Some useful links

There is plenty of basic information on dietary therapy throughout the Internet. If you are interested in the latest medical findings you should consult the global database PUBMED of the medical publications. Below are examples of IBS-related studies:

Tolerability of FODMAP - reduced diet in irritable bowel syndrome - efficacy, adherence, and body weight course.

 FODMAP reduced diet (fermentable oligo-, di-, monosaccharide, and polyols) belongs to the established therapy strategies in irritable bowel syndrome (IBS). However, disadvantages of this diet are significant and may lead to weight loss and insufficient patient adherence. Reports from Germany are not available yet.  In a prospective study, 93 patients with IBS according to Rom III were investigated. Sixty-three patients were recruited for the study and received standardized investigation, informed consent, and structured dietary instructions about the FODMAP reduced diet. Patients complaints were documented by a validated questionnaire and a standardized Lickert scale before and 8 weeks after the start of the diet. Stool characteristics were documented by the Bristol stool form scale.  Patients adherence was low because 30 patients stopped the diet. Of the remaining 33 patients, 36 % developed significant weight loss during the FODMAP therapy. Patients completing the study reported significant global improvement of symptoms in 79 % of cases. In addition, the severity of symptoms was significantly reduced. Fourteen patients developed changes of their stool characteristics according to the Bristol stool form scale, 11 of whom improved diarrhea and 3 improved constipation.  FODMAP reduced diet is an efficient therapy in IBS. However, adherence of the patients is poor and the therapy bears the risk of significant weight loss.  Die FODMAP-reduzierte Kost (fermentierbare Oligo-, Di-, Monosaccharide und Polyole) gehört zur etablierten Therapiestrategie beim Reizdarmsyndrom (IBS). Die Nachteile dieser Diät sind allerdings gravierend und können zum Gewichtsverlust und zur mangelnden Patientenadhärenz führen. Zahlen in Deutschland liegen allerdings hierüber nicht vor.  In einer prospektiven Studie wurden 93 Patienten mit IBS nach Rom-III-Kriterien untersucht. 63 Patienten konnten für die Studie rekrutiert werden. Es wurde eine standardisierte Untersuchung, Aufklärung und FODMAP-Ernährungsberatung mit schriftlichem Informationsmaterial durchgeführt. Die Beschwerden wurden anhand validierter Fragebögen und einer standardisierten Lickert-Skala vor und 8 Wochen nach Beginn der Ernährungstherapie erfasst. Die Stuhleigenschaften wurden anhand der Bristol-stool-form-Skala dokumentiert.  Die Patientenadhärenz war gering, da 30 Patienten die Therapie frühzeitig beendeten. Von den 33 verbliebenen Patienten entwickelten 36 % einen signifikanten Gewichtsverlust unter FODMAP-Diät. Die Patienten gaben in 79 % eine signifikante globale Besserung ihrer Beschwerden an. Ebenfalls war die Schwere der Symptome signifikant reduziert. 14 Patienten entwickelten eine Veränderung ihres Stuhlverhaltens mit einer Verbesserung der durchfälligen Stühle bei 11 Patienten und der Verstopfung in 3 Fällen.  Die FODMAP-reduzierte Kost ist eine effektive Therapie bei IBS. Allerdings ist die Patientenadhärenz gering und die Therapie kann einen signifikanten Gewichtsverlust erzeugen.

Dietary intervention for canine epilepsy: Two case reports.

Epilepsy is a common neurologic disorder in humans and domesticated canines. In both species the etiology is diverse and complex, and even with medication a significant portion of the population does not experience sufficient seizure control and/or has unacceptable side effects. Humans often try alternatives such as dietary therapy or brain surgery, but in dogs, brain surgery is rarely an option and, despite potential benefits, there are no standard recommendations for a dietary approach. Herein we describe 2 retrospective case studies detailing the effects of homemade diets prepared for dogs with uncontrolled epileptic seizures and/or toxic side effects of medication. Basic recipes are provided for each formula-a high-fat "ketogenic" diet and a partial "whole food" diet. Carbohydrate content was reduced or controlled, and in one case this was proven to be essential for seizure control: ingesting carbohydrates would reverse the benefits of the diet and precipitate a seizure. Both dogs experienced fewer seizures and side effects when eating these modified diets compared to when they were administered antiepileptic drugs, including complete cessation of seizures for extended periods. Practical advantages and success of these homemade dietary interventions highlight the potential for diet-based metabolic therapy as a treatment option for seizures not only in humans but also in dogs.

