Frequent Small Meals Research Articles

PSIV-A-8 Effects of meal frequency on heart rate in horses

Abstract In humans, meal size has been shown to affect heart function with meal ingestion being associated with an increase in heart rate (HR) and cardiac output lasting significantly longer when larger meals are consumed. In horses, HR spikes at the sight of feed due to anticipation, but no studies have specifically evaluated the effect of meal frequency or size on HR. Heart rate has also been used as a measure both positive and negative stress. Domesticated horses are often meal fed, with small frequent meals requiring more labor than large infrequent meals. Fewer larger meals may have negative welfare implications for a grazing species. As part of a larger project investigating the effects of meal frequency on the behavior and metabolism of horses, the objective of this study was to evaluate equine HR in response to feeding frequencies commonly practiced in the field [once (1x), twice (2x), or thrice (3x) per day]. Feeding times were at 0800 (1x, 2x, and 3x), 1300 (3x), and 1800 (2x and 3x) h. The 12 adult clinically healthy horses [average ± SD; 14 ± 6 yr and 572 ± 32 kg body weight (BW)] were separated into two equal groups before completing a 14-d acclimation period to the diet during which they were fed 2x. The diet was provided at 2% BW on a dry matter (DM) basis (1.55% BW grass hay in a slow feed hay net plus 0.45% BW complementary fortified feed). During the study the same diet was fed but the meal frequency, and therefore meal size, differed between the treatments. The order of treatments, lasting 1 wk each, was decided at random for each group. On d 6 of each treatment HR was measured using individual H10 Polar HR monitors, which recorded every second from 0700 to 1900 h yielding 1,514,799 data points. During this time the aisleways housing the stalled horses were blocked off to minimize exposure to human presence other than at feeding time(s). After removing outliers, the mode was calculated for HR of each horse, which was considered to be the resting HR for that horse and ranged from 31 to 46 beats/min. The percentage of data above, below, or at the mode was calculated for each horse over the 12 h period and evaluated using Chi Square tests for statistical significance. The proportion of HR values above, below, or at the mode differed between treatments (P = 0.02). When fed 1x, 69 ± 14% of the HR readings were above the mode on average, as compared with 42 ± 18% and 44 ± 18% for 2x and 3x, respectively. These results suggest that the increase in HR was more than anticipatory and that there may be sustained stress when horses are fed at fewer frequency, such as once daily.

Quality of Life and Its Association With Time in Range Among People With Type 2 Diabetes Mellitus Following Different Dietary Interventions: A Crossover Clinical Trial.

Background Quality of Life (QoL) is an essential consideration in healthcare. Numerous studies have examined QoL in India; however, data on QoL following different dietary interventions are lacking. Similarly, the use of technology such as continuous glucose monitoring (CGM) for diabetes care has independently demonstrated improvements in glycemic control; however, its association with QoL remains limited. Purpose The purpose was to study the role of different dietary interventions on QoL and its association with Time in Range (TIR), Time Above Range (TAR), and Time Below Range (TBR) among the Type 2 Diabetes Mellitus (T2DM) population. Methodology A crossover interventional clinical trial (CTRI/2022/07/044356) was conducted among participants with T2DM of less than 5 years' duration, aged between 25 and 55 years, with an HbA1c level of less than 8%, and who were on Metformin only. Their QoL was assessed after following two diet patterns: the Continuous Calorie Restricted Diet (CCRD) - calorie reduction with small frequent meals, and Time Restricted Intermittent Fasting (TRIF) - calorie reduction with only two meals a day, using the Modified QoL (MDQOL-17) questionnaire. The association between post-dietary interventions QoL and TIR was studied using a 14-day CGM device. Results The overall QoL of 51 participants at the end of the dietary interventions was significantly better compared to their QoL before any dietary intervention (85.6±19.0% and 63.1±13.0%, respectively, p = 0.000). Decreased TIR correlated with increased role limitations due to physical functioning (p = 0.002) and decreased energy levels (p = 0.00). As TBR increased, role limitation due to emotional well-being increased, and energy levels decreased significantly (p = 0.01). As TAR increased, energy levels decreased (p = 0.01). A simple linear regression model was statistically significant for role limitations due to physical functioning (p = 0.003) and energy fatigue (p = 0.000), suggesting that higher TIR is associated with higher scores in these domains. Conclusion Dietary interventions that improve the TIR and reduce the TAR and TBR can enhance the QoL of individuals with T2DM.

