Standard RUTF vs. locally-made RUSF for acutely malnourished children: A quasi-experimental comparison of the impact on growth and compliance in a rural community of Pakistan.

BACKGROUND: The reduction in severe and moderate acute malnutrition (SAM and MAM) rates in Pakistan has been sub-optimal compared to other low-and middle-income countries (LMICs). Specially-formulated products have been designed globally to manage SAM and MAM, such as ready-to-use therapeutic food (RUTF) and ready-to-use supplementary food (RUSF), with variable efficacies. RUTF is primarily produced and patented in industrialized countries, raising supply challenges in resource-constrained regions with a high burden of acute malnutrition. RUSF minimizes costs by using locally-available ingredients while providing similar nutritional value. In this study, we compared the efficacy, side effects, and compliance of two months of supplementation with either RUTF or RUSF. METHODS: Children aged nine months in the rural district of Matiari, Pakistan, with a weight-for-height z-score (WHZ) <-2 received either RUTF (500 kcal sachet) for two months in 2015 or RUSF (520 kcal sachet) for two months in 2018. RESULTS: The RUSF group had a higher height gain and mid-upper arm circumferences (MUAC) score. Higher compliance was noted with lower side effects in the RUSF group. A higher compliance rate did correlate with the growth parameters in respective groups. CONCLUSION: Our study found that both RUTF and RUSF partially improve the anthropometric status of acutely malnourished children, with neither being superior to the other.

Webinário sobre conscientização sobre o consumo do açúcar

Saúde promove conscientização sobre o consumo de açúcar em webinário No dia 21/01 o evento que integra o ciclo de encontros virtuais debaterá as ações para abordar e reverter o consumo excessivo de açúcar Estudos mostram que o consumo excessivo de açúcar está relacionado ao ganho de peso, à obesidade, ao diabetes tipo 2, às doenças cardiovasculares e à cárie dentária. No Brasil, segundo a Pesquisa de Orçamentos Familiares (POF 2017-2018), 85,4% da população adiciona açúcar em alimentos e bebida.

Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial.

BACKGROUND: The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients. METHODS: Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h. INTERVENTION: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea. RESULTS: Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44-65] versus 55[40-65] years) and GCS (6[3-7] versus 5[3-7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78-1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group. CONCLUSION: Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition. TRIAL REGISTRATION: EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).

Replacement of breastfeeding with medical food for the treatment of galactosemia and phenylketonuria: maternal stress.

Breastfeeding replacement is the only treatment for galactosemia (GAL) and phenylketonuria (PKU) during infancy. We aimed to evaluate the stress degree in mothers who were obliged to replace breastfeeding with special formulas as the only treatment for the diseased newborns. Thirty-two mothers with GAL newborns, 19 on breastfeeding only and 13 on breastfeeding plus formula, participated in this study. Additionally, 54 mothers with PKU infants, 32 offered breastfeeding only and 22 breastfeeding plus formula, participated in the study. Stress degree was evaluated in both groups: GAL and PKU. Mothers on breastfeeding only experienced the highest degree of stress than those who were on breastfeeding plus formula. After 1 month of psychological support, most mothers were ameliorated: mothers on breastfeeding only felt better as compared to those on breastfeeding plus formula. Conversely, in mothers on breastfeeding plus formulas, symptoms and signs of stress almost disappeared. In conclusion, GAL or PKU mothers with breastfeeding only experienced the highest degree of stress when asked for breastfeeding replacement. Psychological support made all the studied groups to feel better or free of symptoms and signs of stress.

Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adults using the 'Protein & Energy Requirements Fed for Every Critically ill patient every Time' (PERFECT) protocol: a before-and-after study.