KEYWORDS: dog, ketogenic diet, ketones, metabolic therapy, nutrition, seizures

Sea bass (Lateolabrax maculatus) accelerates wound healing: A transition from inflammation to proliferation.

Sea bass (Lateolabrax maculatus) has been used for dietary therapy practice for wound healing of puerperal or surgery patients in China. Traditional Chinese medicinal books also documented that sea bass can be used to manage inflammation-associated conditions such as wound, miscarriage and cough. Some studies also proved that dietary supplement with fish benefited for treating many inflammatory - associated conditions, such as cardiovascular disease, ulcerative colitis and hyperlipidemia. However, the studies on the pharmacological mechanisms of wound healing efficacy of sea bass remain lack of investigation. The aim of this study is to investigate the molecular mechanisms of sea bass on wound healing efficacy. Establishing a further justification for clinical application of aqueous extract of sea bass (ASB) in treating wound healing. Transition from inflammation to proliferation phase treated as the critical step in wound repair which were investigated via in vitro and in vivo study. A series of inflammatory mediators associated with wound healing and proliferation effects of fibroblasts upon treatments were studied via Western blotting, enzyme-linked immunosorbent assay (ELISA), real time reverse transcription-polymerase chain reaction (RT-PCR) and scratch assay. The cutaneous wound model was applied on skin wound healing study to observe the healing process in C57BL/6 mice upon ASB treatments. Hematological parameters and tumor necrosis factor-α (TNF-α) secretions in serum were determined. Histopathological examinations were conducted by hematoxylin and eosin (H&E) staining and Masson staining. Immunofluorescence were performed to identify infiltrating neutrophils (MPO) and α-Smooth muscle actin (α-SMA). Results showed that ASB significantly reduced the production of inflammatory mediators cyclooxygenase-2, nitrite oxide (NO) production and TNF-α. The phosphorylation and nuclear protein levels of transcription factor nuclear factor-κB (NF-ĸB) in toll-like receptor 4 signaling were decreased by ASB treatment as well. Wound closure rate and cyclin D1 expression level of fibroblasts were significantly increased by ASB treatments. Moreover, cutaneous wound model in C57BL/6 mice presented many similarities in appearance to the process of wound healing. The in vitro study demonstrated an inhibitory effect of ASB on the inflammatory mediators regulated by TLR4 signaling pathways, providing evidence that ASB treatment potentially accelerate the wound healing through migration and proliferation enhancement. Additionally, the in vivo study suggested that ASB treatment has a potential in accelerating the proliferation phase of wound healing via well-organized abundant collagen deposition, angiogenesis and re-epithelialization in wounds. The present findings can be treated as a pharmacological basis for the folk use of sea bass and further studies in biological and medical fields.

KEYWORDS: Angiogenesis, Inflammation, Proliferation, Sea bass, Wound healing

Glycemic control and complications in glycogen storage disease type I: Results from the Swiss registry.

Regular carbohydrate intake to avoid hypoglycemia is the mainstay of dietary treatment in glycogen storage disease type I (GSDI). The aim of this study was to evaluate the quality of dietary treatment and glycemic control in a cohort of GSDI patients, in relation to the presence of typical long-term complications. Data of 25 patients from the Swiss hepatic glycogen storage disease registry was analyzed cross-sectionally. Frequency and type of hypoglycemia symptoms were assessed prospectively using a structured questionnaire. Diagnostic continuous glucose monitoring (CGM) was performed as part of usual clinical care to assess glycemic control in 14 patients, usually once per year with a mean duration of 6.2 ± 1.1 consecutive days per patient per measurement. Although maintenance of euglycemia is the primary goal of dietary treatment, few patients performed capillary blood glucose measurements regularly. Symptoms possibly associated with hypoglycemia were present in 13 patients, but CGM revealed periods of low glucose in all patients, irrespective of the presence of symptoms. GSDIa patients with liver adenomas showed a higher frequency and area under the curve (AUC) of low blood glucose than patients without adenomas. Similarly, the presence of microalbuminuria was also associated with the frequency of low blood glucose. Z-Scores of bone density correlated negatively with lactate levels. The quality of glucose control is related to the presence of typical long-term complications in GSDI. Many patients experience episodes of asymptomatic low blood glucose. Regular assessment of glucose control is an essential element to evaluate the quality of treatment, and increasing the frequency of glucose self-monitoring remains an important goal of patient education and motivation. CGM devices may support patients to optimize dietary therapy in everyday life.