THU390 Case Report On Hirata Syndrome: A Rare Cause Of Hypoglycemia

Abstract Disclosure: M. Pranala: None. V. Kuttiyil Oommen: None. V. Sanker: None. S. Vallabhaneni: None. K. Ajith: None. A. Thomas: None. Introduction: Hirata's disease, also known as insulin autoimmune syndrome (IAS), is a rare cause of hypoglycemia that is characterized by episodes of spontaneous hypoglycemia and insulin autoantibodies in patients who have not received exogenous insulin. IAS has been associated with rheumatoid arthritis and Graves' disease in 96% of Japanese IAS patients, and it has also been associated with other autoimmune disorders like Graves' disease. Case History: We report a case of 73-year-old male presented with the complaints of episodes of profuse sweating, palpitation and numbness over his head. Patient was initially treated symptomatically and since the symptoms were not resolving further evaluation was done. Two hourly GRBS, c- peptide, insulin levels and serum cortisol of our patient was monitored. Patient had extremely high serum insulin levels. Serum insulin antibodies level was also high (>300 U/ml). CT abdomen ruled out pancreatic pathology. It has been speculated that hypoglycemia occurring in IAS is due to dissociation of insulin from its antibodies in the post absorptive state. Our patient was diagnosed with IAS based on the criteria of Hirata. The age at onset, sex, and duration of hypoglycemic attacks, outcome or treatment, medication taken prior to the onset of IAS and background disease were all taken into consideration. In our patient, hypoglycemia occurred spontaneously in the post-absorptive state 4–6 hours after meal rather than after a 72-hour fast test. Extremely high levels of insulin (>200 µIU/mL) and Serum insulin antibodies found to be >30 U/ml were constructive in the diagnosis of IAS. The patient improved on dietary management alone consisting of frequent small meals. Conclusion: In order to facilitate early recognition and prevent unnecessary investigations, this could be the most significant syndrome in the differential diagnosis of endogenous hyper-insulinemic hypoglycemia (EHH). In such patients with a high index of suspicion, insulin autoantibodies should be examined. IAA prevents insulin to bind its receptor in the postprandial phase, possibly resulting in mild hyperglycemia; thereafter, insulin is released from the complexes irrespective of blood glucose concentrations, thus inducing hypoglycemia Presentation: Thursday, June 15, 2023

A Case Study on PCOS

Polycystic ovary syndrome (PCOS)is a condition in which the ovaries produce an abnormal amount of androgens, male sex hormones that are usually present in women in small amounts. Features of PCOS in this case are oligomenorrhoea and left ovary bulky (not meeting criteria of Rottadarm,10cm size, >10 follicles, >10 mm follicles). Her symptoms aggravated leading to hospitalization with hypoglycaemia. Initial work up showed decreased gonadtrotpins and raised insulin levels with raised prolactin and with behavioural therapy and small frequent meals there is no recurrence of hypoglycaemia. Initial work up showed decreased gonadtrotpins and raised insulin levels with raised prolactin and with behavioural therapy and small frequent meals there is no recurrence of hypoglycaemia and has normalization of FSH, LH, Estradiol and prolactin with normal insulin levels. Clinical and biochemical profile is suggestive of functional Hypothalamic Amenorrhoea.

ODP554 insulinoma with a delayed diagnosis of 25 years

Abstract Introduction Most insulinomas are rare pancreatic neuroendocrine tumours that are typically sporadic, solitary, with the great majority less than 2cm in diameter at presentation 1; fewer than 5% of insulinomas are larger than 3cm, and in such cases are not infrequently malignant. The median duration of symptoms before diagnosis is variable, but is usually brief, often just 12–18months, although longer durations are occasionally reported. We report the case of a benign insulinoma whose diagnosis was delayed for 25 years, and who eventually presented with a relatively large but benign tumour >4cm in diameter. Case presentation The patient was a50year-old male who presented to our service with a history of hypoglycaemia episodes dating back 25 years. The first, whilst living in Pakistan, he became unwell on his wedding day and was found to have an unspecified but very low blood glucose, confirmed at his local hospital. Since that time, he reported that he had "learned to live with the symptoms" by eating frequent small carbohydrate-rich meals, although missing a meal led to typical hypoglycaemic symptoms. He continued this regimen on moving to the UK, but over a recent period of three months he reported a substantial deterioration in his symptoms(confusion, disorientation, slurred speech, generalised weakness, tachycardia and palpitations), and indeed collapsed on two occasions. He had a fasting glucose of 2.9 mmol/L with grossly elevated and inappropriate insulin and C-peptide level, with a normal cortisol response to Cosyntropin. MRI demonstrated asingle4.1cm lesion in the body of the pancreas, however 68 Gallium-DOTATATE-PET scanning showed no uptake at any site. Accordingly, he was started on diazoxide 50mg tds and referred to the surgical team for distal pancreatectomy: histopathology revealed a 4.4 cm well-differentiated pancreatic neuroendocrine neoplasm of intermediate grade (NET G2, 2017 WHO Pancreatic-NET classification) which immunostained positive for insulin. Post-operatively, his hypoglycaemic episodes have ceased and he remains under active surveillance. Conclusion The great majority of insulinomas are small benign tumours, with a short history, with large tumours often indicating malignancy. Our case demonstrates that untreated and without specific therapy, such tumours may continue to grow and attain a large size without this indicating malignant potential. 68 Gallium-DOTATATE-PET is negative in more than 50% of benign insulinomas. We believe that this represents the longest survival, 25 years, of a patient with a benign insulinoma in the absence of treatment. Presentation: No date and time listed

S2432 A Rare Case of Dysphagia Megalatriensis Presenting With Acute Decompensated Heart Failure

