A tasting experiment comparing food and nutritional supplement in anorexia nervosa

Anorexia nervosa (AN) is a severe psychiatric disorder leading to life-threatening emaciation. Weight restoration is crucial in treatment but few data are available on how to achieve it. Nutritional supplements are needed in treatment but patients' preferences about natural versus medical foods and their gustatory/hedonic perception are unclear. We aimed to measure disgust and reward-based eating in AN and to assess psychological, interoceptive awareness-related, behavioral, and hedonic aspects comparing natural versus medical food. Thirty-three inpatients with AN and 39 healthy controls (HCs) were recruited and received 50 ml of either apricot juice or nutritional liquid supplement with apricot flavor on two consecutive days. Disgust, reward-based eating, and eating psychopathology were evaluated. Visual Analogue Scales measuring anxiety, hunger, confusion about internal states, need for over-exercise, restraint, and satiety were completed before and after the experiment. Disgust and hedonic responses were measured after the experiment. Patients with AN reported preserved disgust sensitivity and higher reward-based eating drive. When compared to HCs, inpatients with AN reported higher scores on anxiety, hunger, confusion about internal states, urge to over-exercise, urge to eating restraint, and satiety before and after the tasting experiment. The supplement slightly increased patients' anxiety with HCs reporting the same trend. Still, patients reported more food-related disgust after the supplement but their overall hedonic evaluation was similar for both conditions. Also, anxiety, confusion about internal states, and urge to over-exercise and restraint did not significantly increase after consuming either food. Therefore, if we take into account patients' level of heightened satiety and suppressed hunger, supplements could be helpful for patients with severe AN since greater energy intakes could be provided with only small volumes of food and little changes of eating concerns.

Recent advances of medical foods in China: The opportunities and challenges under standardization

Malnutrition with high incidence in hospitalized patients in China has brought a significant burden of disease. Although many clinical studies have demonstrated the importance of nutritional for patients with malnutrition, the application of medical foods in China is still restricted. For the classification, limits, production and registration of medical foods, the Chinese government newly enacted a series of regulations. In this review, comparing the policy, researches, and product variety of medical foods in China with other countries, although the current status of the development of medical foods in China is still far behind that of developed countries, some of regulations are stricter than those of many other countries or organizations. The medical foods in China are divided into four categories, the nutrients and environmental contaminants are limited to ensure the safety. As a prospect, the development of medical foods in China is expected to get out of the predicament of lack of emphasis, shortage of supply, backward of local processing technology and the imperfect management system. After all, in view of the huge population and the increasing demand of nutrition in China, there must be a very good prospect for the future development of the medical foods industry in China.

Medicinal Foods for Functional GI Disorders

PURPOSE OF REVIEW

Over the past 10 years, there has been a dramatic increase in basic and clinical research involving functional gastrointestinal disorders (FGIDs). New diagnostic and biomarker procedures are helping to identify physiologic disruptions associated with FGIDs on cellular and molecular levels. Simultaneously, clinicians are using new approaches to help manage patients with FGIDs. Among these, an important component of care has been the use of medical foods. These include probiotics, prebiotics, synbiotics, peppermint oil, caraway oil, curcumin, bovine immunoglobulin and many others.

RECENT FINDINGS

The putative effects of different medical foods make these therapies attractive for the management of FGIDs. These include effects on several pathophysiological mechanisms such as anti-inflammatory, smooth muscle relaxation, analgesia, mitigation of gut barrier dysfunction, and stimulation or inhibition of gastrointestinal receptors. Recent research has also demonstrated the efficacy of medical food products such as peppermint oil and serum-derived bovine immunoglobulin for the management of irritable bowel syndrome. Older data supports the probiotic VSL#3 and Bifidobacterium species. For functional dyspepsia, positive effects have been observed with the combination of caraway seed oil and peppermint oil as well as with STW-5, a botanical combination preparation, although robust RCTs are lacking. With advancing knowledge regarding the pathogenesis of FGIDs, it is likely that the compounds available in the medical food category will increase dramatically, and they could play an important role in the management of several common and bothersome gastrointestinal conditions in the future.

Protein intake and physical activity are associated with body composition in individuals with phenylalanine hydroxylase deficiency

OBJECTIVE

Determine whether body composition as it relates to dietary protein in patients with phenylalanine hydroxylase (PAH) deficiency is associated with genotype, dietary factors, and lifestyle choices.

METHODS

We examined associations between protein intake (intact and medical foods: MF) and body composition in PAH-deficient patients along with, physical activity, and genotype. Protein intakes (total, intact, and MF) were analysed from three-day food records with Nutrition Data System for Research (NDSR) in 59 children and 27 adults (N=86, median age=16.0years). The severity of PAH deficiency was classified using the genotype assigned value method (AV sum). Physical activity was assessed using a study-developed question (light vs. intense activity). Body composition was measured by DXA, including android:gynoid ratio (A:G), fat-free mass index (FFMI), fat mass index (FMI), and FMI:FFMI ratio.

