J Inherit Metab Dis (2011) 34:449–454
DOI 10.1007/s10545-010-9276-2
ORIGINAL ARTICLE
Dietary treatment of phenylketonuria: the effect
of phenylalanine on reaction time
Charlotte Dawson & Elaine Murphy & Charlé Maritz &
Heidi Chan & Charlotte Ellerton & R. H. S. Carpenter &
Robin H. Lachmann
Received: 30 September 2010 / Revised: 30 November 2010 / Accepted: 28 December 2010 / Published online: 3 February 2011
# SSIEM and Springer 2011
Abstract There is no evidence that high phenylalanine
(Phe) levels have irreversible effects on the adult brain.
Many adults with phenylketonuria (PKU) no longer follow
a protein-restricted diet. Neuropsychological studies have
shown that reaction time in adults with PKU is slower than
controls. There are no data to show that this is directly
related to Phe levels. Another way to assess reaction time is
to measure saccadic latency. We have used a portable, head-
mounted saccadometer to measure latency in the outpatient
setting. Patients with PKU were split into three groups: off-
diet (Phe>1,200 μmol/l), on-diet (Phe <800 μmol/l) and
maternal diet (Phe 100–400 μmol/l). Reciprocal median
latency (RML) was compared between groups. Latency was
significantly slower in patients who were off-diet than in
patients on-diet, on a maternal diet or in normal controls.
Reaction times in both diet-treated groups were not
significantly different from normal controls. In 16 women
planning pregnancy we obtained values before and after
they commenced the maternal diet. Stricter control of Phe
levels resulted in a significant improvement in reaction
times. We conclude that saccadometry is useful in moni-
toring PKU patients. Adult patients with PKU not on a
Communicated by: Bruce A. Barshop
Competing interest: None declared.
C. Dawson : E. Murphy : C. Maritz : H. Chan : C. Ellerton :
R. H. Lachmann (*)
Charles Dent Metabolic Unit,
National Hospital for Neurology and Neurosurgery,
Box 92, Queen Square,
London WC1N 3BG, UK
e-mail: robin.lachmann@uclh.nhs.uk
R. H. S. Carpenter
Physiological Laboratory, University of Cambridge,
Cambridge, UK
protein-restricted diet have significantly slower reaction
times than controls. In addition, off-diet patients have
significantly slower reaction times than on-diet. Paired data
show that effects of Phe levels on reaction time are
reversible.
Introduction
Phenylketonuria (PKU, OMIM #261600) is one of the most
common inherited metabolic disorders with an incidence of
about 1 in 10,000 (Scriver et al. 2008). The majority of
cases result from deficiency of phenylalanine hydroxylase
(PAH) which converts phenylalanine into tyrosine. In PKU,
phenylalanine (Phe) accumulates, with high levels in the
blood and brain and a relative deficiency of tyrosine.
The infant brain is sensitive to high Phe levels and, if left
untreated, PKU gives rise to severe mental retardation.
Microcephaly is common and about 25% of patients have
epilepsy. Many older patients have behavioural problems
and some suffer from psychiatric illnesses. A few patients
develop movement disorders with pyramidal and extrapy-
ramidal signs (Brenton and Pietz 2000). The precise
mechanism of neurotoxicity is not fully understood (de
Groot et al. 2010), but neurological, neurocognitive and
neuropsychological outcomes in children are correlated
with blood Phe levels (Scriver et al. 2008).
The aim of dietary management in PKU is to reduce the
flux through the affected metabolic pathway and thus
reduce the accumulation of Phe. Strict control of Phe levels
in infancy and early childhood allows normal intellectual
development (Burgard 2000). Newborn screening for PKU
was introduced in the UK in 1969. Diagnosis is now made
in the first week of life and it is possible to institute dietary
therapy before the infant sustains any irreversible brain
450
damage. This has completely transformed the prognosis of
this disorder, and patients with PKU now lead normal lives
with intellectual and physical achievements similar to their
peers.