BACKGROUND: Underfeeding in critical illness is common and associated with poor outcomes. According to large prospective hospital studies, volume-based feeding (VBF) safely and effectively improves energy and protein delivery to critically ill patients compared to traditional rate-based feeding (RBF) and might improve patient outcomes. A before-and-after study was designed to evaluate the safety, efficacy and clinical outcomes associated with VBF compared to RBF in a single intensive care unit (ICU). METHODS: The sample included consecutively admitted critically ill adults, mechanically ventilated for at least 72 h and fed enterally for a minimum of 48 h. The first cohort (n = 46) was fed using RBF, the second (n = 46) using VBF, and observed for 7 days, or until extubation or death. Statistical comparison of percentage feed volume, energy and protein delivered, plus indices of feed intolerance, were the primary outcomes of interest. Secondary observations included ventilation period, mortality, and length of ICU stay (LOICUS). RESULTS: Groups were comparable in baseline clinical and demographic characteristics and nutrition practices. Volume delivered to the VBF group increased significantly by 11.2% (p ≤ 0.001), energy by 13.4% (p ≤ 0.001) and protein by 8.4% (p = 0.02), compared to the RBF group. In the VBF group, patients meeting > 90% of energy requirements increased significantly from 47.8 to 84.8% (p ≤ 0.001); those meeting > 90% of protein requirements changed from 56.5 to 73.9% (p = 0.134). VBF did not increase symptoms of feed intolerance. Adjusted binomial logistic regression found each additional 1% of prescribed feed delivered decreased the odds of vomiting by 0.942 (5.8%), 95% CI [0.900-0.985], p = 0.010. No differences in mortality or LOICUS were identified. Kaplan-Meier found a significantly increased extubation rate in patients receiving > 90% of protein requirements compared to those meeting < 80%, (p = 0.006). Adjusted Cox regression found the daily probability of being extubated tripled in patients receiving > 90% of their protein needs compared to the group receiving < 80%, hazard ratio 3.473, p = 0.021, 95% CI [1.205-10.014]. CONCLUSION: VBF safely and effectively increased the delivery of energy and protein to critically ill patients. Increased protein delivery may improve extubation rate which has positive patient-centred and financial implications, warranting larger confirmatory trials. This investigation adds weight to the ICU literature supporting VBF, and the growing evidence which advocates for enhanced protein delivery to improve patient outcomes.

Testing potential psychological predictors of attitudes towards cultured meat.

Cultured meat is an emerging food technology that has the potential to resolve many of the social, environmental and ethical issues surrounding traditional factory farming practices. Recently, research has begun to explore consumer attitudes to the product, revealing a number of barriers and demographic predictors. However, our understanding of the psychological mechanisms that underpin attitudes to cultured meat remains limited. In the current study, we draw on an attitude roots model (Hornsey & Fielding, 2017) to explore a range of psychological mechanisms that may underpin attitudes to cultured meat. In terms of negative attitudes and intentions toward cultured meat, the most powerful predictors were food neophobia, political conservatism, and distrust of food scientists. When it comes to absolute opposition to cultured meat - defined by the unconditional belief that it should never be allowed under any circumstances - the strongest predictors were food and hygiene disgust sensitivity subscales, food neophobia, and conspiratorial ideation. A number of presumed mechanisms held no relationships to cultured meat attitudes, including social dominance orientation, speciesism, and naturalness bias. The null results on naturalness bias are of particular interest given recent research identifying concerns about naturalness as a key barrier to consumer acceptance. These results demonstrate the need for a more nuanced understanding of the psychological mechanisms that contribute to cultured meat attitudes and engagement.

The effect of an elemental diet on oral mucositis of esophageal cancer patients treated with DCF chemotherapy: a multi-center prospective feasibility study (EPOC study).

PURPOSE: Oral mucositis (OM) is one of the most uncomfortable adverse events experienced by cancer patients undergoing chemotherapy. Previous reports have revealed that the oral administration of an elemental diet (ED) may prevent OM. However, the incidence of OM has not been accurately determined by specialized diagnostic methods and the effects of an ED on OM remain unclear. We investigated the dose that could feasibly be administered and its effects with regard to the suppression of OM in esophageal cancer patients undergoing chemotherapy. METHODS: We performed a prospective multi-center feasibility study of the administration of an ED (160 g/day) with 2 cycles of docetaxel/cisplatin/5-FU (DCF) chemotherapy. We assessed compliance to the ED for 49 days and the incidence of OM according to the amount of the ED that was orally administered. The incidence of OM was graded by a dental specialist who was experienced in dental oncology using a central OM review system. RESULTS: Fourteen of 20 patients (70%) were able to complete the orally administered ED (160 g/day) during the course of chemotherapy. Three patients (15%) could not take the ED orally for 9, 14, and 21 days, respectively, while 1 patient (5%) took the ED orally at an average dose of 80 g/day for 35 days. The remaining 2 patients (10%) could not take the 80 g/day dose for 11 and 12 days, respectively. The incidence of grade ≥ 2 OM in the ED completion group (15.4%, 2 of 13 patients) was significantly lower than that in the non-completion group (66.7%, 4 of 6 patients) (p = 0.046). CONCLUSIONS: An ED might be a one of the test treatment to reduce the incidence of OM in esophageal cancer patients treated with DCF and should be evaluated in further randomized study. CLINICAL TRIAL: The date of submission: Dec 08th, 2017.