KEYWORDS: Adenoma, Bone, CGM, GSD, Glucose, Glycogen storage disease, Nephropathy

[Irritable Bowel Syndrome].

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder. Its diagnosis is based on symptoms, and the Rome IV criteria are recognized as the gold diagnostic standard. The Korean Society of Neurogastroenterology and Motility (KSNM) recently updated their clinical practice guidelines for the treatment of IBS, which were last issued in 2011. In this updated edition, the KSNM defines IBS as a chronic, recurrent symptom complex that includes abdominal pain or discomfort, changes in bowel habits, and bloating for at least 6 months, which is somewhat broader than the previous definition. Four major topics have been changed in the up-dated version in-line with the results of recent studies, that is, colonoscopy; a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; probiotics; and rifaximin. Herein, we review the 2017 revised edition of the KSNM with respect to recommended clinical practice guidelines for IBS and compare these with other guidelines.

KEYWORDS: Evidence-based practice, Irritable bowel syndrome, Practice guideline

Microbial Colonization at Early Life Promotes the Development of Diet-Induced CD8αβ Intraepithelial T Cells.

Intraepithelial lymphocytes (IELs) develop through the continuous interaction with intestinal antigens such as commensal microbiome and diet. However, their respective roles and mutual interactions in the development of IELs are largely unknown. Here, we showed that dietary antigens regulate the development of the majority of CD8αβ IELs in the small intestine and the absence of commensal microbiota particularly during the weaning period, delay the development of IELs. When we tested specific dietary components, such as wheat or combined corn, soybean and yeast, they were dependent on commensal bacteria for the timely development of diet-induced CD8αβ IELs. In addition, supplementation of intestinal antigens later in life was inefficient for the full induction of CD8αβ IELs. Overall, our findings suggest that early exposure to commensal bacteria is important for the proper development of dietary antigen-dependent immune repertoire in the gut.

Within- and Between-Subject Variation in Dietary Intake of Fermentable Oligo-, Di-, Monosaccharides, and Polyols Among Patients with Irritable Bowel Syndrome.

A diet low in fermentable carbohydrates, fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) is a promising treatment option for patients with irritable bowel syndrome (IBS). In order to correctly estimate and study the intake of FODMAPs, information about within- and between-subject variations in intakes is needed, but is currently lacking. The aim was to characterize the variation in FODMAP intake among patients with IBS and to calculate how many days of observations are required to capture absolute intakes as well as to rank individuals. Food intake was recorded during 4 consecutive days, and intakes of energy and FODMAPs were calculated. The coefficient of variation within subjects (CV w ), coefficient of variation between subjects (CV b ), number of days required to estimate an individual's intake, and number of observations required to correctly rank individuals into quartiles of consumption were calculated. Diet records were provided from 151 women and 46 men with IBS. The reported mean energy intake was 2039 ± 502 kcal among women and 2385 ± 573 kcal among men, and the median FODMAP intakes were 18.7 g and 22.8 g, respectively. The ratio of CV w /CV b for total FODMAP intake was 0.83 for women and 0.67 for men, and below 1 for all FODMAPs. To capture intake of FODMAPs at the individual level, 19 d of observations are required. Ranking individuals within a group would require 2-6 d of observations. There is more variation between subjects than within subjects regarding FODMAP intake. To correctly estimate an individual's absolute intake of FODMAPs, the number of days of diet records required exceeds what is reasonable for a participant to accomplish. However, ranking individuals into quartiles of FODMAP consumption can be achieved using a 4-d food record. This trial was registered at www.clinicaltrials.gov as NCT02107625 and NCT01252550.

KEYWORDS: FODMAP, dietary assessment, dietary intake, fermentable carbohydrates, irritable bowel syndrome, variation

Joint Hypermobility Syndrome Affects Response to a Low Fermentable Oligosaccharide, Disaccharide, Monosaccharide and Polyol Diet in Irritable Bowel Syndrome Patients: A Retrospective Study.

