PEN eNews 9(3) October 2019
PEN
® eNews is a monthly e-newsletter shared with the global PEN Community and created to help dietitians position themselves as leaders in evidence-based nutrition practice. In addition, users of the PEN System will find articles on the new evidence, resources and features available and how to maximize one's use of PEN.
Increasing Omega-3s During Pregnancy
The Question
What is the effect of increasing omega-3 fatty acid intake during pregnancy?The Evidence
Women receiving omega-3 fatty acids (primarily via supplements) during pregnancy versus women who did not had:
- less preterm birth <37 weeks and early preterm birth <34 weeks
- a possible reduced risk of low birth weight, perinatal death and neonatal care admission
- a possible small increased risk of large-for-gestational age infants (but no macrosomia)
- a probable increase in the incidence of pregnancy continuing beyond 42 weeks
- no higher rates of induction, in the few studies that examined this outcome.
There were no differences between the omega-3 groups and controls for side- or adverse effects, including no greater bleeding risks, with the exception of an unpleasant taste and belching/burping with fish/fish oil in the mothers.
The Recommendation
Increasing omega-3 intakes can be considered by women concerned about preterm birth and low birth weight. A wide variety of omega-3 supplement (DHA/EPA) doses (less than 500 mg/day to over 1000 mg/day) and additional fish servings were effective in the studies. However, dose-response data is not available and so one specific dose cannot be recommended over another at this time. Pregnant women can be encouraged to consume fish on a regular basis, consistent with
Prenatal Nutrition Guidelines.
- 5 Knowledge Pathways
- 78 Practice Questions
- 64 Client Handouts.
PEN® Client Handouts – What You Need to Know
There are hundreds of PEN-developed handouts in the PEN System; many of which have been culturally adapted and are available in a variety of languages.
Handout Collections
There are eight PEN Handout Collections:
- Breastfeeding Friendly
- Food Service
- Food Sources and Nutrients (Canada)
- Food Sources and Nutrients (U.K.)
- Health Conditions
- Healthy Living
- Nutrition Over the Lifespan
- Pediatrics
Read more about the Handout Collections in this PEN eNews article.
New and Updated Handouts
Some of our latest new and updated handouts include:
The Common Cold and Vitamin C - To Take or Not to Take?
Does vitamin C supplementation improve immune function, including preventing or treating the common cold?
- Habitual vitamin C supplementation may reduce cold severity and duration, pneumonia incidence and exercise-induced bronchoconstriction symptoms. For the general population, it does not reduce cold incidence or improve asthma outcomes, but an exception may be decreased cold incidence in individuals undergoing brief periods of heavy physical stress (soldiers and athletes).
- Treatment with vitamin C after the onset of symptoms does not reduce cold severity or duration and does not improve acute pancreatitis outcomes but may reduce pneumonia severity and hospital length of stay in individuals with low plasma vitamin C.
- Vitamin C supplements of ≤2 g/day have not been associated with adverse effects, except in individuals with severe acute pancreatitis.
To see the evidence, comments, rationale and supporting references, click here.
See the Immune System Knowledge Pathway for more information on the immune system and nutrition, including:
- Zinc
- Selenium
- Probiotics
- Sugar
- Herbal supplements
- Hot beverages, including chicken soup.
Plus, tools and resources on a variety of topics, including food safety, HIV and more!
What is the Latest with Osteoarthritis
The PEN Osteoarthritis Knowledge Pathway has been just updated! Click here to see information on:
- Weight Loss - GRADE
- Vitamins
- Herbal therapies
- Glucosamine and chondroitin - GRADE
- Omega-3 fatty acids
- Cetyl myristoleate
- S-Adenosyl-L-Methionine
- Other dietary supplements.
To see what else is new or updated in the PEN System, click here.
Are you a new PEN User?
Welcome! You will need to set up your account. Watch this video clip to see how. Find out about the PEN System with this Storyboard, tours and video tutorials. Learn more about handout customization, content alerts and building your personal library.
Jane Bellman's Surprised Finding - Balsam of Peru (BOP) Avoidance Diet
It is always refreshing to learn something completely new. Earlier this year, a caller to the Dial-a-Dietitian call centre in Newfoundland and Labrador asked for information about a Balsam of Peru (BOP) Avoidance Diet, which had been prescribed to her by her dermatologist. None of the PEN Team members had heard of this diet but discovered it is well known in the dermatology world. While the diet is related to the avoidance of some foods, the majority of avoidance is fragrances.
About Balsam of Peru
Balsam of Peru has been used for medicinal purposes since the 17th century and used in the perfume, cosmetic and soap industries, and as a flavouring for years (1-3). The official English names are balsam of Peru, balsam of tolu, santos mahogany and tolu balsam (3).
In 2007, BOP had an incidence patch-test reaction rate of 10.4% (4). Noting though, that while people may have positive patch-test reaction (are allergic to fragrances), only a few go on to have clinical allergies to fragrances (allergic contact dermatitis).
The resin from BOP comes from the tree Myroxylon (M.) balsamum, native to tropical America (from northern South America to southern Mexico) (3). The tree has been introduced and now grows in many other topical areas and is used for the production of wood, shade and as cultivated crops.
M. balsamum has mild antiseptic properties and has been used as a topical to treat superficial skin lesions and poor healing wounds (1,3). It is also added to perfumes, soaps, and cosmetics as a fragrance (3).
The M. balsamum and M. balsamum var. pereirae contain a gum or resin (Peru and Tolu balsams), which is made up of a mixture of chemicals that include cinnamic acid, eugenol and vanillin, which are used as flavourings in many food products including confectionary, baked goods, soft drinks, ice cream, gum and syrups (1,3).
