Nutritional counseling in childhood and adolescence: a systematic review

Healthy eating habits are the basis for good health status, especially for children and adolescents, when growth and development are still ongoing. Nutrition educational programs are essential to prevent and treat chronic diseases. Nutritional counseling (NC), as a collaborative process between the counselor and the client process, could help to achieve better outcomes. This review aims to collect information about the utilization of NC during childhood and adolescence and to highlight its possible impact on adherence/compliance rates, nutrition knowledge, status and dietary intake. The methods applied in this systematic review followed the instruction of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The search in PubMed/Medline, Scopus, Web of Science, LILACS, and Science Direct included observational or randomized studies. RoB 2.0 and Robins-I tools was used for the risk of bias assessment in randomized and non-randomized studies, respectively. The quality of evidence was checked by the Mixed Methods Appraisal Tool system. A total of 21 articles were selected, computing 4,345 individuals. 11 achieved at least 4 stars quality level. The highest risk of bias for randomized studies was related to the randomization process. 42.9% of non-randomized studies had some concerns of bias, mainly because of a lack of control of all confounding factors. Different strategies of NC were used in children and adolescents with positive results for health or diseases. NC strategies can be effectively used in children and adolescents. In general, NC showed benefits in pediatrics age for anthropometric or body composition parameters, dietary intake, nutrition knowledge and physical activity improvement. Performing NC in pediatrics is challenging due to the counseling strategies that must be adapted in their contents to the cognitive ability of each age. More structured research must be done focused on this population. Investments in healthy eating behaviors in pediatrics can lead to better health outcomes in the future population with substantial benefits to society.Systematic review registration[https://www.crd.york.ac.uk/prospero/#recordDetails], identifier [CRD42022374177]

Atividade física de gestantes e desfechos ao recém-nascido: revisão sistemática

A systematic review was carried out aiming at analyzing daily physical activity during pregnancy and the outcomes of birth weight, prematurity, and intrauterine growth restriction. Of 52 articles indexed in Medline, 22 that showed better methodological quality were included. Among the 22 articles analyzed, only two did not detect a significant association between physical activity and the outcomes studied. There was large variation between the indicators of maternal physical activity, which included occupational, household, recreational and, all or some, locomotive activities. Among ten articles that measured total daily physical activity, only one article did not find any association. The results support the hypothesis that both excessive and insufficient physical activity impact negatively on pregnancy outcomes.Revisión sistemática con el objetivo de analizar la actividad física cotidiana durante la gestación y los efectos en el peso al nacer, prematurez y restricción de crecimiento intrauterino. De 52 artículos indexados en Medline, fueron incluidos 22 que presentaron mejor calidad metodológica. Entre los 22 artículos analizados, sólo dos no detectaron asociación significativa de la actividad física con los efectos estudiados. Hubo gran variabilidad con relación a los indicadores de la actividad física materna, envolviendo actividades ocupacionales, domésticas, en el ocio y para locomoción de manera global o parcial. Entre diez que midieron la actividad física cotidiana global, sólo un artículo no encontró asociación. Los resultados apoyan la hipótesis de que tanto el exceso como el déficit de actividad física ejercen influencia negativa sobre los resultados de la gestación.Revisão sistemática com o objetivo de analisar a atividade física cotidiana durante a gestação e os desfechos de peso ao nascer, prematuridade e restrição de crescimento intra-uterino. De 52 artigos indexados no Medline, foram incluídos 22 que apresentaram melhor qualidade metodológica. Entre os 22 artigos analisados, apenas dois não detectaram associação significativa da atividade física com os desfechos estudados. Houve grande variabilidade quanto aos indicadores da atividade física materna, envolvendo atividades ocupacionais, domésticas, no lazer e para locomoção de maneira global ou parcial. Entre dez que mensuraram a atividade física cotidiana global, apenas um artigo não encontrou associação. Os resultados apóiam a hipótese de que tanto o excesso quanto o déficit de atividade física exercem influência negativa sobre os desfechos da gestação

Systematic review of the literature on the use of probiotics in cystic fibrosis and nutritional profile of patients treated at Children\'s Institute - HCFMUSP