Their diet is, however, quite demanding and, although
compliance is normally good in infants and young
children, it is not uncommon for older children and
young adults to want to be able to eat the same things as
their friends and family (Walter et al. 2002). Although
there was initially much concern about possible cognitive
decline in adolescent patients who stopped their low-
protein diets, experience has on the whole been good, and
it now seems that, after the age of 10, IQ is fixed, and the
brain is no longer susceptible to the sort of irreversible
injury seen in infants exposed to high Phe levels (Brenton
and Pietz 2000; Burgard 2000).
The only group of adult patients for whom it is essential
to obtain strict dietary control of Phe levels is women who
are pregnant or considering pregnancy. Exposure of the
foetus to high maternal Phe levels results in the maternal
PKU syndrome, which consists of a combination of cardiac
and skeletal defects, microcephaly, developmental delay
and low birth weight (Levy and Ghavami 1996). The
syndrome can be entirely prevented if mothers maintain
low Phe levels throughout their pregnancies (Maillot et al.
2008).
In our centre we care for about 400 adults with PKU. Of
these, only around 150 are following a protein-restricted
diet at any time, about 30 of whom are on a pre-conception
or maternal diet. Most of the adults who no longer follow a
protein-restricted diet do not themselves notice any ill
effects associated with having high blood Phe levels. Some,
however, do find that their concentration, mood and temper
are better when their levels are lower and choose to return
to a low protein diet, as has been reported by others (Gassió
et al. 2003)
Neuropsychological studies in adults with PKU have
shown that performance on certain tests of executive
function can be related to Phe levels, but these effects are
not consistent, and their significance to everyday life is
unclear (Christ et al. 2010). Nonetheless, there is concern
that an accumulation of subtle neuropsychological deficits
may lead to significant psychosocial morbidity in adults
with PKU which is not always recognised and which might
be improved by stricter control of Phe levels (Gentile et al.
2010).
A more quantitative assessment of the effects of high
Phe levels on the adult brain may be possible by measuring
reaction time. A meta-analysis of neuropsychological
studies comparing reaction times in patients with and
without PKU has shown that there is a relationship between
high Phe levels and slower reaction times for children and
adolescents with PKU (Albrecht et al. 2009). In adults,
J Inherit Metab Dis (2011) 34:449–454
however, although reaction times for all people with PKU
were slightly slower than for people who don’t have PKU,
this was independent of whether they were on dietary
treatment or not, and there was no direct relationship
between Phe levels and reaction time. It is important to
note, however, that all groups of adult PKU patients studied
had relatively high Phe levels (above 700 μmol/l), and it
was therefore not possible to investigate whether reaction
times would return to ‘normal’ at levels closer to the normal
reference range (33–81 μmol/l).
If we are going to advise our adult patients to continue
on or return to a protein-restricted diet, we need to be able
to demonstrate that they will gain real benefit from doing
so. The literature demonstrates that it is often difficult for
professionals to interpret the results of neurocognitive tests,
and it may therefore be hard for patients to make decisions
which will have a profound effect on their everyday life
based on the results of neuropsychological assessments. A
simple test of reaction time, which can be expressed
numerically, might be easier for patients and their carers
to interpret.
In the current study we have used saccadic latency as a
measure of reaction time in adult PKU patients. Saccades are
rapid, conjugate eye movements elicited in response to a
stimulus. Saccadic latency or reaction time is determined by
mostly cortical decision-making processes, and prolonged
saccadic latency can be a sign of subtle cortical dysfunction,
even in the absence of symptoms (Ali et al. 2006; Pearson et
al. 2007). We used a portable, head-mounted saccadometer
which allowed us to gather data simply and quickly in the
outpatient clinic.
We compare saccadic reaction times in adult PKU
patients off-diet, on-diet and on a highly restrictive pre-
conception/maternal (PC/M) diet. Saccade data for each
group of patients were also compared with data from adults
without PKU.