Introduction: Dysphagia is a common complaint that can manifest in a large variety of conditions. Dysphagia megalatriensis is a rare cause of esophageal dysphagia and is caused by extrinsic compression of the esophagus by a dilated left atrium. This results in solid food dysphagia in the mid-distal esophagus. Symptoms can be minimal to debilitating. Case Description/Methods: A 52-year-old male with a past medical history of dilated cardiomyopathy and heart failure with ejection fraction less than 25% presented with acute decompensated heart failure and NSTEMI. The patient reported that for the past few months he had a sensation of solid food getting stuck in his mid-chest. He denied any alcohol or tobacco use, hematemesis, nausea, or vomiting. On physical examination, the patient had no abdominal pain or distention. He denied any weight loss or family history of cancers. Vital signs were stable on admission and laboratory testing revealed an elevated troponin of 0.23 ng/mL, creatinine of 1.43 mg/dL, and INR of 2.4. He was started on 40 mg pantoprazole twice a day, upper GI series was ordered which showed smoothly marginated extrinsic compression on the esophagus related to cardiomegaly. The narrowing was positional and most pronounced in the antero-posterior (AP) plane. This was worse during atrial dilation in the cardiac cycle and resulted in delayed emptying of the upper and middle esophagus. Figures A and B show extrinsic compression in diastole and systole respectively. The patient was advised to have small frequent meals and aggressive diuretic therapy was performed. These measures resulted in the improvement of his symptoms. Discussion: This case highlights the importance of the recognition of dysphagia secondary to cardiomegaly. Patients typically have mitral valve stenosis (cause of atrial dilation) which was not present in our case. Although rare, dysphagia megalatriensis can be an early sign of impending decompensation in heart failure patients [1]. In our case, the patient’s dysphagia developed weeks before decompensated heart failure. Hence this condition should be identified sooner than later. Barium esophagram yields the best diagnostic results while diet and diuretics are the cornerstones of therapy. The most severe complication is fatal atrioesophageal fistula formation.Figure 1.: A: Mid and distal extrinsic esophageal compression during cardiac diastole. B: Mild resolution of extrinsic compression during cardiac systole.

Frequent Snacks Improved Energy Intake and Nutritional Status in Community-Dwelling Older Adults at Risk of Malnutrition, Chiang Mai, Thailand

Background: Inadequate dietary intake and malnutrition are commonly found in older adults. They tend to have early satiety that limits intake from main meals. Some reports indicated that small frequent meals may promote higher intake. From that point of view, snacks may be useful. Therefore, this study aimed to determine the effects of frequent snacks on energy intakes and nutritional status in older adults at risk of malnutrition. Methods: A randomized controlled study was conducted among older adults at risk of malnutrition in a suburban community from November 2020 to March 2021 in Chiang Mai, Thailand. Two villages were randomly assigned to either a control group (n=17) or an intervention group (n=17), and they were matched pairs by age and gender. An intervention snack consisted of 2 desserts and a box of milk (total 548 kcal) was used. For the first 3 weeks, an intervention snack was provided every day although it was too heavy for some participants. Therefore, after that, the intervention snack was provided every other day for 4 weeks. A nutrition survey by the 24-hour recall method for 3 days, body weight, mid-arm circumference (MAC), triceps skinfold (TSF), and grip strength were assessed at weeks 3 and 7 as baseline. Results: Thirty-one participants completed the study (91%). The average age was 71.8±4.8 years, and body mass index (BMI) was 19.0±2.1 kg/m2 . In the intervention snack group, there was an increased daily energy intake by 316 kcal and 214 kcal at weeks 3 and 7, respectively, (P<0.001, effect size: 0.884), with a body weight of 0.8 kg (P<0.001, effect size: 0.314), BMI of 2% (P=0.009, effect size: 0.314), and MAC of 4% (P<0.001, effect size: 0.265) compared with baseline, but such energy intake was not observed in the control group. Conclusion: Providing frequent snacks was an effective way to improve energy intake and nutritional status in community-dwelling older adults at risk of malnutrition.

Hypoglycemia due to insulin autoimmune syndrome (Hirata’s disease): a rare cause of hypoglycaemia

Although the most common cause of recurrent hypoglycaemia is diabetes mellitus as patient is on antidiabetic medications which can be prevented by modification of antidiabetic doses, nutrition therapy and lifestyle modifications. Some endogenous hyperinsulinemic conditions like insulinoma, functional beta cell disorders and insulin autoimmune syndromes, hormonal deficiencies can cause serious and sometimes life threatening hypoglycaemia. So further laboratory evaluation like plasma/serum glucose levels, c-peptide levels, insulin levels, insulin antibodies and imaging studies are needed to evaluate unexplained hypoglycaemia. Here we report a case of insulin autoimmune syndrome in a 67 year old Indian male who had presented to us with multiple episodes of spontaneous hypoglycaemia. On further workup, the patient was found to have endogenous hyperinsulinemic hypoglycemia. As the patient’s abdominal imaging revealed no apparent cause of EHH, on further evaluation he came positive for insulin antibodies. Patient was diagnosed as IAS and he was given frequent small meals and complex carbohydrate diet and he had improved symptomatically. The incidence of IAS is most common in Japan and very few cases have been reported from India, so it should be kept in differential diagnosis of recurrent hypoglycaemia.

