About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times. Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997. For many families, more practical matters about our office include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.

Nutrition Symposium Georgia AAP (Part 1)

Posted on November 15, 2015 by gutsandgrowth

At this year’s nutrition symposium, Dr. Stan Cohen presented the latest information on nutrition and inflammatory bowel disease. His entire presentation will be on the Nutrition4Kids website. While I took a few pictures, my notes from his presentation were minimal, mainly because I had to give a talk afterwards. He reviewed how the microbiome can be influenced by diet and that this in turn can result in phenotypic changes. Specific complications from poor diet/nutrient deficiencies were discussed. In addition, data from exclusive enteral nutrition and the specific carbohydrate diet were presented. Here are some slides from his lecture (also available at Georgia AAP Symposium Website):

Related blog posts:

In the News: Weight Loss Intragastric Balloons

Posted on November 14, 2015 by gutsandgrowth

Two intragastric balloons have been approved for weight loss by the FDA.

FDA approval of ReShape The FDA announced that 326 obese patients participated in a clinical trial where 187 who were randomly selected to receive the balloon lost an average of 14.3 pounds or 6.8 percent of their body weight when the device was removed at six months. The control group lost an average of 7.2 pounds or 3.3 percent of their body weight. Six months later, the patients who received the balloon had kept off 9.9 pounds of the original 14.3 pounds.

FDA approval Orbera intragastric balloon The pivotal study of ORBERA, known as IB-005, was a multicenter, prospective, randomized, non-blinded comparative study. Subjects from 15 U.S. investigational sites were enrolled between June 20, 2008 and October 10, 2010. The database for this PMA reflected data collected through October 28, 2011 and included 448 subjects…

From GI & Hep News: During a 20- to 30-minute procedure, the deflated Orbera silicone balloon is placed in the stomach via an endoscopic procedure under a mild sedative, where it is then filled with saline until it is about the size of a grapefruit, according to the company. The patient usually can go home on the same day; the balloon is deflated and removed 6 months later….

At 6 months, the mean percent total body weight loss was about 10% in the balloon group, vs. 4% in the control group, a significant difference (P less than .001)… The majority of excess weight loss achieved at 6 months was also maintained at 12 months.

Understanding Your Food and Biotechnology (Part 3)

Posted on November 13, 2015 by gutsandgrowth

This is the last of my blog posts on the topic of biotechnology and foods from Ronald Kleinman’s lecture: Biotechnology, Nutrition, and Agriculture: A Perspective and Implications for Child Health. The posts over the past 4 days describe in detail why the hysteria over genetically modified foods/genetically modified organisms (GMOs) is detrimental. Unfortunately, the lack of understanding has led to widespread adoption of “GMO-free” labeling by food manufacturers which perpetuates the misplaced idea that these foods may not be safe. The slides and lecture will be available at the Nutrition4Kids website.

This mother’s blog: “I don’t feed them organic food and I’m not a bad Mom.” It is a sad commentary that someone needs to write this.

Humans, unlike plants, do not have the enzyme that Roundup (glyposate) targets –so it is safe. By targeting this enzyme, genetic engineering can allow the crop to be herbicide resistant, making it fairly easy to kill off weeds without hurting crop. With biotechnology, we can kill weeds without killing plants. Thus, no till farming is needed. Current herbicides are much safer than prior agents. Roundup (glyphosate) is water-soluble; it is not stored in fat. There is a 30 yr hx/o safe use. There is no data indicating cancer risk in humans or fertility risk.

In the past, testing breastmilk for roundup used a flawed methodology. F/u study by McGuire M (sponsored by US govt) showed no Roundup (glyphosate) in breastmilk.

Drought-resistant crops are becoming increasingly important. Meeting global food production will require more ‘crop per drop’ due to increasing population and less lands available for farming. Not just 3rd World –look at California. There are low crop yields in areas without biotech (Subsaharan Africa) and higher mortality.

Key points:

Genetically Modified Foods/Genetically modified organisms (GMO). These foods are safer and better than foods that are not genetically modified.
Roundup is not dangerous for humans.
Attacks on GMOs are part of a larger “War on Science.” As with vaccinations, there is a great deal of misleading and exaggerated information.
Biotechnology can help solve food crisis, improve the lives of small farmers, and reduce malnutrition. Genetically modified food reduces the needs for chemicals and can improve health.

Understanding Your Food and Biotechnology (Part 2)

Posted on November 12, 2015 by gutsandgrowth

This blog continues on the issue of genetic engineering and how it affects your food. The information was presented in a lecture by Ronald Kleinman (see the posts from the last two days): Biotechnology, Nutrition, and Agriculture: A Perspective and Implications for Child Health. The slides and lecture will be posted on Nutrition4Kids website.

Biotechnology/genetic engineering is more precise in selecting desirable crop traits

Why Newer Techniques (Genetic Engineering) Are Safer: Fewer Genes Affected Than Traditional Breeding and Mutagenesis along with Required Safety Testing

In the slide above, the first column shows traditional breeding of crops and how this can introduce thousands of changes into the crop. The second column illustrates the use of chemicals and radiation (mutagenesis) to change crops; this type of crop engineering preceded genetic engineering and has not required the rigorous testing of the final two columns which depict modern biotechnology with either RNA interference of transgenetics. Both of the later two methods are precise and undergo ~6-10 years of testing before introduction.

