Sudden unexpected death in epilepsy (SUDEP) is the most common cause of death in chronic refractory epilepsy patients. Dravet Syndrome (DS) is an infantile-onset epilepsy with severe seizures commonly due to mutations of the sodium channel gene SCN1A. DS patients have a high risk of SUDEP, but the mechanisms of death are not well defined. The principal risk factor for SUDEP is a high frequency of seizures. The recent MORTality in Epilepsy Monitoring Unit Study (MORTEMUS) reported the largest series of SUDEP cases while in Epilepsy Monitoring Units (EMUs). Most cases occurred after a generalized seizure, and were associated with both cardiac and respiratory dysfunction. None of the SUDEP cases in the MORTEMUS study had direct measurements of breathing, but visual analysis of video recording suggested that apnea occurred early in the sequence of events preceding death. Since SUDEP is always identified after death and is impossible to predict its incidence, it is not possible to run clinical trials in patients. Therefore, developing animal models of SUDEP is beneficial. In a DS mouse model with an Scn1aR1407X/+ mutation, death occurs after spontaneous and induced seizures. This postictal death is likely to be relevant to the mechanisms of SUDEP in DS patients. In a previous study, electrocardiogram (EKG) recordings from DS mice have shown that postictal death after heat-induced seizures is due to progressive bradycardia and asystole. However, postictal breathing has not been measured during experiments studying postictal death in these mice, so it is unknown if respiratory dysfunction, such as central apnea, contributes to postictal death. The first goal of this dissertation is to design and develop a mouse EMU that monitored electroencephalogram (EEG), nuchal electromyography (EMG), EKG, video, whole body plethysmography (breathing), body temperature, room temperature, and humidity from mice until the occurrence of postictal death. Using a mouse EMU we sought to evaluate the primary cause of death in multiple mouse strains with seizure-induced death, and to determine whether they have a common final pathway of death. We induced seizures acutely in multiple non-epileptic mouse strains that are prone to sudden death in response to seizures: 1) maximal electroshock (MES)-induced seizures in Lmx1bf/f/p mice, 2) MES-induced seizures in C57Bl6 mice, and 3) audiogenic seizures in DBA/1 mice. These seizures caused immediate and permanent respiratory arrest (terminal apnea) in all 3 strains of mice. In each strain, EKG activity continued for 3 to 5 minutes after terminal apnea. We interpret these data as indicating that the primary cause of postictal death was central apnea, and the resulting hypoxia then caused bradycardia and asystole. The second goal of this dissertation is to understand the mechanism(s) of SUDEP in DS. Here we found that DS patients have frequent postictal respiratory dysfunction, while cardiac activity was normal. One of these patients who had severe postictal hypoventilation later died of SUDEP. Also, we studied mice with an Scn1aR1407X/+ mutation to determine the role of respiratory dysfunction in postictal death after spontaneous and acutely induced seizures. In DS mice, death occurred after spontaneous, heat-induced, and MES seizures while monitoring in a mouse EMU. Death always occurred after a severe seizure with tonic extension. We found that both non-epileptic and epileptic mice have consistently died by the same primary mechanisms of central apnea. Death could be prevented after heat-induced and MES seizures by mechanical ventilation. We conclude that the primary cause of postictal death was central apnea that began during the seizures and induced secondary bradycardia due to the hypoxia, ultimately leading to terminal asystole. The final goal of this dissertation is to propose a new alternative dietary therapy for DS patients. Some epilepsy children with refractory seizures, especially DS patients, have been able to reduce their seizures by following a strict high-fat and low-carbohydrate ketogenic diet (KD). Although the exact anti-epileptic mechanisms of KD diet are unknown, producing ketone bodies and creating ketosis have been widely believed to contribute to the anti-epileptic effects. Our collaborator (Toshi Kitamoto, PhD, Univ. of Iowa) has found that a diet containing milk whey was able to prevent seizures in Drosophila with an orthologous sodium channel mutation. Here we tested the effect of both KD and milk whey supplementation on DS mice. Two types of KD (with and without milk additives), KD with glucose water to eliminate ketone formation, milk whey supplementation, and standard diet were administered to growing DS mice age from P16 to P40. Compared to a standard diet, all KDs, KD with glucose water, and milk whey supplementation had beneficial effects on seizure control and prevention of postictal death. Compared to a standard diet, all KDs greatly elevated ketone body levels (β-hydroxybutyrate) and mice consistently weighed less, whereas the milk whey diet had no effect on ketosis or weight. KD with glucose water did not produce high ketone levels, but mice weighed less. These results demonstrate that ketone bodies are not the main reason for the anti-epileptic property of ketogenic diets. Taken together, these data indicate it is important to obtain data on both cardiac and respiratory function to make conclusions about the mechanisms of SUDEP in both humans and animals. Data in this dissertation show that severe postictal respiratory dysfunction in DS patients may play a major role in causing SUDEP, and may be a biomarker for those at highest risk. Death in DS mice with spontaneous seizures may be directly related to the mechanism of SUDEP in humans. Defining the specific mechanisms of postictal apnea may help to identify methods for prevention of SUDEP. We propose a SUDEP prevention strategy in DS through a new alternative diet supplemented with a milk whey compound. Milk whey supplementation of diet has a great potential to prevent postictal death in an economical and non-invasive manner without detrimental metabolic outcomes, such as ketosis and weight reduction. Milk whey supplementation of diet may be a new treatment to prevent SUDEP in DS patients.