Fibrose cística é uma doença hereditária, caracterizada por alterações no transporte de cloro nas membranas das células epiteliais, gerando a produção de muco espesso e anormal, o que pode obstruir os ductos de glândulas exócrinas de vários órgãos. As manifestações clínicas principais da doença abrangem os sistemas respiratório (com infecções pulmonares recorrentes e crônicas) e gastrointestinal (com insuficiência pancreática e consequente má-digestão e absorção de nutrientes, levando a desnutrição energético-protéica). Existem evidências de que a constituição da microbiota intestinal pode influenciar a colonização do trato respiratório de indivíduos com fibrose cística. Esta dissertação teve como objetivo realizar revisão sistemática e metanálise das publicações científicas sobre o uso de pré, pró ou simbióticos em fibrose cística, além de avaliar a situação nutricional dos pacientes com fibrose cística acompanhados no Instituto da Criança - HCFMUSP. A revisão sistemática e metanálise seguiu protocolo proposto pela Colaboração Cochrane, com buscas em bases de dados eletrônicas com os termos prebioticos ou probióticos ou simbióticos e fibrose cística. Foram incluídos ensaios clínicos randomizados que abordassem os desfechos de inflamação intestinal e/ou exacerbações pulmonares. O estudo de avaliação nutricional foi realizado através de levantamento de dados antropométricos e clínicos, além de questionários aplicados a pacientes e responsáveis sobre dados de consumo alimentar e características socioeconômicas. Na busca bibliográfica foram encontrados 48 diferentes estudos, e somente 6 atingiram os critérios para integrar a metanálise. Foi observado efeito protetor do uso de probióticos e simbióticos na taxa de exacerbação pulmonar em pacientes com fibrose cística quando comparados com placebo (OR= -1,01 (IC 95% -1,66; -0,37), p = 0,002). Os níveis de calprotectina fecal (indicador de inflamação intestinal) tiveram redução significativa após intervenção (OR= -12,18 (IC 95%: -22,50; -1,86), p = 0,02), e houve diminuição dos pacientes com inflamação intestinal (calprotectina > 50 mcg/g de fezes) com OR= 0,31 (IC 95%: 0,13; 0,79), p = 0,01. Na avaliação do perfil nutricional foram incluídos 101 pacientes (59,4% do gênero masculino, 86,4% caucasianos), e a mediana de idade na inclusão foi de 10 anos. A maioria dos pacientes foi classificada como eutrófica, com consumo alimentar adequado. Valores menores de escore Z de IMC foram observados em escolares e adolescentes, e a proporção de pacientes com peso abaixo do esperado aumenta de 10% entre pré-escolares para 35% na faixa etária escolar. As características socioeconômicas não demostraram relação com consumo alimentar ou estado nutricional. Os valores de função pulmonar foram mais baixos em adolescentes e indivíduos com pior estado nutricional, porém sem diferença significante. Dados da metanálise, apesar da limitação amostral, apontaram o uso de probióticos como fator de proteção para exacerbações respiratórias, bem como para inflamação intestinal. Resultados da avaliação nutricional indicam que a transição das faixas etárias pré-escolar para escolar é um momento crítico, portanto abordagens direcionadas para estas faixas etárias podem ser de grande importância para preservação da saúde nutricional. Sendo assim, recomenda-se que mais estudos de estratégias nutricionais preventivas sejam realizados em faixas etárias precoces, como suplementação de probióticos, visando a melhora do prognóstico de pacientes com fibrose cística.Cystic fibrosis is a hereditary disease characterized by deficiency of chloride transportation in epithelial cell membranes, resulting in thick and abnormal mucus, which may obstruct ducts of exocrine glands in several organs. The main clinical manifestations include the respiratory (recurrent and chronic lung infections) and gastrointestinal systems (pancreatic insufficiency and consequent maldigestion and absorption of nutrients, resulting in malnutrition). There is evidence that intestinal microbiota composition may impact the respiratory tract colonization of individuals with cystic fibrosis. This study aimed to verify current evidence regarding the effects of supplementation of probiotics, prebiotics or both in cystic fibrosis patients, concerning gastrointestinal and respiratory outcomes. We performed a systematic review and meta-analysis, and additionally carried out a survey of the nutritional status of patients with cystic fibrosis attending the outpatient clinic of the Instituto da Criança HCFMUSP. The systematic review and meta-analysis was performed according to the protocol proposed by the Cochrane Collaboration, searching electronic databases using the terms \"prebiotics\" or \"probiotics\" or \"symbiotic\", and \"cystic fibrosis\". Randomized clinical trials addressing intestinal inflammation and/or pulmonary exacerbations were included. The assessment of nutritional status was carried out through a cross-sectional survey of medical records concerning clinical and anthropometric data, and also by applying a questionnaire to patients and caregivers concerning food consumption, and socioeconomic characteristics. The bibliographic search identified 48 different studies, but only 6 fulfilled criteria to be included in the meta-analysis. A protective effect of probiotic and symbiotic use was observed in the rate of pulmonary exacerbations when compared to placebo (OR = -1.01 (95%CI -1.66, -0.37), p=0.002). The levels of fecal calprotectin (indicator of intestinal inflammation) had a significant reduction after intervention (OR = -12.18 (95%CI: -22.50, -1.86), p=0.02) and there was a decrease in the proportion of patients with intestinal inflammation (calprotectin> 50 mcg/g feces) with OR = 0.31 (95%CI: 0.13, 0.79), p=0.01. Regarding nutritional assessment, 101 patients were included (59.4% male, 86,4% white race), and median age at inclusion was 10 years old. The majority of patients were considered to be eutrophic and have adequate food intake, but lower values of BMI Z-score were observed in schoolchildren and adolescents. The proportion of underweight patients increased from 10% among preschoolers to 35% of the school age group. The socioeconomic characteristics were not associated to the food consumption or nutritional status. Lung function was lower in adolescents and individuals with poor nutritional status, but without significant difference. Data from the meta-analysis, despite the limitations of sample size, indicated that the use of probiotics may be a protective factor for respiratory exacerbations as well as intestinal inflammation. Results of the nutritional assessment indicate that the transition from the pre-school to the school age groups is a critical period, and therefore approaches directed to these age groups may have a significant impact in the nutritional health. Towards that, further studies using preventive nutritional strategies such as probiotic supplementation, are recommended for younger age groups, aiming to improve the prognosis of patients with cystic fibrosis