Use and Costs of Medical Foods and Convenience-Packaged Drugs in the California Workers' Compensation System.

BACKGROUND: Sales of medical foods (MFs) and convenience packages (CPs) are projected to exceed $2 billion in the United States, with an annual growth rate of 10%. Several studies have highlighted the rapid growth of MF use within the California Workers' Compensation System (CAWCS). To curb this growth, California implemented Assembly Bill 378 (AB 378) in 2012 to regulate physicians' incentives to dispense MFs and CPs. AB 378's regulation on only physician-dispensed MFs and CPs and not pharmacy-dispensed MFs and CPs generated a setting for evaluating the differential effect of the bill on MF and CP use and cost. OBJECTIVES: To (a) examine the use and cost of MFs and CPs in the CAWCS that are not for inborn errors of metabolism and (b) evaluate the regulatory effect of AB 378. METHODS: This study adopted a quantitative approach and employed descriptive statistics and t-tests. The analyses used the most recent complete annual claims data from the Workers' Compensation Information System dataset to evaluate MF and CP claims frequencies and dollar amounts reimbursed from 2011 to 2013 and to compare the difference between physician-dispensed and pharmacy-dispensed products. RESULTS: Of 151,107 MFs and CPs billed, 95,528 (63.2%) prescriptions were reimbursed. The reimbursed MFs and CPs accounted for approximately $19 million paid to pharmacies and physicians over 3 years. Physician-dispensed MFs, which were regulated by AB 378 in January 2012, experienced a reduction in mean amount reimbursed by $9.95 (P < 0.001)-from $195.64 to $185.68-compared with the mean amount reimbursed in 2011. Conversely, physician-dispensed CPs, as well as pharmacy-dispensed MFs and CPs, did not experience a decrease in mean amount reimbursed. CONCLUSIONS: The results indicated that AB 378 was associated with a statistically significant reduction in physician-dispensed MFs. Concomitantly, the results from t-tests showed no statistically significant difference in mean amount reimbursed for MFs and CPs to pharmacies before and after AB 378. The finding was expected and as hypothesized because AB 378 did not regulate pharmacy-dispensed MFs and CPs. Legislative measures, such as AB 378 in California, may influence rising costs and use of MFs and CPs in general. Other workers' compensation systems could adopt similar legislation to affect the behavior of physician prescribing of non-inborn errors of metabolism MFs and further test these findings. DISCLOSURES: Funding for this study was contributed by the California Workers' Compensation System. The authors have nothing to disclose.

Innovative optimization of ready to use food for treatment of acute malnutrition.

Treatment of acute malnutrition typically requires the provision of ready-to-use food (RUF). Common RUF is effective but expensive, being manufactured from costly ingredients, and shipped worldwide from few global suppliers. I developed a linear programming tool to create RUF optimized for low cost using locally grown crops while maintaining necessary nutritional goals and other constraints. My tool utilizes a database of the nutritional value, price, and water efficiency of suitable ingredients and allows adjustment of constraints, including nutrients, flavour, and crop water efficiency. It is designed to (a) address nutrient requirements conforming to current standards and practice; (b) optimize RUF formulae for low cost using a wide range of ingredients for nutritional value and acceptability improvement; (c) ensure protein quality through protein digestibility corrected amino acid score; and (d) adjust RUF formulae according to locally grown crop selection, local prices, and crop water footprint. The tool creates formulae free of expensive dairy ingredients, ensuring desired protein digestibility corrected amino acid score by automatically balancing proteins with complementary quantities of essential amino acids. Using publicly available data with an application to Nigeria, my tool created RUF formulae suitable for local production using local crops to meet all nutrient requirements at a fraction of the ingredient cost and water footprint of current formulae, demonstrating the tool's effectiveness. Optimization of RUF for low cost using locally grown crops will facilitate local production and reduce ingredient as well as transport costs, so more patients can receive lifesaving treatment.