Balsam-Restrictive or Avoidance Diet Description
The food avoidance diet has been noted to be most effective for individuals who are allergic to BOP but did not improve after removing external fragrances (2), and in particular those who continue to have symptoms of a reaction (typically reddening, swelling, ulcers and skin eruptions) (3,5).
The diet consists of avoiding foods that contain the balsam, which include citrus fruit, tomatoes and certain spices (particularly cinnamon, vanilla and cloves) and food containing these spices, such as baked goods, condiments and liquors (2,6). Other potential triggers include chocolate and colas (2).
In a 2019 review paper (1) the author directs the reader to the Dermatitis Academy Balsam of Peru Diet, which provides lists of processed foods and drinks that often contain ingredients high in BOP and of primary ingredients such as vanillin, eugenol and cinnamon with the suggestion to start with avoiding citrus; spices such as cinnamon, cloves, vanilla and curry and products containing these spices; ice cream; flavoured beverages and colas; and tomatoes.
A fact sheet from the Contact Dermatitis Institute describes both products and foods that may contain BOP.
Critical Review of the Diet
In the 2019 critical review of the literature regarding the usefulness of restrictive diets in individuals allergic to the resin, the author concluded that the value of a low balsam diet is not clear cut. More scientifically sound, current studies are needed to assess the effect of dietary restrictions on the improvement of symptoms. Until that time, suggestions within the paper included:
Individuals with dermatitis, especially systemic allergic and those with positive patch test reactions to M. pereirae, may benefit from a diet that restricts foods containing balsams and spices such as cinnamon, cloves and vanilla.
The diet can be tried for at least four weeks. If there is significant improvement to the dermatitis, the diet can be followed long term.
Following four weeks, individuals can try reintroducing a food group into the diet every few weeks to test if the dermatitis worsens (1).
A suggestion made by Scheman, et al., is that individuals can try dividing the food allergens in M. pereirae into these groups: eugenol, cinnamate, vanillin, benzoate, ferulic acid and coniferin to better target which foods and drinks should be avoided (7). Refer to this reference for more details.
Note: Information on this topic will be incorporated into the PEN Adult Allergy Background in the near future.
References
- De Groot AC. Myroxylon pereirae resin (balsam of Peru) – a critical review of the literature and assessment of the significance of positive patch test reactions and the usefulness of restrictive diets. Contact Dermatitis. 2019 Jun;80(6):335-53. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30843216
- Katta R, Schlichte M. Diet and dermatitis; food triggers. J Clin Aesthet Dermatol. 2014 Mar;7(3):30-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/24688624
- Pasiecznik N. Myroxylon balsamum (Peru balsam). In: Invasive Species Compendium. 2018. Available from: https://www.cabi.org/isc/datasheet/35225
- Storrs FJ. Allergy of the year: fragrance. Medscape. 2007. Available from: https://www.medscape.com/viewarticle/559985_2
- Avalos-Peralta P, García-Bravo B, Camacho FM. Sensitivity to Myroxylon pereirae resin (balsam of Peru). A study of 50 cases. Contact Dermatitis. 2005 Jun; 52(6):304-6. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/15932578
- Salam TN, Fowler JF. Balsam-related systemic contact dermatitis. J Am Acad Dermatol. 2001 Sep;45(3):377-81. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/11511833
- Scheman A, Rakowski EM, Chou V, Chhatriwala A, Ross J, Jacob SE. Balsam of Peru: past and future. Dermatitis. 2013;24:153‐60. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/23857009
Written by:
Jane Bellman MEd, RD
PEN Resource Manager
How is PEN® “GRADE”ing the evidence for you?
Reposted from PEN eNews June 2016
PEN® has joined more than 100 organizations around in the world in using the GRADE system! To help dietitians understand the advantages of the GRADE system, how it will it impact what we see in PEN, and how as dietitians we can interpret and use this information in our practice, we presented The new face of PEN®: “GRADE”ing the evidence for you at the national Dietitians of Canada Annual Conference.
GRADE stands for Grading of Recommendations, Assessment, Development and Evaluation.
GRADE recommendations have two parts:
- Reviewing the evidence and indicating the quality of evidence, from high to very low.
- Our confidence in the actual results decreases with decreasing quality of evidence. For high quality evidence, we can be very confident in a result (called the effect estimate) or have little confidence in the effect estimate for very low quality evidence. We looked at examples of evidence tables to gain an appreciation of the factors considered in assessing the quality of evidence.
- Making a recommendation and indicating how strong a recommendation is. Developing a recommendation for a proposed course of action involves balancing benefits and harms, patients’ values and preferences, and the resources required to implement the intervention in question. We went through examples of strong and conditional recommendations, and the justification for these recommendations.
Reviewers play a key part in the PEN GRADE process. GRADE recommendations explicitly provide the key underlying information needed to act on a recommendation. Therefore reviewers’ feedback is necessary in several steps of the process from question identification to developing the recommendation. International review panel (IRP) members represent academic experts and practitioners with acknowledged expertise in topic areas. IRP members may be involved in:
- Reviewing the questions and identifying patient-important outcomes
- Reviewing the search strategy and literature retrieved
- Providing feedback on the evidence tables and recommendations.
One of the many benefits of moving to the PEN GRADE process includes helping readers understand how we arrived at a recommendation, thereby making recommendations more transparent. We are currently in a transition phase with GRADE implementation into the PEN system. Some questions that deal with diagnosis or prognosis, will use our existing PEN process. We will be focusing on using GRADE for intervention questions in PEN when we update and develop new content.
Dietitians, there are opportunities for you to be involved in the PEN GRADE process:
PEN eNews
October 2019 Volume
9 (3)
A Publication of the PEN® System Global Partners,
a collaborative partnership between International Dietetic Associations.
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