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IMPROVEMENT IN MUCOSAL INTEGRITY AND FUNCTION IN IBD PATIENTS AND REDUCTION IN GI SYMPTOMS IN HIV PATIENTS WITH DIETARY PEPTIDES FROM HYDROLYZED WHITE FISH Nichols TW, DelRossi JCenter for Nutrition and Digestive Disorders, Hanover, PA, USA ABSTRACT (Regulatory Peptides. 2002;108(1):31) Dietary peptides are known to have biological importance beyond their nutritive value as protein, influencing structural, immune, and gastrointestinal functions. The GI benefit of supplementation with a dietary bioactive peptide supplement prepared from hydrolyzed white fish was studied in two distinct populations in separate trials. In the first study, 15 IBD patients assessed to have gut mucosal hyperpermeability by a urine test utilizing lactose and mannitol ratios were given either 3g per day of the fish peptide supplement or a control for 6 weeks, followed by a second permeability test and symptom assessment scoring. Results with the IBD patients taking the supplement showed a trend towards improvement in both intestinal permeability and symptom assessment versus controls. We then hypothesized that if GI symptoms resulting from current recommended HIV therapy are associated with a similar inflammatory mechanism, these patients would also respond favorably to the peptide supplementation. Accordingly, a second population of 23 HIV-infected males experiencing GI side effects on highly active antiretroviral therapy (HAART) were given either 3g per day of the fish peptide supplement or a control for 5 months, with symptoms assessed before and after the treatment period. In the HIV patients, the number of GI symptoms collectively reported as decreased in the supplement group was significantly greater than the number of symptoms collectively reported as decreased in the control group. These bioactive peptides appear to have a dual function in HIV patients: controlling intestinal permeability as a potential long-term risk factor of HAART and reducing the GI side effects of HAART, which may relate to increased compliance and improved treatment outcome. 1. INFLAMMATORY BOWEL DISEASE (IBD) Background/Aims: Inflammatory Bowel Disease (IBD) is a chronic inflammatory condition generally categorized as either ulcerative colitis (UC) or Crohn’s disease, based on established disease criteria and the location of the inflammation. Recommended medical treatment includes corticosteroid therapy, as well as nutritional interventions, such as elemental peptide diets and micronutrient supplementation.<!--[if !supportFootnotes]-->[1]<!--[endif]--> Oligomeric (small-chain peptides or hydrolyzed protein) supplementation is preferred over monomeric (free amino acid) or polymeric (whole protein) supplementation based on evidence of increased biological value<!--[if !supportFootnotes]-->[2]<!--[endif]--> and increased nitrogen balance in Crohn’s patients.<!--[if !supportFootnotes]-->[3]<!--[endif]--> Seacure® is a commercially available hydrolyzed fish protein supplement that provides peptides, as well as omega-3 fatty acids and minerals. Both UC and Crohn’s are associated with intestinal epithelial hyperpermeability, although the evidence is more established for the latter.<!--[if !supportFootnotes]-->[4]<!--[endif]--> Successful treatment of Crohn’s with elemental diets is demonstrated by a reduction in intestinal permeability (IP), and normal IP in IBD patients has prognostic implications and may predict well-being.<!--[if !supportFootnotes]-->[5]<!--[endif]--> Methods: In a randomized, double-blind, placebo-controlled trial, 15 IBD patients were given either Seacure® (N=7) or barley placebo (N=8), 2x500mg capsules TID, for 6 weeks. IP was assessed before and after the trial period using lactulose and mannitol probes in urine, testing performed by Great Smokies Diagnostic Laboratories, Asheville, NC. Successful treatment of IBD is matched by a reduction in lactulose:mannitol ratio.<!--[if !supportFootnotes]-->[6]<!--[endif]--> Statistical analysis was performed using SAS, paired T-tests.