“The Unusual Suspect” - Insulin Autoimmune Syndrome, an Extremely Rare Cause of Hypoglycemia

Background: Insulin autoimmune syndrome (IAS), also called Hirata syndrome, is a rare diagnosis which is characterized by hypoglycemia, normal or elevated fasting insulin level, and elevated anti-insulin antibody titers. Clinical Case: 45-year-old nondiabetic Caucasian female presented to the emergency department (ED) with chief complaint of near-syncope. She reported difficulty concentrating and feeling faint roughly 1 hour after consuming breakfast. Upon ED arrival, fingerstick glucose (FSG) was 47 mg/dL. Her symptoms resolved with ingestion of orange juice and repeat blood glucose (BG) 15 minutes later was 120 mg/dL. She reported similar symptoms in the last 5 years happening “every few months” without a predictable pattern; twice with witnessed loss of consciousness. Workup for syncope in the past included normal neurologic, cardiac, and tilt-table testing. She had no prior low FSG/BG recorded, no personal history of bariatric surgery or family history of diabetes mellitus and no access to antihyperglycemic medications. Past medical history included ulcerative colitis and medications included sulfasalazine and multivitamins. Pertinent review of systems was negative for weight loss, nausea, and diarrhea. Vital signs were within normal limits. Physical exam was unremarkable. Height was 165 cm, weight 67.8 kg and body mass index 24.9 kg/m2. Blood draw after overnight fast revealed BG of 78 mg/dL, C-peptide 0.7 ng/mL (ref range 0.8–3.5), insulin 10 µIU/mL (3–19), proinsulin <1.6 pmol/L (<8.0), insulin-like growth factor-2 (IGF-2) 339 ng/mL (180–580) and insulin antibody level 10.0 U/mL (0.0–0.4). She was managed conservatively with frequent small meals and patient has continued to do well without recurrence of symptoms. Conclusion: IAS is an exceedingly rare disease entity with about 460 cases described in literature, mostly in patients of Asian descent. Workup for hypoglycemia in non-diabetic patients should include insulin antibody titers to rule out IAS. There appears to be a genetic predisposition to developing IAS in patients with major histocompatibility complex (MHC) genes HLA-DQA1, HLA-DQB1 and HLA-DRB1. It is now being more frequently described in patients of non-Asian descent, particularly those with other autoimmune or plasma cell dyscrasias. It is also associated with drugs containing sulfhydryl groups and viral infections. Treatment should be tailored to severity of disease. Most drug induced IAS resolves after cessation of culprit drug. Conservative management is usually the first step with frequent, low carbohydrate meals with diazoxide or octreotide as adjunctive options. Immunosuppression (high-dose prednisolone or rituximab) and plasma exchanged are reserved severe or refractory cases.

Refractory Hypoglycemia Related to Gastric Bypass Complicated by Hypothyroidism

A 29-year-old African-American female was brought to the emergency department for sudden onset nausea, dizziness, and loss of consciousness at work. She was found to have low blood sugar and was fed with juice and crackers. She had history of similar episodes in the past, migraine headache, post-thyroidectomy hypothyroidism, seizures, generalized anxiety disorder, gastroesophageal reflux disease, and Roux-en-Y gastric bypass 9 months ago for morbid obesity related refractory Pseudotumor Cerebri (failed VP Shunting). She lost 41 kg, and had intolerance to foods from dumping syndrome. Her vital signs were within normal limits upon arrival to the ER. Laboratory parameters were remarkable for hypoglycemia of 52 mg/dL. She was immediately given dextrose intravenously. ECG showed sinus bradycardia. Though she regained consciousness, her blood sugar levels were persistently low, the lowest recording being 43 mg/dL. She was placed on a continuous D10 infusion. Further investigations revealed negative toxicology screens for 1st and 2nd generation sulfonylureas, and normal insulin levels at the time of the hypoglycemic event. Her TSH was found to be very high (99 nIU/mL). Her thyroglobulin (2.8 ng/mL), free T4 (0.25ng/dL), thyroglobulin antibody (99.18 uIU/mL), cortisol levels in morning (14.2 ug/mL), and evening (4.6 ug/dL) were found to be within normal range. Abdominal MRI did not reveal Insulinoma or any other pathology. Repeat ECG showed normal sinus rhythm with occasional PVCs. She was treated for nausea with ondansetron, promethazine, scopolamine, and dronabinol. Dextrose infusion was titrated down with rise in blood sugar levels. She confessed non-compliance to thyroid replacement. Therefore, she was initially treated with intravenous thyroxine replacement, which was later switched to oral therapy. Psychiatry evaluation ruled out any eating disorder. She was counselled to eat small frequent meals, increase dietary proteins, and restrict high glycemic index sugars. Educational value: National data indicates an increasing trend for admissions related to morbid obesity and bariatric procedures, especially laparoscopic (vertical) sleeve gastrectomy (see Fig 1). (1) Complex alteration in the signaling pathway to pancreas owing to changing metabolism causes hypoglycemia after bariatric surgery. When compounded by severe untreated hypothyroidism, as in our case, causes severe hypoglycemia needing hospitalization. Patient education for adjustment in dietary habits would have played a key role in preventing episodes of severe hypoglycemia.Reference:1.HCUPnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD. https://hcupnet.ahrq.gov/.Fig 1: Trends for admissions for Morbid Obesity and Sleeve Gastrectomy