Materials and methods
Subjects
Subjects were adult PKU patients over the age of 18 years
attending the Metabolic Clinic at the National Hospital for
Neurology and Neurosurgery, London, UK. All participants
had been diagnosed by newborn screening and started
dietary treatment early in life. They had remained on a low
protein diet and amino acid supplements at least until
adolescence. Patients with late diagnosed PKU or other
serious neurological or psychiatric disorder were excluded.
Patients were split into three groups (Table 1). The off-
diet group were those who, at the time of saccadometry, had
an unrestricted dietary protein intake and were not taking
J Inherit Metab Dis (2011) 34:449–454
Table 1 Baseline characteristics
of patient groups
Number (M/F)
Age (mean ± SD), years
Target blood Phe, μmol/l
Measured blood Phe (mean ± SD), μmol/l
any amino acid supplements. In practice, people who
follow a protein-restricted diet during childhood often
never acquire a taste for meat, and PKU adults who are
‘off-diet’ commonly have a lower meat, fish and dairy
intake than average. Only data from patients whose Phe
level was greater than 1,200 μmol/L, suggesting adequate
natural dietary protein, were included in the analysis. The
on-diet group were subjects following a protein-restricted
diet and taking amino acid supplements. The current
recommended treatment target in the UK is to obtain blood
Phe levels less than 700 μmol/L. In fact, few patients are
able to consistently achieve this, and all patients achieving
a Phe level <800 μmol/L at the time of saccadometry
measurement were included. The pre-conception/maternal
group (PC/M) were female patients who were either trying
to conceive or actually pregnant at the time of saccadom-
etry measurement. To prevent maternal PKU syndrome, we
advise women to maintain Phe levels between 100 and
300 μmol/L before conception and throughout pregnancy.
A sub-group of 16 of these patients on a PC/M diet also
had saccadometry performed when they were on a less
restricted diet, with higher Phe levels [mean off-diet Phe
1,223 (±330) μmol/L; mean PC/M diet Phe 277 (±108)
μmol/L). For this group, a further paired analysis was
performed comparing the two data sets.
Saccade data was also collected from healthy age-
matched volunteers without PKU. Control groups were
constructed which were age- and sex-matched to the
experimental groups (n=56 for off-diet group, n=21 for
on-diet, n=33 for PC/M group).
Following an explanation of the procedure, consent was
obtained from each subject and saccadometry performed
during a routine outpatient appointment. This study was
approved by the local research ethics committee.
Procedure
A head-mounted saccadometer (Ober Consulting, Poland)
was used. This projects red 0.1° 13 cd m-2 target dots onto a
blank wall approximately 1.5 m in front of the seated
subject at three different horizontal positions (10° left, 0° or
10° right of centre); because the stimuli move exactly with
the head, it is not necessary to stabilise the head with a bite-
bar. Subjects were seated comfortably and were asked to
follow the target dot with their eyes keeping their head as
451
Off-diet On-diet Pre-conception/maternal diet
56 (25/31) 21 (2/19) 33 (0/33)
32.8±5.7 29.4±6.6 32.3±5.2
NA <800 100–300
1,461±185 640±103 250±87
still as possible. Eye movements were recorded by
binocular infra-red scleral reflectance (Ober et al. 2003)
with a band-width of 1 kHz.
The saccadometer is fitted to the head with elastic straps,
is comfortable to wear and requires no specific skill or
training for use either by the examiner or the subject.
Saccadometry was performed in the outpatient clinic. Each
subject performed a single run of 80–100 saccades on each
occasion, taking less than 5 min.
Data analysis
Data for each patient were downloaded onto a computer
running LatencyMeter version 4.4 (Ober Consulting,
Poland) which automatically rejects invalid data caused
by, for example, blinks, saccades in the wrong direction, or
saccades falling outside the amplitude range 5–15° or
latency range 50–600 ms. Reciprobit plots were generated
using SPIC software (Advanced Clinical Instrumentation,
Cambridge), which combines data from subjects’ leftwards
and rightwards saccadic latencies and automatically
generates best-fit values of the underlying LATER param-
eters by minimisation of the Kolmogorov-Smirnov one-
sample statistic (Carpenter and Williams 1995).
