Pancreatic Enzyme Replacement Therapy in CF Patients

Cystic fibrosis is the most common fatal genetic disorder in North America. CF affects the epithelial transport in exocrine tissues. The disorder produces thick, sticky mucus secretions that may seriously impair the function of various organ systems. The organ systems that are affected include the respiratory tract, the gastrointestinal tract, the liver, the genitourinary system, and the sweat glands.

CF has three major consequences: chronic lung disease, pancreatic insufficiency, and abnormally high electrolyte concentrations in the sweat.

Cystic fibrosis causes pancreatic insufficiency in most cases, causing 85-90% of serious cases to require pancreatic enzyme replacement therapy (PERT). With age, damage to the pancreas becomes worse. The thick mucus obstructs the small pancreatic ducts and interferes with the secretion of digestive enzymes, pancreatic juices, and pancreatic hormones. Eventually, the pancreatic cells are surrounded by mucus and are gradually replaced by fibrous tissues. Malabsorption of many nutrients including fat, protein, vitamins, and minerals often leads to malnutrition. Additionally, the secretion of insulin may be affected resulting in glucose intolerance and diabetes.

With high energy needs, fat restrictions are inappropriate. Instead, pancreatic enzyme replacements are used to control Steatorrhea, relieve abdominal pain, and reduce the mass and frequency of stools passed. To improve the effectiveness of the enzyme replacements, H2-blockers are often provided as well. Even with enzyme replacements, from 10-20% of food energy is lost in the stools.

Pancreatic insufficiency has a strong influence on nutrition status and is a predictor of long-term outcome. The thickened secretions obstruct the pancreatic ducts and prevent the secretions of lipase, amylase, proteases, and bicarbonate. When pancreatic insufficiency is present, individuals are treated with pancreatic enzyme extracts. All enzyme products contain the various enzymes synthesized by the pancreas, including amylase, proteases and lipase in varying amounts. Commercial enzyme products vary in lipase activity from 4,000-25,000 U lipase/capsule. They are available in powder form as tablets that are acid labile or as enteric-coated microspheres- the enteric coating is designed to protect the enzyme from destruction by the acidic environment of the stomach.

Pancreatic enzymes are always taken when food or beverages are consumed. The dosage for enzymes in individualized based on the patient’s diet, nutritional status, degree of pancreatic insufficiency, intestinal pH, and GI anatomy and physiology. Because of inconsistencies in enzyme formulations, the Food and Drug Administration (FDA) has issued a rule requiring manufacturers of pancreatic enzyme supplements to obtain approval for their products. Prior to obtaining approval, manufacturers will need to test the enzymes in clinical trials and demonstrate that they are safe and effective. This rule means that the FDA now requires pancreatic enzymes to meet the same standards of testing as any other new drug.

CFF

Cystic-Fibrosis-World

Food Allergies in Foodservice Rotations

While being in my Institutional Food Service, Production, and Management rotation this summer, a common concern from management has come to my attention. And this concern would be…  Food Allergies!

A food allergy is the body’s immune system reaction to certain foods. Symptoms of an allergic reaction include itching or swelling in or around the mouth, face, and scalp; tightening in the throat; wheezing or shortness of breath; hives; abdominal cramps, vomiting, diarrhea; loss of consciousness; and even death.

Food allergies are a growing public health concern. As many as 15 million people in the U.S. have food allergies. An estimated 9 million, or 4%, of adults have food allergies. Nearly 6 million, or 8%, of children have food allergies with young children affected the most. Although children allergies to milk, egg, wheat, and soy generally resolve in childhood, they appear to be resolving more slowly than in previous decades, with many children still allergic beyond age 5 years. Allergies to peanuts, tree nuts, fish, or shellfish are generally lifelong allergies.

The top food allergens are categorized into eight food groups. These eight food groups account for 90% of all food-allergic reactions. They include: milk, eggs, peanuts, tree nuts, fish, shellfish, soy, and wheat. The estimated prevalence among the American population is:

          Milk and eggs: based on data within and obtained outside the United States, this rate is likely to be 1-2% for young children and 0.2-0.4% in the general population.