The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet causes significant clinical improvement in patients with irritable bowel syndrome (IBS). Joint hypermobility syndrome (JHS), defined as musculoskeletal symptoms in a hypermobile individual in the absence of systemic rheumatological disease, may be associated with functional gastrointestinal symptoms, including IBS. The aim of this study is to examine whether JHS can affect the response to the low FODMAP diet in patients with IBS. In this retrospective study, we included patients with IBS according to Rome III criteria who had followed a low FODMAP diet. Symptoms scores were measured before and after the low FODMAP diet. A total of 165 patients were included. Diarrhea predominant IBS (IBS-D) was present in 40.6% of our patients while JHS was present in 21.2%. The score for abdominal pain was higher for JHS compared to non-JHS prior to intervention. Symptoms improved in both groups of patients after a low FODMAP diet. The largest effects were shown with significant decreases of the average score and bloating. When broken down by JHS and IBS type, a low FODMAP diet significantly improved pain, bloating, diarrhea, constipation, and the average score with the largest effect in JHS/constipation predominant IBS (IBS-C), JHS/mixed IBS and unclassified IBS (IBS-M), JHS/IBS-D, non-JHS/IBS-C and JHS/IBS-M, respectively. Our study suggests that a low FODMAP diet has a greater effect on IBS symptoms in JHS than non-JHS patients.

KEYWORDS: Bloating, FODMAP, Irritable bowel syndrome, Joint hypermobility syndrome, Pain

Microbial Population Changes and Their Relationship with Human Health and Disease.

Specific microbial profiles and changes in intestinal microbiota have been widely demonstrated to be associated with the pathogenesis of a number of extra-intestinal (obesity and metabolic syndrome) and intestinal (inflammatory bowel disease) diseases as well as other metabolic disorders, such as non-alcoholic fatty liver disease and type 2 diabetes. Thus, maintaining a healthy gut ecosystem could aid in avoiding the early onset and development of these diseases. Furthermore, it is mandatory to evaluate the alterations in the microbiota associated with pathophysiological conditions and how to counteract them to restore intestinal homeostasis. This review highlights and critically discusses recent literature focused on identifying changes in and developing gut microbiota-targeted interventions (probiotics, prebiotics, diet, and fecal microbiota transplantation, among others) for the above-mentioned pathologies. We also discuss future directions and promising approaches to counteract unhealthy alterations in the gut microbiota. Altogether, we conclude that research in this field is currently in its infancy, which may be due to the large number of factors that can elicit such alterations, the variety of related pathologies, and the heterogeneity of the population involved. Further research on the effects of probiotics, prebiotics, or fecal transplantations on the composition of the human gut microbiome is necessary.

KEYWORDS: gut microbiota, health status, inflammatory bowel disease, microbial population changes, non-alcoholic fatty liver disease, non-communicable diseases, obesity, randomized clinical trial

How often is antiseizure drug-free ketogenic diet therapy achieved?

The ketogenic diet (KD) is often started not only for seizure reduction but also to potentially wean antiseizure drugs (ASDs) in children with epilepsy. Although there have been several publications regarding ASD reduction on the KD, it is unknown how often complete medication withdrawal occurs. We reviewed the charts of all children started on the KD at Johns Hopkins Hospital and Johns Hopkins All Children's Hospital from 1/11 to 4/18. Children were defined as achieving drug-free diet (DFD) status if they started the KD on at least 1 ASD and achieved a period of time where they were on the KD alone. Over the time period, 232 children were evaluated; DFD status occurred in 43, of which 32 remained off ASDs for the remainder of their KD treatment course. Eleven children restarted ASD after a mean of 7 months. Children achieving DFD therapy were more likely to be younger, have fewer ASDs at KD onset, have Glut1 deficiency or epilepsy with myoclonic-atonic seizures, but were less likely to have Lennox-Gastaut syndrome or a gastrostomy tube.

KEYWORDS: Antiseizure drugs, Dietary therapy, Epilepsy, Ketogenic diet, Seizure

Eosinophilic esophagitis: Pathophysiology, diagnosis, and management.