SAT-117 Refractory Paraneoplastic Non Islet Cell Tumor Hypoglycemia (NICTH) from Hepatocellular Carcinoma Managed with Somatostatin Analogue and Glucocorticoids

Non islet cell tumor hypoglycemia (NICTH) is a rare paraneoplastic syndrome generally seen in tumors of mesenchymal and hepatic origin. This syndrome is characterized by life threatening hypoglycemia caused by over expression of high molecular weight insulin-like growth factor 2 (IGF 2). The main stay of treatment is surgical resection of the tumor with no clear medical management being reported as standard of care.We present the case of a 72 year old Cambodian man with no history of diabetes mellitus who presented to our institution with severe hypoglycemia complicated by a seizure and was found to have hepatocellular carcinoma (HCC). Hypoglycemia occurred during times of fasting. Laboratory evaluation revealed a serum glucose of 30mg/dl with insulin level of 2.2 mcIU/mL [2.6 - 24.9 mcIU/ml], C-Peptide of 0.17 ng/mL [0.80 - 3.85 ng/ml], BHB <0.1 mmol/L [0.0 - 0.3 mmol/L] and Proinsulin of <0.4 pmol/L [< or = 18.8 pmol/L]. Hypoglycemic agents screening was negative. Insulin Antibody was negative <0.4 U/mL [<0.4 U/mL] and adrenal insufficiency and hypothyroidism was ruled out. Patient was found to have an elevated IGF 2: IGF 1 ratio of 78 confirming the diagnosis of NICTH. IGF 2 level was 780 ng/ml [333 - 967 ng/ml] while IGF-1 was < 10 ng/ml [32-200 ng/ml] He was not a candidate for surgery due to portal vein involvement and tumor radioembolization was unsuccessful. Despite Prednisone dose of 10 mg twice daily and frequent complex carbohydrate meals, he still continued to have hypoglycemia ultimately requiring hospitalization. During hospitalization, he was treated with 50% dextrose infusion, 37.5 grams of dextrose gel every three hours and frequent small meals. Hypoglycemia remained refractory and a trial of diazoxide was ineffective. He was then started on octreotide with titration to 100mg every 8 hours with significant reduction in hypoglycemic episodes. He continues to remain on octreotide, Prednisolone 20mg twice a day, dextrose gel and dextrose infusion. Goal is to wean dextrose infusion and transition him to Pasireotide 40mg monthly.Hepatocellular carcinoma has been associated with NICTH in the literature. NICTH is characterized by an IGF2:IGF1 ratio >10 as there is no commercially available assay for big IGF II. Definitive treatment involves surgical resection or tumor debulking. Octreotide has antiangiogenic and antineoplastic properties and unfortunately, few studies have shown improved survival and quality of life in patients with advanced HCC. In the case of our patient, tumor was unresectable and NICTH improved with octreotide and prednisolone.

The Impact of a 4-Week Low-FODMAP and mNICE Diet on Nutrient Intake in a Sample of US Adults with Irritable Bowel Syndrome with Diarrhea

BackgroundA diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has gained increasing acceptance for the treatment of irritable bowel syndrome but safety concerns have been raised regarding nutritional adequacy. Changes in nutrient intake during the elimination phase of the low-FODMAP diet remain predominantly unknown. ObjectiveTo determine changes in the mean reported daily nutrient content before and after 4 weeks of a low-FODMAP diet vs modified National Institute for Health and Clinical Excellence (mNICE) dietary intervention and to identify nutritional inadequacies based on comparison to the Dietary Reference Intakes in patients with irritable bowel syndrome-diarrhea subtype. DesignPost hoc analysis of a randomized controlled trial entailing a 4-week trial period comparing the low-FODMAP and mNICE diets. Participants and settingA total of 78 patients (41 low FODMAP and 37 mNICE) meeting the Rome III criteria for irritable bowel syndrome-diarrhea subtype were consecutively recruited from gastroenterology and primary care clinics at the University of Michigan Medical Center between October 2012 and November 2015. MethodsParticipants randomized to the low-FODMAP arm were instructed to decrease their dietary intake of FODMAPs, whereas participants randomized to the mNICE intervention arm were instructed to eat small frequent meals, avoid trigger foods, and avoid excess alcohol and caffeine. Main outcome measuresPost hoc evaluation for presence of micronutrient deficiencies per Dietary Reference Intakes when implementing low-FODMAP vs mNICE dietary interventions. Dietary intake was analyzed via 3-day food diaries at baseline and during the final week of the assigned diet. Statistical analyses performedA post hoc analysis utilizing either a t test or χ2 analysis was conducted between before and after data. ResultsBoth diets resulted in fewer daily kilocalories consumed, fewer number of daily meals consumed, and less daily carbohydrate intake. Among the patients following the low-FODMAP diet, there was a statistically significant decrease from baseline in several micronutrients, which was not observed in the mNICE cohort. However, these differences in the low-FODMAP group remained significant only for riboflavin after correcting for calorie-adjusted nutrient intake. Comparing Dietary Reference Intakes of participants pre- and postintervention, fewer patients met the Dietary Reference Intakes for thiamin and iron in the low FODMAP group, and for calcium and copper in the mNICE group. ConclusionsDuring a 4-week dietary intervention, the mean daily intake of most micronutrients remained stable and within the Recommended Dietary Allowances for both diets. Although decrease in several micronutrients was observed with implementation of the low-FODMAP diet relative to the mNICE diet, most of these disappeared after adjusting for energy intake.