Results: We did not show a significant change in IP scores among control patients (p=0.41), while Seacure® patients demonstrated a non-significant trend towards improvement in IP scores (p=0.07). As shown, the percent changes in IP scores, calculated by standardizing starting points for both control and test patients, were 76% improvement in Seacure® patients and 32% improvement in control patients (maintained on standard treatment without supplementation).
2. HIV- HAART THERAPY Background/Aims: When properly used in HIV management, highly active antiretroviral therapy (HAART) can prevent opportunistic infections (OIs), maintain weight, improve viral counts, delay the progression to AIDS, and extend life.<!--[if !supportFootnotes]-->[7]<!--[endif]-->,<!--[if !supportFootnotes]-->[8]<!--[endif]--> However, GI complaints, such as diarrhea, affect an estimated 50-70% of HIV patients on HAART.<!--[if !supportFootnotes]-->[9]<!--[endif]-->,<!--[if !supportFootnotes]-->[10]<!--[endif]--> Such events can limit compliance to HAART, which leads to sub-therapeutic drug levels, viral mutations against HAART agents, and failure to achieve or maintain viral suppression. The management of GI issues in HIV patients on HAART relates to quality of life and may play a role in compliance with medications and treatment outcome. An apparent relationship exists between HIV and the health of the GI tract, including intestinal permeability, gut-associated immune function, and oxidative stress,<!--[if !supportFootnotes]-->[11]<!--[endif]--> although the particular inflammatory and functional changes in HIV-related intestinal disease remain unclear.<!--[if !supportFootnotes]-->[12]<!--[endif]--> Prompted by success with GI symptoms among IBD and irritable bowel syndrome (IBS) patients with the fish peptide supplement Seacure®, we hypothesized that if similar mechanisms are in effect, HIV patients experiencing GI symptoms on HAART might also respond favorably to the fish peptide supplementation. Methods: The site for the study was a large urban private medical practice with approximately 400 HIV-positive patients. Thirty-two patients were selected over a two-month period based on the following inclusion criteria: · HIV-positive · Ability to provide informed consent · Ability to adhere to daily supplement regimen · Life expectancy of at least 6 months · Age greater than 18 years · Absence of any OIs · Compliance with uninterrupted HAART for at least 6 months · Viral load of less than 50 copies/mL and exclusion criteria: · Female gender · Life expectancy of less than 6 months · Opportunistic malignancy requiring systematic chemotherapy within 30 days of study entry · The presence of any OIs · Concurrent use or prior use of anabolic agents/appetite stimulants/corticosteroids within 30 days of study entry
Study design was as follows: · Randomized, double-blind, placebo-controlled · 5 month duration with follow up · Treatment: Seacure® (N=18) or barley placebo (N=14), 2 x 500mg capsules TID · Outcome-based study design using patient questionnaires and clinician interviews. The use of questionnaires to evaluate quality of life issues related to HAART and nutritional support has been documented.<!--[if !supportFootnotes]-->[13]<!--[endif]--> · Statistical analysis was performed using unpaired, two-tailed T-tests assuming normal distributions and equal variances. P-value of <0.05 was required for statistical significance. Results: Mean age of patients was 43.9 years (30-64). Five patients in the Seacure® group were lost to follow up, one patient withdrew from the study prior to completion, and one patient died from Hepatitis B two months into the study. Two patients in the placebo group withdrew prior to completion. Twenty-three patients completed the study (test N=11, control N=12) and were used for data analysis. Blood profiles were monitored and remained stable for all patients. Table 1. Analysis of study results based on 11 patients in Seacure® group and 12 patients in placebo group at the start of the study.
Table 2. Statistical analysis of study results based on 11 patients in Seacure® group and 12 patients in placebo group at the conclusion of the study (5 months).