Different enteral nutrition formulas have no effect on glucose homeostasis but on diet-induced thermogenesis in critically ill medical patients: a randomized controlled trial.

BACKGROUND/OBJECTIVES: Hyperglycemia is common in critically ill patients and associated with increased mortality. It has been suggested that different nutrition formulas may beneficially influence glucose levels in surgical intensive care patients. In this prospective randomized clinical cohort study we investigated glucose homeostasis in response to different enteral nutrition formulas in medical critically ill patients. SUBJECTS/METHODS: 60 medical critically ill patients were randomized to receive continuous fat-based (group A, n = 30) or glucose-based enteral nutrition (group B, n = 30) for seven days. Indirect calorimetry was performed to determine energy demand at baseline and on days 3 and 7. Glucose levels and area under the curve (AUC), insulin demand, glucose variability, and calorie and substrate intake per 24 h were assessed for 7 days. RESULTS: Over the course of 7 days patients had similar average daily glucose (p = 0.655), glucose AUC (A: 758 (641-829) mg/dl/day vs B: 780 (733-845) mg/dl/day, p = 0.283), similar overall insulin demand (A: 153.5 (45.3-281.5) IE vs B: 167.9 (82.3-283.8) IE, p = 0.525), and received similar amounts of enteral nutrition per 24 h. Resting energy expenditure was similar at baseline (A: 1556 (1227-1808) kcal/day vs B: 1563 (1306-1789) kcal/day, p = 0.882) but energy expenditure increased substantially over time in group A (p < 0.0001), but not in group B (p = 0.097). CONCLUSION: Fat-based and glucose-based EN influence glucose homeostasis and insulin demand similarly, yet diet-induced thermogenesis was substantially higher in critically ill patients receiving fat-based enteral nutrition.

Therapeutic efficacy of an elemental diet for patients with crohn's disease and its association with amino acid metabolism.

BACKGROUND/AIM: We investigated the association between blood amino acid concentration changes caused by elemental diet (ED) and their relationship to its therapeutic effect. PATIENTS AND METHODS: Patients with active Crohn's disease (CD) followed ED for 12 weeks. Patients not previously treated with ED were defined as new ED, and those with previous ED therapy (≥900 kcal/day) were defined as previous ED. Disease activity markers [Crohn's disease activity index (CDAI) and C-reactive protein (CRP) level], blood biochemistry test results, and plasma amino acid concentrations were measured before and after the treatment. RESULTS: Histidine (His), tryptophan (Trp), valine (Val), and methionine (Met) increased after the treatment in the 17 patients with clinical remission, however, no increase occurred in plasma amino acid concentrations in the 8 patients without remission. The multivariate index using AminoIndex™technology (MIAI) was correlated with the CDAI (r = 0.475,P < 0.001), and it decreased as patients' conditions improved during the treatment. All patients in the new ED group (n = 11) exhibited increases in the nutritional indices, albumin level, and body mass index after treatment, as well as increased levels of His, Trp, Val, and phenylalanine. None of these changes were observed in the previous ED group (n = 14). CONCLUSIONS: Plasma amino acid concentrations and MIAI may provide useful noninvasive markers for evaluating disease activity and response to treatment. ED was effective in improving disease activity, nutritional status, and plasma amino acid levels, and thus it may be particularly effective for poorly nourished patients with CD who have not previously undergone this treatment.

Influencia de la composición nutricional de distintas fórmulas de nutrición enteral ricas en fibra en el tiempo de administración de nutrición por gravedad y riesgo de obturación / Influence of the nutritional composition of different fiberenriched enteral nutrition formulas on the administration time by gravity and the risk of tube feeding obstruction