MON-134 Use of CGMS for Evaluating Hypoglycemia in Non-Diabetic Patients

Introduction: Continuous Glucose Monitoring System (CGMS), is a tool for measuring blood glucose (BG) levels in patients with Diabetes Mellitus (DM). Post-prandial Hypoglycemia (PPH) is a known complication of Roux-en-Y gastric bypass (RYGB). We present two cases of PPH following RYGB, confirmed by CGMS. Case 1: 70-year-old non-diabetic male, with RYGB 20 yrs. ago, presented with episodes of tremors, generalized weakness and blurring of vision, lasting about 10-15 min, occurring after eating simple carbohydrate foods. Onset and duration of episodes were unclear. In clinic, a POCT BG was 40 mg/dl with symptoms after eating doughnuts prior to the visit. VS- BP 122/58 Sitting, BP 108/57 Standing, P 87/m, Wt. 70.9 kg, BMI 22.mkg/m². Labs: BG 74 mg/dL, Sulphonylurea screen-negative, Cortisol AM 15.4 ug/dL, ACTH 23 pg/mL, C-Peptide 1.31 ng/mL (nl 0.81 - 3.85), Fasting Insulin 4.5 mIU/L (nl 0.0 - 24.9), IGF-I 76 ng/mL (nl 41 - 279), IGF-II 299 ng/mL (nl 267 - 616), BOH-butyrate 0.377 mmol/L (nl 0.020 - 0.270); IA-2 Ab <0.8U/mL (nl <0.8 U/mL). CGMS for 15 days-multiple episodes of PPH. Patient was advised to follow high protein, low carbohydrate diet, later started with Acarbose therapy. CGMS was repeated 3 months later, with marked reductions in PPH. Case 2: 32-year-old male, with RYBG 5 years ago, resulting in 150 lbs. weight loss, presented to clinic for progressive episodes of hypoglycemia. He did not test BG on a regular basis, but when tested occasionally in the morning, reported BG were 90-199 mg/dl, unless he skipped a bedtime snack. Patient reported having one episode when he woke up in the middle of the night “jittery and sweaty,” and BG was 37 mg/dl. His symptoms resolved after juice. He reports not being able to eat large meals and has been eating frequent small meals. He noted symptoms of hypoglycemia, when he eats simple carbohydrates. He also reported some high BG levels (170-180 mg/dl) although he is not previously known to have DM. VS-BP 115/67, HR 67; no orthostasis; Wt 287 lbs, BMI 45. Kg/m². POCT Glucose 64, Fasting Labs: BG 86 mg/dL, HbA1C 5.8%, C-Peptide 1.48 ng/mL, BOH-butyrate 0.7 mmol/L, Cortisol AM 12.2 ug/dL, Insulin Fasting 8.0 mIU/L, Proinsulin 2.4 pmol/L (nl ≤8.0), Insulin Antibody <0.4U/mL (nl 0.0-0.4 U/mL). CGMS for 2 weeks demonstrated repeated PPH and nocturnal hypoglycemia. Diet changes were recommended. Discussion: CGMS compared to blood glucose monitoring, is more efficacious in recording hypoglycemic events, especially if hypoglycemia occurs between testing times, or in usual settings like PPH. Current guidelines recommend use of CGMS in DM patients with hypoglycemic unawareness, nocturnal hypoglycemia, postprandial hyperglycemia. In our cases, CGMS was proven to be effective in diagnosing PPH in RYBG patients. CGMS is also an efficient device to measure therapeutic responses and avoiding hypoglycemia, as well as improving quality of life.