Reciprocal median latency follows a Gaussian distribu-
tion, and unpaired two-tailed t tests were therefore used to
compare the mean reciprocal median latency between each
subject group. A paired two-tailed t test was used to
compare data from patients in the PC/M group for whom
there were on-diet and off-diet saccade recordings.
Results
It has been previously reported that age increases saccadic
latency by about 1 ms/year but the sex of the patient does
not influence saccades (Klein et al. 2005). There was no
significant difference in age between groups (Table 1).
Approximately half of the off-diet group were female,
whereas the on-diet groups were predominantly female
(Table 1).
Our results show that there is a significant (p=0.02)
difference in reciprocal median latency between patients
with PKU who are off-diet and controls (Table 2). Median
latency for the PKU subjects was 12 ms longer than the
452 J Inherit Metab Dis (2011) 34:449–454

Table 2 Comparison of recip-

rocal median latency in patients Reciprocal median p-Value
off-diet, on-diet or on latency ± SD (s-1)
pre-conception/maternal diet
Off-diet (n=56) vs. controls 5.56±0.77 vs. 5.92±0.11 0.02
On-diet (n=21) vs. controls 6.00±0.92 vs. 5.94±0.18 0.82
Pre-conception/maternal diet (n=33) vs. controls 6.03±0.84 vs. 5.99±0.13 0.85
Off-diet vs. on-diet 5.56±0.77 vs. 6.00±0.92 0.04
Off-diet vs. pre-conception/maternal diet 5.56±0.77 vs. 6.03±0.84 0.01
In women planning pregnancy (N=16) prior to 5.86±0.84 vs. 6.25±0.87 0.04
commencing diet vs. on pre-conception/maternal diet

controls. In contrast, both for PKU subjects on standard and
PC/M diets, median latency was not significantly different
from control groups. PKU subjects who were on a normal
unrestricted diet had longer median latencies than those on
a low protein diet (+13 ms, p=0.04) or those on PC/M diet
(+14 ms, p=0.01).
For 16 women with PKU we recorded latency data
before and after they commenced PC/M diet. Paired t test
showed that median latency improved from 171 ms before
PC/M diet to 160 ms on diet (p=0.04) (Table 2 and Fig. 1).
Overall, there was a negative correlation between
reciprocal median latency and Phe level (r2 =0.05, p=
0.02) (Fig. 2). This relationship persisted following adjust-
ment for age.
Discussion
These data show that adults with PKU who are following
an unrestricted diet have significantly slower reaction times
than a control population who don’t have PKU. This
finding supports previous neuropsychological studies
(Albrecht et al. 2009). However, our data also show that
10
Reciprocal latency (s-1)
in individuals with PKU on a protein-restricted diet,
reaction times are related to the blood Phe level. In the
diet-treated population with a Phe level of 800 μmol/l or
less, reaction times did not differ significantly from people
who don’t have PKU.
These differences in reaction time do not represent a
fixed deficit. In a group of women with PKU returning to a
protein-restricted diet in order to become pregnant, reaction
times improve as their blood Phe levels come down,
returning to the normal range once the diet is established.
The magnitude of the increase in latency seen in subjects
with PKU on unrestricted diets as compared to those on low
protein diets (13 ms) is similar to that which has previously
been measured in control subjects breathing sub-anaesthetic
doses of sevofluorane but less than those seen in boxers
suffering from head trauma and concussion after a bout
(Pearson et al. 2007).
Decision processes determining reaction time and
saccade latency are controlled by a widely distributed
network of high level cortical neurones (Carpenter 2000,
2005). Adult patients with PKU can have white matter
changes on MRI (Pietz et al. 1996) which may represent
oedema of myelin tracts (Vermathen et al. 2007). It is
possible that these ‘lesions’ might affect cortical function
and be related to the prolonged saccadic latency we have
documented in adult PKU patients with high Phe levels. We
do not routinely request MRI brain scans for patients with
PKU so were unable to test this hypothesis in our patients.

8 Interestingly, it has been shown that these white matter

changes resolve if patients return to diet and their blood Phe
levels come down (Cleary et al. 1995).