Introducción: la administración de nutrición enteral por gravedad es un método de administración muy útil en la práctica clínica, pero a la vez muy poco preciso y que presenta unas limitaciones importantes, como la dificultad a la hora de establecer una velocidad de goteo precisa y la probabilidad de enlentecimiento del goteo según la fórmula administrada. Objetivos: evaluar el tiempo de paso de caída libre y el riesgo de obturación de cinco fórmulas de nutrición enteral ricas en fibra con diferente concentración proteica y densidad calórica, administradas por gravedad a través de sondas nasogástricas (SNG) de diferentes calibres. Valorar la influencia de la composición en la velocidad de paso por gravedad de las fórmulas estudiadas. Métodos: se compararon cinco fórmulas de NE ricas en fibra de distintos tipos y se utilizaron SNG con un calibre de 8, 10 y 12 Fr. La fluidez de las fórmulas de NE por gravedad se estimó cronometrando el tiempo de paso de cada fórmula a máxima velocidad y se calculó el tiempo medio de caída libre (TMCL), registrándose las posibles obturaciones. Posteriormente se realizó una simulación in vitro de la administración de 1.500 ml de cada una de las fórmulas a una velocidad determinada para que el producto pasara en cinco horas. Se registró el enlentecimiento y la detención del paso como indicadores de riesgo de obturación. Resultados: los dos productos que con diferencia presentaron un mayor TMCL fueron los productos de mayor concentración energética. El tiempo de paso en caída libre de estos dos productos a través de la sonda de 8 Fr superó las cuatro horas. Para el resto de los productos y SNG utilizadas el tiempo fue inferior a dos horas y cinco minutos. No se detectó enlentecimiento del paso ni obturación de la sonda en ningún caso cuando se determinó el tiempo de caída libre a máxima velocidad. Cuando se ajustó la velocidad para que el producto pasara en cinco horas, en tres de los productos estudiados (los de menor concentración calórica y viscosidad) se observó enlentecimiento del goteo y, en algunos casos, el goteo se detuvo totalmente. El factor que se relacionó de forma más importante con el TMCL fue el contenido en lípidos, seguido de la viscosidad, la concentración calórica y el contenido en proteínas. El TMCL no se relacionó significativamente con la presencia de fibra en la mezcla nutricional. Conclusiones: todos los productos estudiados pueden administrarse por gravedad a través de sondas nasogástricas en caída libre sin riesgo de obturación, aunque el tiempo de caída libre es muy variable. El menor calibre de las sondas, la mayor concentración calórica y la viscosidad de la mezcla de nutrición enteral son factores limitantes cuando administramos por gravedad fórmulas ricas en fibra (AU)

Introduction: the administration of enteral nutrition by gravity is a very useful method in clinical practice; nevertheless, it may not be very precise. Indeed, this method presents some important limitations, such as the difficulty in establishing a precise dripping rate and the possibility for the dripping rate decrease depending on the formula. Objectives: assess the administration time and the risk of clogging of 5 fiber-enriched enteral nutrition formulas with different protein concentrations and caloric density, all administered by gravity through nasogastric (NG) tubes of different sizes. Assess the influence of the composition on the dripping rate, by gravity, of the tested formulas. Methods: 5 fiber-enriched EN formulas were compared by using nasogastric tubes of the calibers 8, 10 and 12 Fr. The fluidity of these gravity-administered NE formulas was estimated by timing the complete passage of each formula at full speed, thus allowing one to calculate the mean time of free fall (MTFF) and to register any possible obstruction. Subsequently, an in vitro simulation of a 1500 ml administration was performed for each formula at a particular speed, so that the administration time was 5 hours. Slowing flow and stagnated flow were detected as indicators of the risk of obstruction. Results: the two products that especially differed in MTFF were the ones with the highest energy concentration. The passage time in free fall of these two products through the 8 Fr tube exceeded four hours. For the rest of the products and NG tubes used, this time was less than 2 hours and 5 minutes. No slowing flow or tube obstruction was detected in free fall and at maximum speed. When the dripping was adjusted to be administered in 5 hours, three of the studied products (those with the least caloric concentration and viscosity) showed slowing flow and, in some cases, the dripping stopped completely. The most important factor associated to the MTFF was the lipid content, followed by viscosity, energy and protein content. The MTFF measured was not significantly related to the fiber content of the nutritional formula. Conclusions: all studied products can be administered by gravity via nasogastric tubes in free fall without any risk of obstruction, even though the free fall time was very variable. The lowest caliber tubes, the highest energy content and the viscosity of the EN mixture turn-out to be the limiting factors when fiber-enriched formulas are to be administered by gravity (AU)

Qualidade nutricional e microbiológica de dietas enterais artesanais padronizadas preparadas nas residências de pacientes em terapia nutricional domiciliar / Nutritional and microbiological quality of standardized homemade enteral diets for patients in home nutritional therapy