MON-491 Persistent Isolated Hypophosphatemia after Intravenous Ferric Carboxymaltose Infusion in a Patient with Total Gastrectomy

Introduction: Intravenous ferric carboxymaltose infusion has been reported by the FDA to cause hypophosphatemia in 2.1% of patients, with transient low phosphorus level (<2mg/dL) observed in 27% of patients. We present a case of persistent hypophosphatemia where intravenous iron appeared to be a significant contributing cause. Clinical case: A 45 year old woman presented with generalized weakness at an outpatient visit and was discovered to have hypophosphatemia with a lab value of 0.9 mg/dL (ref 2.7 – 4.5 mg/dL). She has a history significant for Non-Hodgkin’s Lymphoma (non-Burkitt’s) at age 16 (s/p chemotherapy at age 18),gastroparesis requiring a jejunostomy tube followed by a total gastrectomy 4 months before admission and reactive hypoglycemia from late dumping syndrome due to gastrectomy. Her nutritional intake consisted of small frequent meals along with tube feedings with no recent change in her diet and taking adequate calcium and vitamin D supplements. Nine days prior to this admission, she had a IV ferric carboxymaltose infusion and a phosphorus level of 0.9 mg/dL discovered on outpatient labs. Before the infusion, she had a normal phosphorus level of 3.2 mg/dL, calcium 9.2 mg/dL (ref 8.5-10.5mg/dL) and magnesium 2.3 mg/dL (ref1.6-2.6mg/dL). Blood tests during admission (two weeks after infusion and one week after initial 0.9 mg/dL level) showed phosphorus level 1.3mg/dL, calcium 9.0 mg/dL, magnesium 2.5 mg/dL and albumin 4.6 (ref 3.4-4.8mg/dL). Further in hospital work-up showed intact PTH 111 (ref 11-95 pg/mL), prealbumin 14.5 (ref 14-38 mg/L), Vitamin D 25(OH)-D3 24 (ref20-100 ng/mL) and Vitamin D 1,25(OH)2 15 (ref 18-72 pg/ml) and increased FGF23 204 (ref <180 RU/mL). A 24 hour urine collection was notable for increased urinary phosphorus of 1343 mg(ref<1100mg/day). Phosphorus was repleted with IV potassium phosphate during admission and she was discharged on oral potassium phosphate 500mg PO BID which was later increased to TID. She was also advised to eat a diet high in phosphorus. She was followed as an outpatient and her phosphorus levels remained <2.1 mg/dL for 4 weeks after the IV ferric carboxymaltose infusion returning to normal thereafter. Conclusion: Although gastrectomy with poor nutrition may cause hypophosphatemia, it is worth considering other etiologies in the setting of persistently low phosphorus levels. With correlative evidence of high urinary phosphorus excretion in the setting of low serum phosphorus and elevated FGF23, we believe that IV ferric carboxymaltose infusion may have been a major contributor to hypophosphatemia in our patient. FGF23 is known to be a “phosphatonin” and ferric carboxymaltose may inhibit FGF23 degradation in osteocytes leading to an increase in its levels. Phosphate levels should be monitored before and after parenteral ferric carboxymaltose infusion, which can persist for weeks.

Insulin Autoimmune Syndrome Diagnosis and Therapy in a Single Chinese Center

PurposeInsulin autoimmune syndrome (IAS) is a relatively rare cause of hypoglycemia characterized by endogenous hyperinsulinism and autoantibodies against endogenous insulin despite no prior exposure to exogenous insulin. We present a series of IAS cases and describe the clinical characteristics of these cases. MethodsThe medical records of inpatients with the final diagnosis of IAS were collected from August 2007 to August 2017 in Peking Union Medical College Hospital. Clinical characteristics and laboratory test results were summarized. The results of serum glucose, insulin, true insulin, and C-peptide testing during 5-h oral glucose tolerance tests were also summarized. Circulating immune complexes were assessed qualitatively by precipitation with polyethylene glycol (PEG) in some patients. FindingsSixteen patients were included in this study. Insulin autoimmune antibody test results were found positive in 12 patients and weakly positive in 1 patient. Nine patients had an insulin to C-peptide molar ratio >1, whereas 6 patients had an insulin to C-peptide molar ratio <1. Circulating immune complexes were verified in all 4 patients who had been assessed with PEG. During 5-h oral glucose tolerance tests, the C-peptide level responded earlier to the glucose tolerance and had a shorter peak value period compared with insulin, although C-peptide's fluctuation still lagged behind the glucose fluctuation. Three patients presented with self-limited disease courses or limited disease course after discontinuing use of the sulfhydryl group drugs. Some patients' symptoms were relieved after small frequent meals, and some were relieved after taking acarbose. Only 3 patients took glucocorticoids as the anti-immune therapy. ImplicationsThe insulin to C-peptide molar ratios were not consistently >1 in patients with confirmed diagnoses of IAS in our study, which suggested the low sensitivity of insulin to C-peptide molar ratio to detect IAS. The therapy in our study also revealed the self-limited disease course of IAS, and despite the effectiveness of anti-immunity therapy, convenient therapy, such as frequent small meals and adding acarbose, performed well in many patients.

The Management of Nausea and Vomiting of Pregnancy: Synthesis of National Guidelines.