O papel da dieta na síndrome metabólica (SM) tem sido estudado em relação a cada um de seus componentes: obesidade, níveis pressóricos elevados, dislipidemia e alterações no metabolismo da glicose. Entretanto, poucos estudos avaliaram os efeitos da dieta na presença da SM como uma entidade clínica independente. O objetivo deste manuscrito foi revisar a importância dos fatores dietéticos e as recomendações dietoterápicas na SM. Estudos recentes demonstraram que o consumo de grãos integrais foi associado negativamente com a SM. Já alimentos com alto índice glicêmico foram associados positivamente com resistência à insulina e prevalência de SM. O seguimento de uma dieta mediterrânea foi capaz de reduzir o número de componentes da SM. Também a adoção da dieta DASH melhorou o perfil de todos os componentes da SM. Recomenda-se para pacientes com SM um valor energético total compatível com a obtenção e/ou manutenção do peso corporal desejável. O conteúdo de gordura, em especial o consumo de gordura saturada, e colesterol deve ser reduzido e o consumo de grãos integrais, frutas e vegetais, aumentado. Provavelmente as fibras alimentares tenham um papel importante no manejo dietoterápico da SM. Novos estudos que avaliem o papel da dieta na presença e no desenvolvimento da SM são necessários. / The role of diet in metabolic syndrome (MS) has been studied regarding each one of its components: obesity, high blood pressure, dyslipidemia, and abnormal glucose metabolism. However, few studies evaluated the effects of diet in the presence of MS as a unique independent disease. The aim of this manuscript was to review the role of dietary factors and dietary recommendations for MS. Recently some studies have demonstrated that intake of whole-grain foods were negatively associated with MS. Foods with high glycemic index were positively associated with insulin resistance and the prevalence of MS. Following a Mediterranean-style diet caused a reduction in the number of MS components. Also, the adoption of the DASH diet improved the profile of all MS components. A total daily energy intake to obtain and/or to maintain a desirable weight is recommended for patients with MS. The fat content, especially from saturated fat, and cholesterol, must be reduced and the intake of whole-grain foods, fruits and vegetables, must be increased. Probably, dietary fibers have an important role in the management of MS. New studies to evaluate the role of diet in the presence and development of MS are needed.

O papel da dieta na síndrome metabólica (SM) tem sido estudado em relação a cada um de seus componentes: obesidade, níveis pressóricos elevados, dislipidemia e alterações no metabolismo da glicose. Entretanto, poucos estudos avaliaram os efeitos da dieta na presença da SM como uma entidade clínica independente. O objetivo deste manuscrito foi revisar a importância dos fatores dietéticos e as recomendações dietoterápicas na SM. Estudos recentes demonstraram que o consumo de grãos integrais foi associado negativamente com a SM. Já alimentos com alto índice glicêmico foram associados positivamente com resistência à insulina e prevalência de SM. O seguimento de uma dieta mediterrânea foi capaz de reduzir o número de componentes da SM. Também a adoção da dieta DASH melhorou o perfil de todos os componentes da SM. Recomenda-se para pacientes com SM um valor energético total compatível com a obtenção e/ou manutenção do peso corporal desejável. O conteúdo de gordura, em especial o consumo de gordura saturada, e colesterol deve ser reduzido e o consumo de grãos integrais, frutas e vegetais, aumentado. Provavelmente as fibras alimentares tenham um papel importante no manejo dietoterápico da SM. Novos estudos que avaliem o papel da dieta na presença e no desenvolvimento da SM são necessários. / The role of diet in metabolic syndrome (MS) has been studied regarding each one of its components: obesity, high blood pressure, dyslipidemia, and abnormal glucose metabolism. However, few studies evaluated the effects of diet in the presence of MS as a unique independent disease. The aim of this manuscript was to review the role of dietary factors and dietary recommendations for MS. Recently some studies have demonstrated that intake of whole-grain foods were negatively associated with MS. Foods with high glycemic index were positively associated with insulin resistance and the prevalence of MS. Following a Mediterranean-style diet caused a reduction in the number of MS components. Also, the adoption of the DASH diet improved the profile of all MS components. A total daily energy intake to obtain and/or to maintain a desirable weight is recommended for patients with MS. The fat content, especially from saturated fat, and cholesterol, must be reduced and the intake of whole-grain foods, fruits and vegetables, must be increased. Probably, dietary fibers have an important role in the management of MS. New studies to evaluate the role of diet in the presence and development of MS are needed.