Eosinophilic esophagitis (EoE) is a multifactorial esophageal inflammation, with a genetic predisposition, which combines a deficient esophageal mucosal barrier, an abnormal immune reaction to environmental allergens mediated by Th2 interleukins, immediate esophageal lesions and dysmotility, with secondary remodeling and fibrosis. Symptoms include reflux, abdominal pain, and food impaction, with a variation according to age. Fibroscopy shows major and minor endoscopic and histologic criteria, with a mucosal count≥15 eosinophils/high power field (Eo/hpf). A new entity has been defined, where gastroesophageal reflux disease (GERD) and EoE share responsibility: the PPIs-sensitive form of EoE (PPI-REE). Children with fibroscopy showing≥15 Eo/hpf need a second endoscopy following 8 weeks of PPI treatment. EoE has a strong association with other atopic disorders. Allergy testing (specific IgE blood test and skin prick tests) identifies patients at risk of anaphylaxis. The dietary therapy is based on a 4- to 12-week elimination test followed by endoscopy to check the disappearance of eosinophilic infiltration. The "dietary approaches are the amino acid-based formula, the allergy testing-based targeted diet, and the six-food elimination diet (empirical elimination of milk, wheat, soy, eggs, peanut/nuts, and fish/seafood). A recent first-line trial elimination of milk has been suggested, with wheat as a second elimination, if necessary. Dietary therapy allows remission and catch-up growth in 65% of cases. Swallowed topical steroids (budesonide in viscous gel or fluticasone propionate for nebulization) are an alternative, for which efficacy varies according to clinical and/or histological criteria and with relapses occurring at dosage tapering. Their use may be restricted by side effects, such as oral and/or esophageal candidiasis. The impact on long-term bone health and growth is unknown. Maintenance therapy is not standardized and is team-dependent, combining or not elimination diets and long-term steroids. The long-term risk of EoE is esophageal stenosis and endoscopic dilation may be repeated. Biotherapies have shown isolated histological improvement without significant clinical efficacy.

KEYWORDS: Diagnosis, Eosinophilic esophagitis, Management, Pathophysiology

Self-reported Food Intolerance in Korean Patients With Irritable Bowel Syndrome.

Various foods trigger and/or worsen the symptoms of irritable bowel syndrome (IBS). However, Korean food-related gastrointestinal (GI) symptoms in IBS patients have not yet been investigated. This study aims to evaluate the prevalence of self-reported food intolerance in Korean IBS patients and determine the Korean food items and food groups perceived by patients to worsen their GI symptoms. We recruited 393 study subjects, comprising 101 IBS patients, 167 symptomatic non-IBS subjects, and 125 control subjects. All participants completed a questionnaire to identify the most problematic foods and assess the occurrence of GI symptoms caused by 119 Korean food items. They also completed the validated Rome III questionnaire for IBS. The prevalence of self-reported food intolerance in Korean IBS patients was 79.2%, which was significantly higher than that in control subjects. The most problematic foods reported by IBS patients who experienced food intolerance were high-fat foods, gluten foods, spicy foods, and dairy products. A total of 63.4% of IBS patients reported GI symptoms related to the consumption of foods high in fermentable oligo-, di-, mono-saccharides and polyols (FODMAP), while 48.5% of IBS patients reported symptoms associated with high-fat foods. Gas problems and loose stools were the most frequently reported symptoms. A large proportion of Korean IBS patients complained of intolerance to certain food items, with high-fat and high-FODMAP foods being the main triggers. This study provides a basis for planning food intervention studies for Korean IBS patients.

KEYWORDS: Diet, Food intolerance, Irritable bowel syndrome, Surveys and questionnaires

Dietary Therapy for Clostridium Difficile Colonization: A case series.

Clostridium difficile (C. difficile) is an important nosocomial pathogen in adults and children. Roughly 4-5% of non hospitalized healthy adults carry the organism in their intestinal flora while adults in long term care facilities have asymptomatic carriage rates estimated at 20-50%. C. difficile colonization results in a spectrum of clinical conditions from asymptomatic carrier state to fulminant colitis. Changes in the fecal microbiome are central in the development of C. difficile colonization and disease pathogenesis. C. difficile infection has been shown to be associated with reduced biodiversity of the gut microbiome and intestinal dysbiosis. With the importance of the intestinal microbiota in development of CDI and with the known impact of diet on the intestinal microbiota, we report the first known case of C. difficile colonization/recurrence successful treated by dietary modification.