Atividade física de gestantes e desfechos ao recém-nascido: revisão sistemática Actividad física de embarazadas y efectos en el recién-nacido: revisión sistemática Physical activity by pregnant women and outcomes for newborns: a systematic review

Revisão sistemática com o objetivo de analisar a atividade física cotidiana durante a gestação e os desfechos de peso ao nascer, prematuridade e restrição de crescimento intra-uterino. De 52 artigos indexados no Medline, foram incluídos 22 que apresentaram melhor qualidade metodológica. Entre os 22 artigos analisados, apenas dois não detectaram associação significativa da atividade física com os desfechos estudados. Houve grande variabilidade quanto aos indicadores da atividade física materna, envolvendo atividades ocupacionais, domésticas, no lazer e para locomoção de maneira global ou parcial. Entre dez que mensuraram a atividade física cotidiana global, apenas um artigo não encontrou associação. Os resultados apóiam a hipótese de que tanto o excesso quanto o déficit de atividade física exercem influência negativa sobre os desfechos da gestação.<br>Revisión sistemática con el objetivo de analizar la actividad física cotidiana durante la gestación y los efectos en el peso al nacer, prematurez y restricción de crecimiento intrauterino. De 52 artículos indexados en Medline, fueron incluidos 22 que presentaron mejor calidad metodológica. Entre los 22 artículos analizados, sólo dos no detectaron asociación significativa de la actividad física con los efectos estudiados. Hubo gran variabilidad con relación a los indicadores de la actividad física materna, envolviendo actividades ocupacionales, domésticas, en el ocio y para locomoción de manera global o parcial. Entre diez que midieron la actividad física cotidiana global, sólo un artículo no encontró asociación. Los resultados apoyan la hipótesis de que tanto el exceso como el déficit de actividad física ejercen influencia negativa sobre los resultados de la gestación.<br>A systematic review was carried out aiming at analyzing daily physical activity during pregnancy and the outcomes of birth weight, prematurity, and intrauterine growth restriction. Of 52 articles indexed in Medline, 22 that showed better methodological quality were included. Among the 22 articles analyzed, only two did not detect a significant association between physical activity and the outcomes studied. There was large variation between the indicators of maternal physical activity, which included occupational, household, recreational and, all or some, locomotive activities. Among ten articles that measured total daily physical activity, only one article did not find any association. The results support the hypothesis that both excessive and insufficient physical activity impact negatively on pregnancy outcomes

