYUft1).

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