KEYWORDS: Clostridium difficile, colonization, diet, microbiome, nutrition, pediatrics, specific carbohydrate diet

Enterococcus faecalis EF-2001 protects DNBS-induced inflammatory bowel disease in mice model.

Recent studies have demonstrated the immunomodulatory effects of heat-killed lactic acid bacteria. The aim of this study was to evaluate the protective effect of heat-killed Enterococcus faecalis EF-2001 on a model of inflammatory bowel disease (IBD). A total of 28 female NC/Nga mice were divided into 4 treatment groups. Controls were fed a normal commercial diet. In the experimental groups, colitis was induced by rectal administration of dinitrobenzene sulfonic acid. Two groups were orally administered 2 and 17 mg/kg EF-2001, respectively. EF-2001 treatment decreased the expression of several cytokines, including cyclooxygenase (COX)-2, inducible nitric oxide synthase (iNOS), interferon (IFN)-γ, interleukin (IL)-1β, and IL-6 in inflamed colon compared to the DNBS alone group. In addition, EF-2001 suppressed DNBS-induced colonic tissue destruction. Therefore, this study strongly suggests that EF-2001 could alleviate the inflammation associated with mouse IBD.

Nonpharmacologic options for treating irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a chronic functional disorder with no organic cause. Risk factors are multifactorial and treatment typically consists of antimotility or stimulant laxatives and antidepressants. This article reviews several newer areas of interest: probiotics, fecal microbiota transplant, a low FODMAP diet, and cognitive behavioral therapy.

Agreement among Mediterranean Diet Pattern Adherence Indexes: MCC-Spain Study.

There are many different methods used to measure the degree of adherence to a Mediterranean diet (MD), limiting comparison and interpretation of their results. The concordance between different methodologies has been questioned and their evaluation recommended. The aim of this study was to evaluate the agreement among five indexes that measure adherence to a Mediterranean dietary pattern. The study population included healthy adults selected in the Multi-Case Control Spain (MCC-Spain) study recruited in 12 provinces. A total of 3640 controls were matched to cases by age and sex. To reach the aim, the following scores of adherence to a Mediterranean dietary pattern were calculated: Mediterranean diet score (MDS), alternative Mediterranean diet (aMED), relative Mediterranean diet (rMED), dietary score (DS) and literature-based adherence score (LBAS). The relative frequency of subjects with a high level of adherence to a MD varied from 22% (aMED index) to 37.2% (DS index). Similarly, a high variability was observed for the prevalence of a low level of MD: from 24% (rMED) to 38.4% (aMED). The correlation among MDS, aMED and rMED indexes was moderate, except for MDS and aMED with a high coefficient of correlation 0.75. The Cohen's Kappa coefficient among indexes showed a moderate⁻fair concordance, except for MDS and aMED with a 0.56 and 0.67 using linear and quadratic weighting, respectively. The existing MD adherence indexes measured the same, although they were based on different constructing algorithms and varied in the food groups included, leading to a different classification of subjects. Therefore, concordance between these indexes was moderate or low.

KEYWORDS: Mediterranean diet pattern, adherence, agreement, indexes

Association of menopausal characteristics and risk of coronary heart disease: a pan-European case-cohort analysis.

Earlier age at menopause has been associated with increased risk of coronary heart disease (CHD), but the shape of association and role of established cardiovascular risk factors remain unclear. Therefore, we examined the associations between menopausal characteristics and CHD risk; the shape of the association between age at menopause and CHD risk; and the extent to which these associations are explained by established cardiovascular risk factors. We used data from EPIC-CVD, a case-cohort study, which includes data from 23 centres from 10 European countries. We included only women, of whom 10 880 comprise the randomly selected sub-cohort, supplemented with 4522 cases outside the sub-cohort. We conducted Prentice-weighted Cox proportional hazards regressions with age as the underlying time scale, stratified by country and adjusted for relevant confounders. After confounder and intermediate adjustment, post-menopausal women were not at higher CHD risk compared with pre-menopausal women. Among post-menopausal women, earlier menopause was linearly associated with higher CHD risk. Women with a surgical menopause were at higher risk of CHD compared with those with natural menopause, but this attenuated after additional adjustment for age at menopause and intermediates. A proportion of the association was explained by cardiovascular risk factors. Earlier and surgical menopause were associated with higher CHD risk. These associations could partially be explained by differences in conventional cardiovascular risk factors. These women might benefit from close monitoring of cardiovascular risk factors and disease.