          Peanut: 0.6-1.3%

          Tree nuts (e.g., walnuts, almonds, cashews, pistachios, pecans): 0.4%-0.6%

          Fish: 0.4%

          Crustacean shellfish (e.g., crab, lobster, shrimp): 1.2%

          All seafood: 0.6% in children and 2.8% in adults

The Centers for Disease Control and Prevention reported that food allergies result in more than 300,000 ambulatory-care visits a year among children under the age of 18 years. From 2004 to 2006, there were approximately 9,500 hospital discharges per year with a diagnosis related to food allergy among children under age 18 years. Even small amounts of a food allergen can cause a reaction. Most allergic reactions to foods occurred to foods that were thought to be safe. Allergic reactions can be attributed to a form of mislabeling or cross-contact during food preparation. Food allergy is the leading cause of anaphylaxis outside the hospital setting. Every 3 minutes a food allergy reaction sends someone to the emergency department. This is approximately 200,000 emergency department visits per year, and every 6 minutes the reaction is one of anaphylaxis. Teenagers and young adults with food allergies are at the highest risk of fatal food-induced anaphylaxis. Symptoms of anaphylaxis may recur after initially subsisting and experts recommend an observation period of about 4 hours to monitor that the reaction has been resolved. Individuals with food allergies who also have asthma may be at an increased risk for severe or fatal food allergic reactions. Children with food allergy are 3-4 times more likely to have other related conditions such as asthma and other allergies, compared without food allergies. It is possible to have anaphylaxis without any skin symptoms (no rash or hives). Failure to promptly (i.e., within minutes) treat food anaphylaxis with epinephrine is a risk factor for fatalities.

Chemical contamination can occur when high-acid foods are prepared or stored in metal-lined containers. Poisoning may result if brass or copper, galvanized, or gray enamelware containers are used. Fruit juices should never be stored in gray enamelware with lead glaze or tin milk cans. Cases of poisoning have been recorded that have been attributed to use of improper metal utensils. Sauerkraut, tomatoes, fruit gelatins, lemonade, and fruit punches have been implicated in metal poisonings.

Toxin metals also have been implicated in food poisoning cases. Copper may become poisonous when it is in prolonged contact with acid foods or carbonated beverages. The vending industry voluntarily discontinued all point-of-sale carbonation systems that do not completely guard against the possibility of backflow into copper water lines. Also, food such as meat placed directly on cadmium-plated refrigerator shelves may be rendered poisonous.

Mayo Clinic

NIH

FARE

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Preventing Foodborne Illnesses this Summer

Preventing Foodborne Illnesses this Summer

With the beginning of summer, many people think they can just keep their picnic food safe from bacteria by storing it in the refrigerator. But, there is one bacteria- that is exempt from that rule…

Unlike most food bacteria, Listeria can grow in cool temperatures. Refrigerating food already contaminated with these bacteria could allow the germs to multiply and spread, according to the USDA.

The bacteria can cause serious illness known as listeriosis, which is especially dangerous for children, older people, pregnant women, and those with compromised immune systems. Foods in which Listeria has been found include deli meats, hot dogs, smoked seafood and store-prepared salads. The FDA advises those at greater risk for developing listeriosis to reheat these ready-to-eat foods until they are steaming hot. They should also avoid unpasteurized milk and soft cheeses.

Listeriosis has also been linked to contaminated cantaloupes. The FDA recommended washing all fruits and vegetables under running water immediately before eating, cutting or cooking them. Firm produce, in particular, should be scrubbed with a produce brush. Examples like this, is specifically important in the summer when fruits are in season.

Other ways to prevent Listeria infection include:

          Set your refrigerator temperature to 40 degrees F or lower to slow the growth of Listeria. Use a refrigerator and freezer thermometer to make sure temperatures are appropriately cold.

          Wrap or cover food before placing it in the refrigerator. Be sure no containers or covers are leaking juices on other foods.

          Do not allow cooked or ready-to-eat (RTE) foods to sit in the refrigerator. Eat these foods right away so Listeria doesn’t have the opportunity to grow. If you have leftovers in your refrigerator, it’s best to throw them out after 3 days, just to be sure. Because remember, it’s always better to be safe than sorry!

          Clean up refrigerator spills immediately. The FDA notes leaks or spills from hot dog packages, raw meat or poultry are mostly of concern. The agency advised cleaning these spills with paper towels to avoid spreading germs to a cloth towel.

          Routinely disinfect the refrigerator. Cleaning the inside walls and shelves of the refrigerator with warm water and soap. Surface cleaners can also be used monthly.

          Sanitize kitchen surfaces where food is prepared with soap and water and surface cleaner.

          Wash cutting boards after every use. Nonporous acrylic, plastic, or glass boards can be sanitized in the dishwasher.

          Wash dish cloths, towels and cloth grocery bags in the hot cycle of the washing machine.

          Before and after handling food, wash your hands with warm water and soap for at least 20 seconds! And if you can’t remember how long- just sing the “Happy Birthday” song. This is a trick we educate children on for food safety and hand washing!

Center for Disease Control and Prevention 

Listeria_Colorado State University

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CDC statistics from 2011

CDC statistics from 2011

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Salmonella in Cucumber Outbreak!

Imported Cucumber Outbreak

According to the Center of Disease Control and Prevention (CDC), over 70 people in America have become sick because of a salmonella outbreak connected to imported Mexican cucumbers. The CDC reported that 14 people have been hospitalized and are trying to identify other people who could have been infected.

The source of the outbreak is thought to be Mexican supplier Daniel Cardenas Izabal and Miracle Greenhouse of Culiacan, Mexico. The cucumbers were distributed by Tricar Sales Inc. of Rio Rico, Ariz., the CDC said.