O papel da dieta na síndrome metabólica (SM) tem sido estudado em relação a cada um de seus componentes: obesidade, níveis pressóricos elevados, dislipidemia e alterações no metabolismo da glicose. Entretanto, poucos estudos avaliaram os efeitos da dieta na presença da SM como uma entidade clínica independente. O objetivo deste manuscrito foi revisar a importância dos fatores dietéticos e as recomendações dietoterápicas na SM. Estudos recentes demonstraram que o consumo de grãos integrais foi associado negativamente com a SM. Já alimentos com alto índice glicêmico foram associados positivamente com resistência à insulina e prevalência de SM. O seguimento de uma dieta mediterrânea foi capaz de reduzir o número de componentes da SM. Também a adoção da dieta DASH melhorou o perfil de todos os componentes da SM. Recomenda-se para pacientes com SM um valor energético total compatível com a obtenção e/ou manutenção do peso corporal desejável. O conteúdo de gordura, em especial o consumo de gordura saturada, e colesterol deve ser reduzido e o consumo de grãos integrais, frutas e vegetais, aumentado. Provavelmente as fibras alimentares tenham um papel importante no manejo dietoterápico da SM. Novos estudos que avaliem o papel da dieta na presença e no desenvolvimento da SM são necessários. / The role of diet in metabolic syndrome (MS) has been studied regarding each one of its components: obesity, high blood pressure, dyslipidemia, and abnormal glucose metabolism. However, few studies evaluated the effects of diet in the presence of MS as a unique independent disease. The aim of this manuscript was to review the role of dietary factors and dietary recommendations for MS. Recently some studies have demonstrated that intake of whole-grain foods were negatively associated with MS. Foods with high glycemic index were positively associated with insulin resistance and the prevalence of MS. Following a Mediterranean-style diet caused a reduction in the number of MS components. Also, the adoption of the DASH diet improved the profile of all MS components. A total daily energy intake to obtain and/or to maintain a desirable weight is recommended for patients with MS. The fat content, especially from saturated fat, and cholesterol, must be reduced and the intake of whole-grain foods, fruits and vegetables, must be increased. Probably, dietary fibers have an important role in the management of MS. New studies to evaluate the role of diet in the presence and development of MS are needed.

Background: Nutritional deficiencies are frequent in celiac disease (CeD), and one of the most common is zinc (Zn) deficiency. Supplements are often prescribed to treat Zn deficiency; however, they have been associated with adverse events and reduced absorption of other minerals. Data collected in our clinic showed that 38% of CeD patients would opt for a diet to improve Zn, however, such a diet may be challenging due to food interactions with phytic acid, which blocks Zn absorption. Therefore, the feasibility and efficacy of a Zn-optimized diet compared to supplementation is unknown. Aims: To assess the feasibility of the protocol and collect data on estimated effect sizes for secondary outcomes to plan a properly powered randomized controlled trial (RCT). Methods: We conducted an open-label, pilot RCT. CeD patients were randomized to Zn supplementation (Zn gluconate 25mg) or a Zn-optimized diet for 3 months and followed up with a 3-month pragmatic approach. We evaluated enrollment rates and adherence to both interventions. Plasma and urine Zn, stool samples, and questionnaires were collected pre- and post-intervention. Results: We enrolled 28 participants and 16 of them have completed the study. Interim analysis shows an enrollment fraction of 26% (i.e. 28/108 eligible participants), and a dropout rate of 17.9%. Eighty-two % of participants allocated to the Zn-supplement intervention and 50% in the dietary intervention were compliant at 3 months. Based on the effect size for normalization of plasma Zn at 3 months, 142 participants are required for an adequately powered RCT in the future. There were no significant differences in gastrointestinal or extra-intestinal symptoms, quality of life, anxiety and depression or adverse events between interventions. Conclusion: Based on this preliminary analysis, recruitment of participants will take 6 months longer than expected. Assessment of reasons for diet non-adherence will allow implementation of strategies to improve feasibility. / Thesis / Master of Science in Medical Sciences (MSMS)

Type 2 diabetes is a chronic metabolic disorder and the seventh leading cause of death in the United States. Type 2 diabetes is linked to many chronic diseases, including cardiovascular disease, stroke, and chronic kidney failure. African American adults have a high prevalence of Type 2 diabetes with early onset of diabetes complications. Poor dietary behavior is the primary cause of Type 2 diabetes and its complications, changing dietary behaviors can prevent the onset of diabetes complications or impede existing ones. The purpose of this phenomenological study was to explore patients' perceptions of diet-only therapy in the prevention of diabetes complications. Face-to-face interviews were conducted with six African American adults with Type 2 diabetes between 40 to 64 years using purposeful sampling method. Health belief model formed the conceptual framework of the study. I applied inductive coding process and manually analyze data for themes. Participants expressed fear of diabetes complications, acknowledged effectiveness of dietary therapy, physician communication and strong family support in Type 2 diabetes management. Findings can produce positive social change among African American adults with type 2 diabetes. Patients can be motivated to change their dietary behaviors to prevent disability and death from diabetes complications. Adherence to diet can reduce medical costs associated with Type 2 diabetes and its complications at the individual, family, community, and government levels. Health care providers can apply the findings in their interactions with patients to provide a more patient-centered education that integrates patients' cultural and dietary preferences to facilitate adoption of dietary interventions and long-term adherence.