KEYWORDS: Epidemiology, Menopause, ageing, coronary disease, risk factors, women

IRRITABLE BOWEL SYNDROME, FOOD INTOLERANCE AND NON- CELIAC GLUTEN SENSITIVITY. A NEW CLINICAL CHALLENGE.

Approximately 80% of irritable bowel syndrome (IBS) patients report that their symptoms are triggered after ingesting one or specific food groups. Gluten, wheat and related proteins (e.g., amylase-trypsin inhibitors, and fermentable oligo-di-mono-saccharides and polyols (FODMAPs) are the most relevant IBS symptom triggers, although the true 'culprit(s)' is/are still not well established. The concept of causal relationship between gluten intake and the occurrence of symptoms in the absence of celiac disease and wheat allergy was termed non-celiac gluten sensitivity (NCGS). The borderline between celiac disease, wheat allergy, IBS and NCGS is not always clearly distinguishable, and the frequency and clinical identity of NGCS are still unclear. An overlap between IBS and NCGS has been detected. The incomplete knowledge of the etiopathogenesis of these clinical conditions, lack of data on their real epidemiology, as well as the absence of a gold standard for their diagnosis, make the overall picture difficult to understand "It is crucial to well define the interaction between IBS, food intolerance and NGCS, since the role of diet in IBS and its dietary management is an essential tool in the treatment of a large number of these patients". The objective of the present review is to provide an overview highlighting the interaction between IBS, food intolerance and NCGS in order to unravel whether gluten/wheat/FODMAP sensitivity represents 'facts' and not 'fiction' in IBS symptoms.

A Proof-of-Principle, Case-Control Study to Compensate for Potential Carbohydrates in Liquid Antiseizure Drugs in Children on the Ketogenic Diet.

Since its creation, patients on ketogenic diet are told to avoid liquid medications due to theoretical concerns of "hidden" carbohydrates. However, switching from liquid to tablet formulations can be problematic, especially for infants and young children. We theorized that increasing the daily ketogenic ratio might compensate for liquid antiseizure drug carbohydrates. Two tables were created, with variables including daily volume of antiseizure drugs and calories. Cases were those who had their ratio increased and liquid medications continued. Children already on tablet formulations, emergency situations, were primarily those included as controls. From May 2016 through August 2018, 59 children ages 0.3-14 years were started on the classic ketogenic diet. Compensated antiseizure drugs most commonly included levetiracetam, clobazam, and valproate. Adjusted ratios for younger children and infants on a 3:1 diet ranged from 3.1 to 3.5:1 and older children on a 4:1 diet from 4.2 to 4.7:1. There was no difference between cases and controls in achieving large ketosis, weight gain, 1 month >50% seizure reduction, or >90% seizure reduction. Four cases had zero or small urinary ketosis, which improved when antiseizure drugs were switched to tablets or discontinued. This proof-of-principle study demonstrates feasibility of compensating for carbohydrates in liquid medications by increases in the daily ketogenic ratio. This ratio adjustment protocol may help ease an already complex adjustment to dietary therapy.

KEYWORDS: carbohydrates, diet, epilepsy, ketogenic, ketosis, liquids

Dietary fiber and risk of irritable bowel syndrome: a case-control study.

The purpose of this study was to determine the relationship between dietary fiber intake and risk of irritable bowel syndrome (IBS). Patients with IBS are usually concerned about their diet, which can exacerbate or relieve their symptoms. In this case-control study, ninety cases and 355 controls were selected from a gastroenterology clinic. Dietary intakes of participants were assessed using a validated and reliable food frequency questionnaire (FFQ). Dietary fiber was calculated according to United States Department of Agriculture (USDA) food composition table. Dietary total fiber intake was significantly associated with lower risk of IBS. The adjusted odds ratio (OR) comparing the highest tertile of dietary total fiber with the lowest tertile was 0.14; however, there was no significant association or dose-response trend for higher intakes of soluble, and insoluble fiber separately with risk of IBS. Our data indicate that dietary fiber is inversely associated with the risk of IBS. Further prospective studies are needed to confirm these data.

KEYWORDS: Case-control, Dietary fiber, IBS, Irritable bowel syndrome