The Food and Drug Administration (FDA) has stopped the imports by Cardenas Izabal and Miracle Greenhouse unless they can prove that their cucumbers are not contaminated with salmonella. As of this point, California has reported the highest number of people who have fallen sick- 28. Among these people, the majority of them became sick between January 12th and April 6th. The outbreak reportedly reached its peak in early March but, the contaminated cucumbers have been pulled from shelves and are no longer on the market. But, the number of ill-stricken people could still rise. Due to the time it takes between when a person becomes ill and when the illness is reported, more sick people could come forward.

Most persons infected with Salmonella bacteria develop diarrhea, fever, and abdominal cramps 12 to 72 hours after infection. For example, the illness usually lasts 4 to 7 days, and most people recover without treatment. In some cases, the diarrhea may be so severe that the patient needs to be hospitalized- due to dehydration. Salmonella infection may spread from the intestines to the bloodstream and then to other body sites and can cause death unless the person is treated promptly with antibiotics. Children younger than 5 years, older adults, and persons with compromised immune systems are more likely than others to develop severe illnesses Salmonella.

Consumers should always follow safe produce handling recommendations like:

          Wash

o   Wash hands with soap and warm water before and after handling/preparing produce

          Prepare

o   Wash all produce thoroughly under running water before eating, cutting or cooking.

          Store

o       Refrigerate cut, peeled, or cooked produce as soon as possible, or within 2 hours.

o       Store produce away from raw meat, poultry, and seafood.

La Times

CDC

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Dear Sequester, Thank You For the Food-Borne Illness

Dear Sequester, Thank You For the Food-Borne Illness

Due to the recent government sequester that went into effect on March 1st, 2013, the Food and Drug Administration (FDA) will administer fewer number of food safety inspections throughout the country. While American consumers may not feel the impact immediately, the loss of $209 million from its budget will force the FDA to conduct about 2,100 less inspections. This reduction in food inspections account for an 18% decline compared to last year. The funding loss will also delay the agency’s implementation of the 2011 Food Safety Modernization Act.

Not only are food-borne illnesses (FBI) of concern but, the approval of new drugs are as well. All of the programs within the FDA are at risk for being compromised because of the huge cuts that are taking place. The Sequester is becoming a really big hit and I think that more and more people will start to experience that, and in turn realize its significance.  The FDA does plan to prioritize programs that have the greatest effect on the public’s health, including disease outbreaks.

These next statistics are so ridiculous to me…. According to the Center for Disease Control and Prevention (CDC), 1 in 6 Americans, which equals 48 million people, develop a FBI each year. Out of these people, 3,000 people die and 128,000 are hospitalized. The FDA is already facing serious criticism, not to mention legal actions, for being slow to implement the food safety law. This law is geared towards refocusing the FDA’s efforts on prevention, instead of responding to crises. Since the law was signed into effect in 2011, it sat for 2 years with the White House Office of Management and Budget where it was rewritten in ways that weakened FDA’s oversight.  The FDA claims that they’re frustrated with this situation, as is the rest of the country.  The more time that goes by without this law going into effect, the more people that are at-risk of getting seriously sick.

But, I don’t believe that the FDA is as innocent as they might be leading on. Even before the Sequester, the FDA was able to inspect less than 2% of all food imports.

The FDA also addressed other key issues like:

        Plan B being sold over-the-counter to anyone, regardless of age.

        Drug shortages

        Outbreaks of fungal meningitis within pharmacies  

USA Today

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The Dirty Dozen

Dirty Dozen

There has, and probably always will be, a debate as to whether consumers should purchase organic versus traditionally grown food sources. And I really didn’t think too much about the topic until I took an Agricultural Values and Ethics class my last year as an undergraduate, as a capstone requirement. Ever since then, I really have become aware of how information can really change how a consumer shops for groceries for their family.

This being said… I came across a term, “The Dirty Dozen”, in several articles about organic food versus traditionally grown food.

Every year, the Environmental Working Group releases a Shopper’s Guide. The guide has information on 45 different conventional fruits and vegetables and their pesticide loads. At the top of the list- the produce found to contain the highest amount of pesticides: is the Dirty Dozen. These are the 12 foods that they recommend consumers always purchase in their organic form. This Shopper’s Guide is based on the EWG’s analysis of pesticide residue testing data from the USDA and the FDA.

Then, on the bottom of the list, are the Clean Fifteen. These are 15 foods that have the lowest pesticide residue. If you’re on a limited budget and have to pick and choose your organic produce, the EWG encourages that you spend the extra money for the Dirty Dozen in their organic form and buy the Clean Fifteen in their conventional form.

Now that I’ve provided the education and substantial background on these organic-friendly foods, don’t get confused as to why I chose not to mention anything based on my opinion in this post. I personally, have different views about organic versus tradition foods. And again, I personally, will go out of my way to avoid purchasing organic foods. But, I’m not here to convince anyone to agree or disagree with my opinions. I’m here to provide nutritionally beneficial education to the public. And I hope I’m achieving this goal more and more as my ISPP Dietetic Internship, and future career as a Registered Dietitian, continue.

St. Louis Fox News

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dd 2011

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