Another mechanism by which high blood Phe levels might
6 affect brain function is by competition with other large neutral
amino acids (LNAAs) for transport across the blood brain
barrier (van Spronsen et al. 2009). All these amino acids
share a single transporter, SCL7A5, and high levels of Phe
4
Prior to diet Preconception/Maternal diet will prevent amino acids such as tyrosine and tryptophan
from entering the brain. The resulting intracerebral deficien-
Fig. 1 Reciprocal median latency in women prior to commencing
cy could lead to reduced neurotransmitter levels: tyrosine is
pre-conception/maternal diet compared with on pre-conception/mater-
nal diet (each colour represents an individual woman, black lines the precursor of dopamine and noradrenaline, and tryptophan
indicate the mean) is the precursor of serotonin. Oral supplementation with
J Inherit Metab Dis (2011) 34:449–454
Fig. 2 Correlation between
reciprocal median latency and
phenylalanine level
LNAAs has been shown to reduce brain Phe levels and
increase brain tyrosine and tryptophan levels in PKU patients
(Pietz et al. 1999), and it would be interesting to see what
effect such supplementation would have on saccadic latency.
Standard dietary treatment of PKU would also be
expected to improve brain levels of tyrosine and tryptophan
by reducing competition for transport across the blood brain
barrier. The low protein diet lowers Phe levels in the blood
and the amino acid supplements contain the other LNAAs.
In summary, this study shows that the portable
saccadometer is a useful tool in monitoring patients with
PKU. Saccadometry can be easily performed in the
routine outpatient setting and may provide a useful surrogate
measurement of cognitive function in PKU patients, having
the advantage that it is relatively objective, less prone to
practice effects than conventional cognitive tests, and capable
of providing standardised information that can be related to
studies in other clinics and laboratories, as well as to the
growing literature examining the neural mechanisms under-
lying the brain’s decision processes. Because we make two or
three saccades every second of our waking life, these tests do
not fatigue the subject in the way that manual tasks can, so that
a great deal of data can be collected in a short period of time—
typically some 100 trials in 3–4 min.
Our data suggest that improved reaction time, as
measured by saccadic latency, is apparent in patients treated
to the current UK recommended target Phe level for adults
of <700 μmol/L. Although there was no significant
453
difference in saccadic latency between PKU patients with
Phe levels <800 μmol/l and controls in our study, the data
from patients on PC/M diets, with Phe levels <300 μmol/l,
suggest that further lowering of Phe levels may lead to
incremental improvements in reaction time. These paired
data imply that any effects which high Phe levels have on
reaction time are reversible if patients return to a protein-
restricted diet. In practice, for individual patients on a low
protein diet, serial saccadometry in the outpatient clinic
should allow us to define the Phe level at which they gain
maximum benefit in terms of reaction time and attention.
A meta-analysis of previous studies involving neuropsy-
chological testing has not been able to demonstrate that the
reductions in reaction time seen in adult patients with PKU
have been related to their blood Phe levels (Albrecht et al.
2009). In contrast, this study shows a clear relationship
between lowering Phe levels and an improvement in
cortical function. As such, our data would appear to
provide a strong argument in favour of ‘diet for life’ for
patients with PKU. However, it is not clear how improve-
ments in surrogate markers of cognitive function such as
these saccadic parameters translate into quality of life for
the patient. It is, for example, instructive to note that the
vast majority of young women who return to diet for
pregnancy choose to revert to a normal, unrestricted diet as
soon as their baby is born. For these women the effects of
improvements in cognitive function may be too subtle to
compensate for the major practical and social inconven-
454
iences of being on-diet. These individual decisions are
likely to be finely balanced, and it will be interesting to see
what effect the ability to give patients with PKU routine
feedback about cognitive parameters, by performing
saccadometry regularly in the outpatient clinic, will have
on their decisions about dietary management.
Acknowledgements This work was undertaken at UCLH, which
received a proportion of funding from the Department of Health’s
NIHR Biomedical Research Centre funding scheme.
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