AVALIAÇÃO DO PERFIL NUTRICIONAL EM PACIENTES PORTADORES DE FIBROSE CÍSTICA DE ACORDO COM FAIXA ETÁRIA

RESUMO Objetivo: Avaliar o perfil nutricional da população atendida em centro de referência em fibrose cística. Métodos: Estudo transversal incluindo pacientes com fibrose cística de um centro pediátrico de referência de São Paulo, em 2014. Todos os sujeitos que concordaram em participar do estudo foram incluídos. Foi aplicado um questionário sobre hábitos alimentares (recordatório de 24 horas) e características socioeconômicas. Dados antropométricos (comparados com referencial da Organização Mundial da Saúde de 2006 e 2007) e função pulmonar foram coletados do prontuário. Os integrantes da pesquisa foram estratificados em faixas etárias para análise estatística. Resultados: Dos 101 pacientes incluídos no estudo, 59,4% eram masculinos, sendo a maioria caucasiana (86,4%), com mediana de idade de 10 anos. A maioria dos pacientes (n=77, 75%) foi classificada como eutrófica, mas valores menores de escore Z de índice de massa corpórea (IMC) foram observados em escolares e adolescentes. A proporção de pacientes com peso abaixo do esperado foi de 10% (n=2) na faixa etária pré-escolar e de 35% (n=6) em escolares. O consumo alimentar mostrou-se adequado, e somente dois suplementos (triglicérides de cadeia média e suplemento em pó completo) tiveram utilização ligada à adequação da ingesta de macronutrientes. Características socioeconômicas não apresentaram associação com o estado nutricional ou com o consumo nutricional. Valores de função pulmonar não apontaram diferença significante em adolescentes nem em indivíduos com pior estado nutricional no grupo estudado. Conclusões: A maioria dos pacientes apresentou estado nutricional e consumo alimentar adequados, indicando bom manejo das ações nutricionais. Novos estudos com foco em pré-escolares devem ser realizados para avaliar se é possível reduzir o risco nutricional de pacientes com fibrose cística em idades posteriores

Factor Analysis of the Brazilian Questionnaire on Adherence to Ketogenic Dietary Therapy: Keto-Check

Background: several strategies are used to assess adherence to ketogenic dietary therapies (KDTs), the most commonly used being ketonemia or ketonuria, despite their limitations. The purpose of this article is to carry out an exploratory and confirmatory factor analysis on the proposed Keto-check (adherence’s KDT Brazilian questionnaire). Methods: there was a methodological study of a quantitative nature, complementary to the analysis realized previously, with a complimentary sample. The factorial analysis was performed with Factor software for parallel exploratory analysis, replicability, and confirmatory factor analysis. Graphical representation was created according to the number of factors resulting from the analysis. Results: 116 questionnaires were reached by complementary data collection (n = 69 actual data, complementing n = 47 previous data) through online forms. A polychoric correlation matrix suitability analysis resulted in a significant Bartlett statistic (p = 0.0001) and a Kaiser–Meyer–Olkin (KMO) test of 0.56. The parallel factorial analysis resulted in two factors, graphically represented as “efficacy” and “adherence”. A confirmatory factor analysis, considered fair, indicated an RMSEA of 0.063, NNFI resulted in 0.872, CFI in 0.926, and GFI in 0.897. Conclusion: this study confirms the validity of Keto-check through a more detailed analysis. Adherence is the key to improving the effectiveness of KDTs; therefore, improving knowledge about it can lead to a better healthcare approach