RESULTS

High intact protein intake was associated with high FFMI (r_s=0.75, p=0.008) and low FMI:FFMI (r_s=-0.59, p=0.04) in adults. Only in children, MF protein (r_s=0.38, p=0.04) was directly proportional to FFMI. Median intact protein intakes of adults (25.1 vs. 9.9g/d, p<0.001) and children (11 vs. 6g/d, p<0.001) were higher than prescribed. Only in adults, the actual median MF protein intake was lower than prescribed (53 vs. 60g/d, p=0.03). In adults and children, light activity was associated with higher fat mass indices compared to intense activity (adults: FMI:FFMI: β=1.1, p=0.001, children: FMI:FFMI: β=1.1, p=0.007; FMI β=2.1, p=0.01; A:G β=1.1, p=0.04). All associations remained significant after covariate adjustment. Genotype was not associated with body composition.

CONCLUSIONS

Although fat-free mass in adults was positively associated with intact protein intake, it should be consumed as prescribed per individual tolerance to maintain plasma Phe concentrations within treatment range. In children, total protein maximized with MF should be encouraged to promote lean mass. Nutrition counselling could be complemented with physical activity recommendations for optimal clinical outcomes.

The Emerging Therapeutic Role of Medical Foods for Gastrointestinal Disorders

In addition to drugs approved by the US Food and Drug Administration (FDA) that treat, cure, or mitigate disease, medical foods are a tool to help manage chronic conditions and diseases. A medical food, according to the FDA, is a food that is developed to be eaten or administered enterally under the guidance of a physician and that is meant for the specific dietary management of a condition or disease for which distinctive nutritional requirements, based upon known scientific principles, are established by medical evaluation. A variety of medical foods exist to help manage a wide range of medical conditions, from Alzheimer disease to HIV-associated enteropathy. EnteraGam contains serum-derived bovine immunoglobulin/protein isolate, which has been studied extensively in diarrhea-predominant irritable bowel syndrome, inflammatory bowel disease (IBD), and HIV-associated enteropathy. VSL#3 is a probiotic that is used in pouchitis for patients with ulcerative colitis as well as irritable bowel syndrome. Modulen IBD is a whole-protein, sole-nutrition formulation used to manage the active phase of Crohn's disease. Vivonex is an elemental diet that is used in a variety of diseases associated with severe gastrointestinal dysfunction. Medical foods are safe and must have proven efficacy in helping to manage a variety of gastrointestinal conditions and diseases. These therapies represent tools that can be used prior or in addition to traditional medical therapies. This article discusses the history and development of medical foods under the FDA and concentrates specifically on medical foods used to help manage diseases of the gastrointestinal tract.

Nutritional interventions in primary mitochondrial disorders: Developing an evidence base

In December 2014, a workshop entitled "Nutritional Interventions in Primary Mitochondrial Disorders: Developing an Evidence Base" was convened at the NIH with the goals of exploring the use of nutritional interventions in primary mitochondrial disorders (PMD) and identifying knowledge gaps regarding their safety and efficacy; identifying research opportunities; and forging collaborations among researchers, clinicians, patient advocacy groups, and federal partners. Sponsors included the NIH, the Wellcome Trust, and the United Mitochondrial Diseases Foundation. Dietary supplements have historically been used in the management of PMD due to their potential benefits and perceived low risk, even though little evidence exists regarding their effectiveness. PMD are rare and clinically, phenotypically, and genetically heterogeneous. Thus patient recruitment for randomized controlled trials (RCTs) has proven to be challenging. Only a few RCTs examining dietary supplements, singly or in combination with other vitamins and cofactors, are reported in the literature. Regulatory issues pertaining to the use of dietary supplements as treatment modalities further complicate the research and patient access landscape. As a preface to exploring a research agenda, the workshop included presentations and discussions on what PMD are; how nutritional interventions are used in PMD; challenges and barriers to their use; new technologies and approaches to diagnosis and treatment; research opportunities and resources; and perspectives from patient advocacy, industry, and professional organizations. Seven key areas were identified during the workshop. These areas were: 1) defining the disease, 2) clinical trial design, 3) biomarker selection, 4) mechanistic approaches, 5) challenges in using dietary supplements, 6) standards of clinical care, and 7) collaboration issues. Short- and long-term goals within each of these areas were identified. An example of an overarching goal is the enrollment of all individuals with PMD in a natural history study and a patient registry to enhance research capability. The workshop demonstrates an effective model for fostering and enhancing collaborations among NIH and basic research, clinical, patient, pharmaceutical industry, and regulatory stakeholders in the mitochondrial disease community to address research challenges on the use of dietary supplements in PMD.