OBJETIVO: Avaliar as propriedades físico-químicas, microbiológicas e nutricionais de dietas enterais artesanais padronizadas preparadas nos domicílios de pacientes em terapia nutricional domiciliar. MÉTODOS: Foram desenvolvidas duas formulações de dietas enterais (F1=1,2kcal/mL e F2=1,5kcal/mL), elaboradas com maltodextrina (155/155g), concentrado proteico de soro de leite (30/15g) e óleos vegetais (30/60g) dissolvidos em água (q.s.p.1000mL). Os cuidadores receberam os ingredientes e as medidas padrão e foram orientados quanto ao preparo e às boas práticas de manipulação. O estudo teve duração de quatro meses, e amostras das dietas preparadas nos domicílios de 33 pacientes foram coletadas e analisadas no início e no final deste período. As amostras foram avaliadas quanto à sua adequação percentual em relação aos valores prescritos de macronutrientes e energia, bem como aos padrões microbiológicos estabelecidos pela legislação vigente. RESULTADOS: As dietas formuladas (Formulação 1/Formulação 2) apresentaram os seguintes teores de macronutrientes, energia e osmolalidade: água - 73,5/70,0%; proteína - 4,4/6,0%; lipídeo - 4,3/6,6%; carboidrato - 16,9/16,4%; energia - 120/150kcal/100mL; osmolalidade - 440/450mOsm/kg.H2O. As variações nas adequações percentuais das amostras domiciliares foram menores que 20,0% tanto na primeira quanto na última amostragem. As proporções de amostras em desacordo com os padrões legais foram significantemente menores nas amostras finais, 24,0% e 36,0% para bactérias mesófilas e coliformes, respectivamente. CONCLUSÃO: O preparo das dietas nos domicílios apresentou boa reprodutibilidade; no entanto, a qualidade microbiológica ainda permanece uma questão preocupante, exigindo uma atuação cuidadosa do profissional de saúde nos domicílios.

OBJECTIVE: This study assessed the physical, chemical, microbiological and nutritional properties of standardized enteral diets prepared at the homes of patients receiving nutritional therapy. METHODS: Two enteral diet formulations were developed (F1=1.2kcal/mL and F2=1.5kcal/mL) containing maltodextrin (155/155g), whey protein concentrate (30/15g) and vegetable oils (30/60g) dissolved in water (q.s.p.1000mL). The ingredients and measuring devices were given to the caregivers, along with preparation instructions and advice on good handling practices. The study lasted four months and the diets prepared at the homes of 33 patients were collected at baseline and endline for analysis. The samples were analyzed to determine the compliance of their macronutrient and energy contents with the prescription and their microbiological contents with the legislation. RESULTS: The study diets (Formulation 1/Formulation 2) contained the following macronutrient and energy contents and osmolality: water - 73.5/70.0%; protein - 4.4/6.0%; lipids - 4.3/6.6%; carbohydrate - 16.9/16.4%; energy - 120/150kcal/100mL; osmolality - 440/450mOsm/kg.H2O. The percent adequacy of the homemade diets did not vary by more than 20.0% at baseline or end of study. The percentages of samples that did not meet the legal standards were significantly lower at the end of the study: 24.0% and 36.0% for mesophilic bacteria and coliforms, respectively. CONCLUSION: Homemade diets presented good reproducibility but their microbiological quality remains a matter of concern, indicating that health professionals must be careful when working at home.

Dietary management of childhood diarrhea in low- and middle-income countries: a systematic review.