Nausea and vomiting of pregnancy (NVP) affects a high proportion of the pregnant population. The aim of this study was to compare and synthesize recommendations from national guidelines regarding the management of NVP. A descriptive review of 3 recently published national guidelines on NVP was conducted: Royal College of Obstetricians and Gynaecologists on "The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum," American College of Obstetricians and Gynecologists on "Nausea and Vomiting of Pregnancy," and Society of Obstetricians and Gynaecologists of Canada on "The Management of Nausea and Vomiting of Pregnancy." These guidelines were summarized and compared in terms of the recommended management of pregnant women. The quality of evidence was also reviewed based on the method of reporting. Several differences were identified on the different guidelines regarding the management of NVP. Frequent small meals and avoidance of iron supplements are recommended for prevention. The consumption of ginger, acustimulations, antihistamines, phenothiazines, dopamine, and serotonin 5-hydroxytryptamine type 3 receptor antagonists is routinely recommended for use in the community as treatment. Evidence-based medicine may lead to the adoption of an international guideline for the management of NVP, which may lead to a more effective management of that entity.

Glycosuria and hyperglycemia in the neonatal period as the first clinical sign of Fanconi-Bickel syndrome

Fanconi-Bickel syndrome is a rare inherited disease characterized by the combination of hepatorenal glycogen accumulation, proximal renal tubular dysfunction and impaired utilization of glucose and galactose. The first symptoms of the disorder are recognized in late infancy as clinical characteristics appear. Therapeutic approach is mainly conservative with supplements of calcium, phosphate and vitamin D and small frequent feedings to avoid hypoglycemia. We report 1 clinical case of very early diagnosis, a 19 days old baby girl, in which the first clinical sign of the disease was the detection of glycosuria and vomits. Serum alkaline phosphatase levels were very high without rickets. The patient presented postprandial hyperglycemia and fasting hypoglycemia. A complete 24-hour glucose profile was obtained using a continuous glucose monitoring system in real time, which was fundamental not only for the diagnosis but also for the prevention of hypoglycemia. She received frequent small meals, galactose-free milk diet, and oral intakes of calcium, phosphorum, bicarbonate and vitamin D supplements with good evolution and normal height and weight gain.

Nutrition Needs for Patients With Head &amp; Neck Cancer

Nutrition Needs for Patients With Head &amp; Neck Cancer

Incretin Kinetics Before and After Miglitol in Japanese Patients With Late Dumping Syndrome.

BackgroundIn patients with late dumping syndrome following gastrectomy, it has been reported that hypoglycemia occurs due to inhibition of glucagon secretion as a result of excessive insulin production facilitated by an increase in glucagon-like peptide-1 (GLP-1).MethodsTo determine the kinetics of incretins in Japanese patients with late dumping syndrome, an oral glucose tolerance test was carried out before and after miglitol administration, and the kinetics of insulin and incretins were analyzed.ResultsAfter miglitol administration, there was improvement of hypoglycemia and early phase insulin secretion, with persistent excessive insulin secretion being minimized. These findings revealed that miglitol inhibited rapid excessive influx of carbohydrates into the blood and persistent elevation of GLP-1, resulting in improvement of early phase insulin secretion and minimizing persistent excessive insulin secretion.ConclusionsEating frequent small meals is generally effective for late dumping syndrome, but patients often find it difficult to continue such a regimen. Based on the present analysis of incretin kinetics, miglitol may be a useful treatment option for late dumping syndrome.

Tretman novorođenčeta s apstinencijalnim sindromom

Narcotic neonatal abstinence syndrome (NAS) is a collection of signs and symptoms exhibited by a newborn mothers of drug addicts. Fetal alcohol syndrome (FAS) exhibits a newborn whose mother during pregnancy, alcohol consumed. The incidence of NAS and FAS is very difficult to determine because of unreliable data on the use of drugs and alcohol during pregnancy and limited diagnostic prenatal exposure to drugs and alcohol newborn. It is a multisystem disorder, most frequently involving central nervous and gastrointestinal system, which is expressed irritability, prolonged high-pitched cry, tremors, convulsions, feeding and sleeping disorders, tachypnea, apnea, tachycardia, termolability and sweating, frequent hiccups, yawning and sneezing, diarrhea, vomiting and dehydration. The aim is that it is examining the available literature make a show review and draw attention to the need for care, the newborn with this problem in the first 48­72 hours of life when most often manifested clinical picture. Support measures include the child in the room darkened room to reduce sensory stimulation and irritability, frequent small meals hiperkalorijske formula to cover the additional caloric requirements, and constant observation of the rhythm of sleeping habits, gain or loss in body weight and change in clinical status, which might suggest another disease process. In these situations, it is necessary to encourage breast­feeding as the best nutrition with all its advantages, including encouraging emotional bond between mother and child or contraindicated if the mother continues to use drugs, alcohol or have infections such as HIV or hepatitis. The consumption of drugs, alcohol and other substance use during pregnancy, expectant mothers expose their children to the risk of premature birth, infection with hepatitis B or C, HIV infection, congenital anomalies, cognitive poremećajema etc. One of the key tasks of health workers to work on prevention: timely education and counseling of pregnant women with addiction problems.