Ketosis and migraine: a systematic review of the literature and meta-analysis

Introduction: Headaches are a prevalent disorder worldwide, and there is compelling evidence that certain dietary interventions could provide relief from attacks. One promising approach is ketogenic therapy, which replaces the brain’s glucose fuel source with ketone bodies, potentially reducing the frequency or severity of headaches. Aim: This study aims to conduct a systematic review of the scientific literature on the impact of ketosis on migraine, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method. Results: After a careful selection process and bias evaluation, 10 articles were included in the review, primarily from Italy. The bias assessment indicated that 50% of the selected articles had a low risk of bias in all domains, with the randomization process being the most problematic domain. Unfortunately, the evaluation of ketosis was inconsistent between articles, with some assessing ketonuria, some assessing ketonemia, and some not assessing ketosis levels at all. Therefore, no association could be made between the level of ketosis and the prevention or reduction of migraine attacks. The ketogenic therapies tested in migraine treatments included the very low-calorie ketogenic diet (VLCKD, n = 4), modified Atkins diet (MAD, n = 3), classic ketogenic diet (cKDT, n = 2), and the administration of an exogenous source of beta-hydroxybutyrate (BHB). The metaanalysis, despite reporting high heterogeneity, found that all interventions had an overall significant eect (Z = 9.07, p < 0.00001; subgroup dierences, Chi2 = 9.19, dif = 3, p = 0.03; I 2 , 67.4%), regardless of the type of endogenous or exogenous induction of ketosis. Conclusion: The initial findings of this study suggest that metabolic ketogenic therapy may provide some benefit in treating migraines and encourage further studies, especially randomized clinical trials with appropriate and standardized methodologies. The review strongly recommends the use of the adequate measurement of ketone levels during ketogenic therapy to monitor adherence to the treatment and improve knowledge of the relationship between ketone bodies and e cacy. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD4202233062

Validation of an Italian Questionnaire of Adherence to the Ketogenic Dietary Therapies: iKetoCheck

Ketogenic dietary therapies (KDTs) are an effective and safe non-pharmacological treatment for drug-resistant epilepsy, but adherence can be challenging for both patients and caregivers. In Europe, there are no adequate tools to measure it other than monitoring ketosis. This study aimed to adapt and validate the Brazilian adherence questionnaire, Keto-check, into the Italian version: iKetoCheck. Using the Delphi technique, 12 judges validated the contents through agreement rates and the Content Validity Index (CVI). The iKetocheck was self-completed electronically by 61 drug-resistant epilepsy or GLUT1 deficiency patients within an interval of 15 days to measure its reproducibility. The test–retest reliability was evaluated using Pearson’s correlation and relative significance test. Exploratory and confirmatory factorial analyses were made using Factor software version 12.03.02. The final tool, iKetoCheck, consists of 10 questions with 5-point Likert scale answers. It evaluates various aspects such as informing caregivers about the diet, organization of meals, measurement of ketosis, weighing food consumed, diet negligence, use of carbohydrate-free medications, attending follow-up visits, reading food labels, consulting an expert for dietary concerns, and cooking at home. The factorial analysis resulted in three factors: “attention,” “organization,” and “precision,” with satisfactory results for indices in exploratory and confirmatory analyses. Although higher mean values of ketonemia measurement were observed in patients with a higher adherence score, these values were not statistically significant (p = 0.284). In conclusion, despite the small sample size, iKetoCheck is a valid tool for evaluating KDTs’ adherence in Italian drug-resistant epilepsy or GLUT1 deficiency patients. It can provide valuable information to improve patient management and optimize the effectiveness of KDTs

A Review of Ketogenic Dietary Therapies for Epilepsy and Neurological Diseases: A Proposal to Implement an Adapted Model to Include Healthy Mediterranean Products

Based on the growing evidence of the therapeutic role of high-fat ketogenic dietary therapies (KDTs) for neurological diseases and on the protective effect of the Mediterranean diet (MD), it could be important to delineate a Mediterranean version of KDTs in order to maintain a high ketogenic ratio, and thus avoid side effects, especially in patients requiring long-term treatment. This narrative review aims to explore the existing literature on this topic and to elaborate recommendations for a Mediterranean version of the KDTs. It presents practical suggestions based on MD principles, which consist of key elements for the selection of foods (both from quantitative and qualitative prospective), and indications of the relative proportions and consumption frequency of the main food groups that constitute the Mediterranean version of the KDTs. We suggest the adoption of a Mediterranean version of ketogenic diets in order to benefit from the multiple protective effects of the MD. This translates to: (i) a preferential use of olive oil and vegetable fat sources in general; (ii) the limitation of foods rich in saturated fatty acids; (iii) the encouragement of high biological value protein sources; (iv) inserting fruit and vegetables at every meal possible, varying their choices according to seasonality