BACKGROUND: Current WHO guidelines on the management and treatment of diarrhea in children strongly recommend continued feeding alongside the administration of oral rehydration solution and zinc therapy, but there remains some debate regarding the optimal diet or dietary ingredients for feeding children with diarrhea. METHODS: We conducted a systematic search for all published randomized controlled trials evaluating food-based interventions among children under five years old with diarrhea in low- and middle-income countries. We classified 29 eligible studies into one or more comparisons: reduced versus regular lactose liquid feeds, lactose-free versus lactose-containing liquid feeds, lactose-free liquid feeds versus lactose-containing mixed diets, and commercial/specialized ingredients versus home-available ingredients. We used all available outcome data to conduct random-effects meta-analyses to estimate the average effect of each intervention on diarrhea duration, stool output, weight gain and treatment failure risk for studies on acute and persistent diarrhea separately. RESULTS: Evidence of low-to-moderate quality suggests that among children with acute diarrhea, diluting or fermenting lactose-containing liquid feeds does not affect any outcome when compared with an ordinary lactose-containing liquid feeds. In contrast, moderate quality evidence suggests that lactose-free liquid feeds reduce duration and the risk of treatment failure compared to lactose-containing liquid feeds in acute diarrhea. Only limited evidence of low quality was available to assess either of these two approaches in persistent diarrhea, or to assess lactose-free liquid feeds compared to lactose-containing mixed diets in either acute or persistent diarrhea. For commercially prepared or specialized ingredients compared to home-available ingredients, we found low-to-moderate quality evidence of no effect on any outcome in either acute or persistent diarrhea, though when we restricted these analyses to studies where both intervention and control diets were lactose-free, weight gain in children with acute diarrhea was shown to be greater among those fed with a home-available diet. CONCLUSIONS: Among children in low- and middle-income countries, where the dual burden of diarrhea and malnutrition is greatest and where access to proprietary formulas and specialized ingredients is limited, the use of locally available age-appropriate foods should be promoted for the majority of acute diarrhea cases. Lactose intolerance is an important complication in some cases, but even among those children for whom lactose avoidance may be necessary, nutritionally complete diets comprised of locally available ingredients can be used at least as effectively as commercial preparations or specialized ingredients. These same conclusions may also apply to the dietary management of children with persistent diarrhea, but the evidence remains limited.

Potential value of nutrigenomics in Crohn's disease.

Crohn's disease is a chronic relapsing condition that has no certain cure. Both genetic susceptibility and nutrition have key roles, but their level of involvement varies between patients. Interacting gene pathways influence the probability of disease development, but these are affected by stress and various environmental factors, including diet. In addition, the role of the gut microbiome must not be underestimated, as it is substantially altered in patients with Crohn's disease. Although an elemental diet might lead to disease remission, reintroducing real foods and sustainable diets in patients with Crohn's disease is currently difficult, and would benefit from the sensitivity and rapid feedback provided by the field of nutrigenomics. Nutrigenomics utilizes high-throughput genomics technologies to reveal changes in gene and protein expression that are modulated by the patient's nutrition. The most widely used technique thus far is transcriptomics, which permits measurement of changes in the expression of thousands of genes simultaneously in one sample. Given the volume of numbers generated in such studies, data-basing and bioinformatics are essential to ensure the correct application of nutrigenomics at the population level. These methods have been successfully applied to animal models of Crohn's disease, and the time is right to move them to human studies.

Replacement of meat by meat substitutes. A survey on person- and product-related factors in consumer acceptance.

What does it take to increase the consumption of meat substitutes and attract new consumers? We identified main barriers and drivers by a consumer survey (n=553) in the U.K. and the Netherlands. Person-related factors (food neophobia and food choice motives) and product-related attitudes and beliefs towards meat and meat substitutes were compared between non-users (n=324), light/medium-users (n=133) and heavy-users of meat substitutes (n=96). Consumer acceptance was largely determined by the attitudes and beliefs towards meat substitutes and food neophobia. Key barriers for non-users and light/medium-users were the unfamiliarity with meat substitutes and the lower sensory attractiveness compared to meat. In addition, non-users had a higher tendency to avoid new foods. Hence, the less consumers were using meat substitutes, the more they wanted these products to be similar to meat. Although non-users and light/medium-users did recognize the ethical and weight-control aspects of meat substitutes, this was obviously less relevant to them. Actually, only heavy-users had high motivations to choose ethical foods, which explains their choice for meat substitutes. In order to make meat substitutes more attractive to meat consumers, we would not recommend to focus on communication of ethical arguments, but to significantly improve the sensory quality and resemblance to meat.

BH(4) therapy impacts the nutrition status and intake in children with phenylketonuria: 2-year follow-up.