The above slide is one example of the safety of genetically modified tomatoes.

BT Corn (insect resistant) is Safer with Less Liver Cancer and Fewer Birth Defects

Key points:

Genetic change in foods is as old as agriculture. Lots of vegetables/crops were not found in nature, including corn and wheat.
Why is it false to talk about genetic modification as a special category? It’s all DNA which is undergoing constant change. Traditional breeding allows selection of random multiple genes and then selecting plant we like. Biotechnology is more precise and safer (eg. only the gene for sweetness for corn is transferred).
240 Agencies from across the globe have confirmed that biotechnology is safe because of the extensive testing that show these agents are at least as safe as ‘natural’ products. 2500 studies of GMO products from across the globe (not just Monsanto!) have proven the safety of these products.
Other examples of beneficial biotechnology: a) BT Corn — safer, less liver cancer, less birth defects (myelomeningocele) b) Golden Rice –can solve iron & vitamin A deficiency. Vitamin A deficiency contributes >1 million deaths/yr due to increased susceptibility to infections. Golden Rice in normal quantities provides RDA of Vit A. This is a lot more effective and less expensive than a supplement.

More tomorrow…

Understanding Your Food and Biotechnology (Part 1)

Posted on November 11, 2015 by gutsandgrowth

Yesterday’s blog post summarized a recent talk by Ronald Kleinman, MD: Biotechnology, Nutrition, and Agriculture: A Perspective and Implications for Child Health. Given the prevalence of misinformation on this topic, I am spending the next few days elaborating on this lecture. The full lecture (video and slides) will be available on the Nutrition4Kids website.

Genetic Engineering Has Allowed Development of Vaccines

Biotechnology in Our Foods is Ubiquitous

Biotechnology Has Reduced Mortality Dramatically

Genetic Change in Crops is as Old as Agriculture. There would not be corn as we know it without crop breeding.

Key points:

Genetic engineering has not only improved our food supply but has been essential in innovations like vaccines and insulin.
Biotechnology is ubiquitous. It’s not just crops, but cheese, wine, etc. Biotechnology has led 16,000 fewer children dying each day compared to 1995; this is largely due to biotechnology. Improved food security and less malnutrition results in fewer secondary complications (eg pneumonia, diarrhea).
Genetic change in foods is as old as agriculture. Lots of vegetables/crops were not found in nature, including corn and wheat. Cross-breeding allowed development of modern corn and wheat.

More tomorrow…

War on Science and Genetically-Modified Food

Posted on November 10, 2015 by gutsandgrowth

In the battlefield of ideas, science is losing badly. The problem with science is that many concepts are complex and sometimes difficult to communicate. For anyone interested in the science of food, and not the hysteria, a great lecture on this topic was presented by Ronald Kleinman, MD: Biotechnology, Nutrition, and Agriculture: A Perspective and Implications for Child Health

Stanley Cohen, Jeff Lewis, Evelyn Johnson (Georgia AAP President), Ronald Kleinman, and Jay Hochman at the Georgia AAP Nutrition Symposium.

I had the opportunity to participate and moderate a nutrition symposium at the Georgia American Academy of Pediatrics (AAP) pediatric meeting. This symposium was sponsored by Nutrition4Kids and funded by an educational grant from Nutricia. The first lecture was given by Dr. Kleinman. He is Chief of the Department of Pediatrics at Massachusetts General Hospital and Physician-in-Chief at MassGeneral Hospital for Children (MGHfC) and Partners Pediatrics. This was a fabulous talk and will be available at the Nutrition4Kids website. This blog post is a summary of the talk. Over the next few days, a couple of these ideas will be discussed further. Key points:

Genetically Modified Foods/Genetically modified organisms (GMO). These foods are safer and better than foods that are not genetically modified.
Roundup is not dangerous for humans. With biotechnology, we can kill weeds without killing plants. Thus no till farming is needed. Current herbicides are much safer than prior agents. Humans, unlike plants, do not have the enzyme that roundup targets –so it is safe. Roundup is water-soluble; it is not stored in fat. There is a 30 yr hx/o safe use. There is no data indicating cancer risk in humans or fertility risk. In the past, testing breastmilk for roundup used a flawed methodology. F/u study by McGuire M (sponsored by US govt) showed no roundup in breastmilk.
GMOs are part of a larger “War on Science.” As with vaccinations, there is a great deal of misleading and exaggerated information.
Genetic engineering has not only improved our food supply but has been essential in innovations like vaccines and insulin.
Biotechnology is ubiquitous. It’s not just crops, but cheese, wine, etc. Biotechnology has led 16,000 fewer children dying each day compared to 1990; this is largely due to biotechnology. Improved food security and less malnutrition results in fewer secondary complications (eg pneumonia, diarrhea).
Genetic change in foods is as old as agriculture. Lots of vegetables/crops were not found in nature, including corn and wheat. Cross-breeding allowed development of modern corn and wheat.
Why is it false to talk about genetic modification as a special category? It’s all DNA which is undergoing constant change. Traditional breeding allows selection of random multiple genes and then selecting plant we like. Biotechnology is more precise and safer (eg. only the gene for sweetness for corn is transferred, so can be more safe).
240 Agencies have confirmed that biotechnology is safe because of the testing that shows these agents are at least as safe as ‘natural’ products. 2500 studies of GMO products from across the globe (not just Monsanto!) have proven the safety of these products.
Most of GMO-farming occurs with small farmers (90% in developing world) who are not rich; these products result in income gains of greater than 30%.
Why is there such widespread adoption of GMO products by farmers? They are better: insect resistance, herbicide resistance, viral resistance, and drought/salt resistance
Other examples of beneficial biotechnology: a) BT Corn — safer, less liver cancer, less birth defects (eg. myelomeningocele) b) Golden Rice –can solve iron & vitamin A deficiency. Vitamin A deficiency contributes >1 million deaths/yr due to increased susceptibility to infections. Golden Rice in normal quantities provides RDA of Vit A. This is a lot more effective and less expensive than a supplement. These products are not commercially available even though nonprofits willing to give seeds for free –due to hysteria, politics. Greenpeace has actually burned Golden Rice rice fields.
Drought-resistant crops are becoming increasingly important. Meeting global food production will require more ‘crop per drop’ due to increasing population and less lands available for farming. Not just 3^rd World –look at California. There are low crop yields in areas without biotech (Subsaharan Africa) and higher mortality.

Unfortunately, shortly after hearing this lecture explain in great detail why GMO-containing products should be praised and not shunned, I picked up a drink. Here’s the label:

Bottomline: The science is sound. Biotechnology and GMOs/genetically modified foods are making are food better, safer and reducing mortality. If only we could communicate this fact effectively.

Related blog posts:

Hyperoxaluria due to Excessive Almond Milk

Posted on November 9, 2015 by gutsandgrowth

A recent report (Ellis D, Lieb J. J Pediatr 2015; 167:1155-8) highlights the high content of oxalate in almond milk products which led to hyperoxaluria and hematuria in three children.

Key points:

“A tendency to low fluid intake and a hereditary predisposition to calcium-based nephrolithiasis may have been contributing factors.”
“Mammals lack oxalic decarboxylase and other enzymes that can degrade oxalic acid…oxalate homeostasis depends on” ..1) dietary intake, 2) endogenous synthesis of oxalate, 3) GI flora degradation and limiting of absorption, and 4) renal processing/excretion of oxalate

My take: In patients with oxalate kidney stones or microscopic hematuria, limiting almond milk and increasing fluid intake would be beneficial.

Gabi

Changing Narrative on Affordability of HCV Treatments

Posted on November 8, 2015 by gutsandgrowth

A recent commentary (J Chhatwal et al. Clin Gastroenterol 2015; 13: 1711-13) makes the point that HCV treatment is looking a lot better lately with regard to cost.

Key points:

“Sofosbuvir-based treatment in 2015, on average, costs 54% of the wholesale acquisition cost”
When considering the recent discounts, “the cost of treatment decreased to $56,000…and the cost per SVR decreased to $58,000.” The cost of an SVR with the first generation protease inhibitors, boceprevir and teleprevir, has been estimated to have been $213,000.
“The discounted cost of treating 1 person with HIV in the United States is $315,000 in 2014 US dollars.” Thus, curing HCV which is more deadly, at 18% of the cost, looks more favorable.
More discounts and more competition are expected.

Bottomline: Based on these cost considerations, the authors state that HCV treatment should be used broadly and not solely in those with advanced fibrosis.

Related blog posts:

Atlanta Botanical Gardens

Down Syndrome -Updated Growth Curves

Posted on November 7, 2015 by gutsandgrowth

Full link to Pediatrics article (www.pediatrics.org/cgi/doi/10.1542/peds.2015-1652 DOI: 10.1542/peds.2015-1652): Growth Charts for Children with Down Syndrome in U.S. (Reference from Kipp Ellsworth)

Excerpt:

New DSGS growth charts were developed by using 1520 measurements on
637 participants. DSGS growth charts for children ,36 months of age showed marked improvements in weight compared with older US charts. DSGS charts for 2- to 20-year-olds showed that contemporary males are taller than previous charts showed. Generally, the DSGS growth charts are similar to the UK charts.

Fecal Diversion for Perianal Crohn’s Disease

Posted on November 6, 2015 by gutsandgrowth

A recent study (S Singh et al. Alimentary Pharmacology & Therapeutics; 2015: 42: 783-92; article first published online: 11 AUG 2015. DOI: 10.1111/apt.13356) gives more specific data regarded the outcomes of fecal diversion for perianal Crohn’s disease. While diversion can be helpful, the meta-analysis indicates that only one-sixth of patients were able to achieve successful bowel continuity/reconnection. The authors did not note a significant improvement in successful bowel continuity restoration in the era of biologics compared with prebiologic era (17.6% vs13.7%).

An excerpt of a summary of this study from Gastroenterology & Hepatology (September 2015)

Related blog posts:

Stranger than fiction?