*p=0.0479 As seen in Table 1, there was no difference between the two study groups in the number of patients reporting symptoms at baseline (p=0.911). At five months, Table 2, the number of symptoms collectively reported as decreased in the Seacure® group was significantly greater than the number of symptoms collectively reported as decreased in the control group (p=0.0479). Further, all 11 Seacure® patients and two of 12 placebo patients felt better overall. CONCLUSIONWe observed a trend towards improvement in IP and symptoms in IBD patients, as well as a significant decrease in total GI symptoms in HIV-positive males on HAART when supplemented with the fish peptides. Clinicians must recognize that, to the patient, the GI effects of HAART are a disease unto themselves. The management of GI issues in HIV treatment may relate not only to quality of life, but also to HAART compliance, and thus, contribute to viral suppression and extend life. Supplementation with these fish peptides may control intestinal permeability as a potential long-term risk factor of HAART and reduce the GI side effects of HAART, which may relate to increased compliance and improved treatment outcome. Further study is indicated. Sponsored by Proper Nutrition, Inc., Reading, PACall 800-555-8868 for more information <!--[if !supportEndnotes]--> <!--[endif]--> <!--[if !supportFootnotes]--> [1]<!--[endif]--> Bashir S, Lipman TO. Nutrition in gastroenterology and hepatology. Primary Care. 2001;28(3). <!--[if !supportFootnotes]--> [2]<!--[endif]--> Poullain MG, Cezard JP, Roger L, et al. Effect of whey proteins, their oligopeptide hydrolysates and free amino acid mixtures on growth and nitrogen retention in fed and starved rats. JPEN. 1989;13:382. <!--[if !supportFootnotes]--> [3]<!--[endif]--> Smith JL, Areaga C, Heymsfield SB. Increased ureagenesis and impaired nitrogen use during infusion of a synthetic amino acid formula. NEJM. 1982;306:1013. <!--[if !supportFootnotes]--> [4]<!--[endif]--> Unno N, Fink MP. Intestinal epithelial hyperpermeability: mechanisms and relevance to disease. Gastroenterol Clin. 1998;27(2):289-307. <!--[if !supportFootnotes]--> [5]<!--[endif]--> Bjarnason I, MacPherson A, Hollander D. Intestinal permeability: an overview. Gastroenterol. 1995;108:1566-81. <!--[if !supportFootnotes]--> [6]<!--[endif]--> Wyatt J, Oberhuber G, Pangratz S, et al. Increased gastric and intestinal permeability in patients with Crohn’s disease. Am J Gastroenterol. 1997;92(10):1891-6. <!--[if !supportFootnotes]--> [7]<!--[endif]--> CDC guidelines for preventing opportunistic infections among HIV-infected persons-2002 recommendations of the Infectious Diseases Society of America. MMWR. 2002;51(RR-8):1-2. <!--[if !supportFootnotes]--> [8]<!--[endif]--> Echeverria PS, Jonnalagadda SS, Hopkins BL, Rosenbloom CA. Perception of quality of life of persons with HIV/AIDS and maintenance of nutritional parameters while on protease inhibitors. AIDS Patient Care STDS. 1999;13(7):427-33. <!--[if !supportFootnotes]--> [9]<!--[endif]--> Volberding PA, Sande M, Deeks SG. The Medical Management of AIDS. Phila:WB Saunders;1999:97-201. <!--[if !supportFootnotes]--> [10]<!--[endif]--> Mooney M, Vergel N. Built to Survive. Los Angeles:PoWeR;1999:111-26. <!--[if !supportFootnotes]--> [11]<!--[endif]--> Kaminski M, Weil S, Bland J, Jan P. AIDS wasting syndrome as an entero-metabolic disorder: the gut hypothesis. Alt Med Rev. 1998;3(1):40-53. <!--[if !supportFootnotes]--> [12]<!--[endif]--> Oktedalen O, Skar V, Dahl E, Serck-Hanssen A. Changes in small intestinal structure and function in HIV-infected patients with chronic diarrhoea. Scand J Infect Dis. 1998;30(5):459-63. <!--[if !supportFootnotes]--> [13]<!--[endif]--> Woodcock A, Bradley C. Validation of the HIV treatment satisfaction questionnaire. Qual Life Res. 2001;10(6):517. |
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