The impact of tetrahydrobiopterin (BH(4)) treatment on phenylalanine tolerance, medical-food consumption, and nutrition status in patients with phenylketonuria (PKU) was investigated. Six children (5-12 years) with well-controlled PKU, responding to a BH(4) dose of 20 mg/kg per day, were assessed for 24 months. Mean dietary phenylalanine tolerance increased from 421 ± 128 to 1470 ± 455 mg/day. Height Z scores significantly improved from 0.25 ± 0.99 at baseline to 0.53 ± 1.16 at 24 months (p for trend < 0.001). Patients tolerated more phenylalanine and more intact protein and required less medical food (protein supplement). Improved linear growth and nutrition status was seen over the course of the 24-month follow-up. Due to the variation in phenylalanine tolerance, dietary recommendations should be tailored to the patient's individual requirements.

The reality of dietary compliance in the management of phenylketonuria.

In phenylketonuria (PKU), it is common for blood phenylalanine (Phe) concentrations to be outside optimal target ranges, particularly in teenagers and adults, indicating inadequate compliance. It is well known that significant noncompliance exists, and the situation in PKU would appear no different than other chronic conditions. In PKU, compliance is complex, being subject to diverse definitions, and factors influencing compliance include the nature and nurture of the patient, as well as the inconvenience, cost and availability of dietary treatment. It is also a dynamic process, with many patients changing between a state of compliance and partial and noncompliance. In PKU, compliance has received little rigorous study, and there have been few observational reports identifying barriers and behaviors impacting dietary compliance. Compliance assessment measures remain inadequately defined. The direct assessment of blood Phe concentration is perhaps the best overall measure, but there is no universal agreement about the number of Phe concentrations that should be within target range and frequency or timing of measurement. Although no one strategy for improving compliance is universally effective, and an individualized approach to noncompliance is essential, it is important to have clear evidence about the most effective strategies in achieving long-term dietary adherence in PKU.

Effectiveness of nonpharmacologic treatment for migraine in young children.

OBJECTIVE: To evaluate the effectiveness of nonpharmacologic treatment for migraine in children younger than age 6 years. BACKGROUND: The mean age of onset of migraine in children is 7.2 years for boys and 10.9 years for girls. Treatment consists of individually tailored pharmacologic and nonpharmacologic interventions. However, data on migraine management in preschoolers are very sparse. METHODS: Demographic, clinical, and outcome data were collected from the files of patients with migraine who attended a pediatric headache clinic. Only those treated by nonpharmacologic measures, namely, good sleep hygiene, diet free of food additives, and limited sun exposure, were included. Clinical factors and response to treatment were compared between children younger than 6 years and older children. RESULTS: Of the 92 children identified, 32 were younger than 6 years and 60 were older. There was no difference between the age groups in most of the demographic and clinical parameters. The younger group was characterized by a significantly lower frequency of migraine attacks and shorter disease duration (in months). Mean age of the patients with no response to treatment (grade 1) was 10.588 +/- 3.254 years; partial response (grade 2), 9.11 +/- 4.6 years; and complete response (grade 3), 8.11 +/- 3.93 years (P = .02). The percentage of patients with complete to partial response as opposed to no response was significantly higher in the younger group (P = .00075). CONCLUSION: As the primary option, conservative therapy for migraine appears to be more effective in children younger than 6 years than in older children, perhaps because of their shorter duration of disease until treatment and lower frequency of attacks.

Use of oral nutrition supplements in long-term care facilities.

PURPOSE: Practices related to oral nutrition supplement (ONS) use were examined in elderly people living in long-term care (LTC) facilities. METHODS: Thirteen LTC facilities within a large regional health authority participated, and 17 people responsible for prescribing ONS in their facilities were interviewed, using a key informant telephone survey. A survey on ONS practice was modified, pilot tested, and used. RESULTS: Oral nutrition supplements were primarily prescribed by nursing staff (59%), followed by physicians, registered dietitians, or other staff; ONS use was prescribed for decreased intake, unintentional weight loss, or wound healing. Various ONS products (e.g., Ensure, Boost, or Resource 2.0) were prescribed. Only 18% of respondents reported using alternative food options first to supplement nutritional intake, before introducing ONS. In terms of follow-up and evaluation, the measures of improvement included weight gain, wound healing, or improved well-being; reasons for discontinuation included weight gain, increased intake, or death. CONCLUSIONS: Within LTC settings, the prescription and monitoring of ONS vary considerably. Evidence-based guidelines for the prescription and monitoring of ONS and for the use of a food-first strategy should be developed, implemented, and evaluated to optimize the nutritional health of the elderly in LTC facilities.