Normal vitamin D levels and bone mineral density among children with inborn errors of metabolism consuming medical food-based diets

A higher incidence of osteopenia is observed among children with inherited metabolic disorders (inborn errors of metabolism, or IEMs) who consume medical food-based diets that restrict natural vitamin D-containing food sources. We evaluated the vitamin D status of children with IEMs who live in the Pacific Northwest with limited sun exposure and determined whether bone mineral density (BMD) in children with phenylketonuria (PKU), the most common IEM, correlated with diet or biochemical markers of bone metabolism. We hypothesized that children with IEMs would have lower serum vitamin D concentrations than controls and that some children with PKU would have reduced bone mineralization. A retrospective record review of 88 patients with IEMs, and 445 children on unrestricted diets (controls) found the 25-hydroxyvitamin D concentrations were normal and not significantly different between groups (IEM patients, 27.1 ± 10.9; controls, 27.6 ± 11.2). Normal BMD at the hip or spine (-2 <z score < 2) was measured in 20 patients with PKU. There was a correlation between lumbar spine BMD and dietary calcium intake. We saw no evidence of low serum vitamin D in our population of children with IEMs compared with control children. We also found no evidence for reduced BMD in children with PKU on specialized diets, but BMD was associated with calcium intake. Dietary intake of essential nutrients in medical food-based diets supports normal 25-hydroxyvitamin D levels and BMD in children with IEMs, including PKU. The risk of vitamin D deficiency among patients consuming a medical food-based diet is similar to the general population.

Inborn errors of metabolism identified via newborn screening: Ten-year incidence data and costs of nutritional interventions for research agenda planning

Inborn errors of metabolism (IEM) are genetic disorders in which specific enzyme defects interfere with the normal metabolism of exogenous (dietary) or endogenous protein, carbohydrate, or fat. In the U.S., many IEM are detected through state newborn screening (NBS) programs. To inform research on IEM and provide necessary resources for researchers, we are providing: tabulation of ten-year state NBS data for selected IEM detected through NBS; costs of medical foods used in the management of IEM; and an assessment of corporate policies regarding provision of nutritional interventions at no or reduced cost to individuals with IEM. The calculated IEM incidences are based on analyses of ten-year data (2001-2011) from the National Newborn Screening Information System (NNSIS). Costs to feed an average person with an IEM were approximated by determining costs to feed an individual with an IEM, minus the annual expenditure for food for an individual without an IEM. Both the incidence and costs of nutritional intervention data will be useful in future research concerning the impact of IEM disorders on families, individuals and society.

Expanding research to provide an evidence base for nutritional interventions for the management of inborn errors of metabolism

A trans-National Institutes of Health initiative, Nutrition and Dietary Supplement Interventions for Inborn Errors of Metabolism (NDSI-IEM), was launched in 2010 to identify gaps in knowledge regarding the safety and utility of nutritional interventions for the management of inborn errors of metabolism (IEM) that need to be filled with evidence-based research. IEM include inherited biochemical disorders in which specific enzyme defects interfere with the normal metabolism of exogenous (dietary) or endogenous protein, carbohydrate, or fat. For some of these IEM, effective management depends primarily on nutritional interventions. Further research is needed to demonstrate the impact of nutritional interventions on individual health outcomes and on the psychosocial issues identified by patients and their families. A series of meetings and discussions were convened to explore the current United States' funding and regulatory infrastructure and the challenges to the conduct of research for nutritional interventions for the management of IEM. Although the research and regulatory infrastructure are well-established, a collaborative pathway that includes the professional and advocacy rare disease community and federal regulatory and research agencies will be needed to overcome current barriers.

Safety and efficacy of Profermin® to induce remission in ulcerative colitis

AIM: To test the efficacy and safety of Profermin^® in inducing remission in patients with active ulcerative colitis (UC).

METHODS: The study included 39 patients with mild to moderate UC defined as a Simple Clinical Colitis Activity Index (SCCAI) > 4 and < 12 (median: 7.5), who were treated open-label with Profermin^® twice daily for 24 wk. Daily SCCAI was reported observer blinded via the Internet.

RESULTS: In an intention to treat (ITT) analysis, the mean reduction in SCCAI score was 56.5%. Of the 39 patients, 24 (62%) reached the primary endpoint, which was proportion of patients with ≥ 50% reduction in SCCAI. Our secondary endpoint, the proportion of patients in remission defined as SCCAI ≤ 2.5, was in ITT analysis reached in 18 of the 39 patients (46%). In a repeated-measure regression analysis, the estimated mean reduction in score was 5.0 points (95% CI: 4.1-5.9, P < 0.001) and the estimated mean time taken to obtain half the reduction in score was 28 d (95% CI: 26-30). There were no serious adverse events (AEs) or withdrawals due to AEs. Profermin^® was generally well tolerated.

CONCLUSION: Profermin^® is safe and may be effective in inducing remission of active UC.