A recent study (G Boyer et al. Am J Gastroenterol 2019; 114: 786-91) examined the promotion of testing and treatment of gluten-related disorders among complementary and alternative medicine (CAM) practitioners. Thanks to Ben Gold for this reference.
Background: CAM expenditures in 2016 by Americans was $30.2 billion in 2016. “Studies have found that it is not uncommon for CAM clinics to make wide-reaching claims as to their abilities to diagnose a plethora of conditions.” In the present study, the authors reviewed the advertising content of 500 CAM clinic websites with regard to gluten-related disorders..
- The authors further identified 232 claims from 114 clinic websites; 138 (59.5%) were judged as unproven or false.
- “Some clinics advertised treatments that pose potential harm;” this includes the sale of digestive enzymes promoted to digest gluten and which purport to allow the person with celiac or nonceliac gluten sensitivity (NCGS) to ingest gluten safely. “This is a baseless claim that could lead to serious harm.”
- “Other clinics falsely claimed that everyone should be on a gluten-free diet regardless of a diagnosis of celiac disease or NCGS.”
My take: Given the popularity of CAM along with the frequency of misleading claims, this suggests the need for increased regulation. These websites are likely to increase confusion about the diagnosis and management of gluten-related disorders (which can be confusing without any help!)
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Studies have shown that adults with obesity who were obese as adolescents have worse medical outcomes than persons who became obese in adulthood (Nat Rev Endocrinol 2018; 14: 183-8; NEJM 2011; 365; 1876-85). Thus, the question is whether earlier intervention would improve outcomes.
A recent study (TH Inge et al. NEJM 2019; 380: 2136-45, editorial TD Adams, pgs 2175-7) compares the 5-year outcomes of adolescents (n=161) and adults (n=396) who underwent Roux-en-Y gastric bypass (RYGB). The two prospectively enrolled cohorts were participants in two related but independent studies.
- There was similar weight loss in both groups at the 5-year mark: -26% in adolescents and -29% in adults
- Adolescents had greater remission in both type 2 diabetes (86% vs 53%) and in hypertension (68% and 41%).
- Three adolescents (1.9%) and seven adults (1.8%) died in the 5-years after surgery. Two of the adolescents deaths were consistent with overdose.
- Reoperations were significantly higher in adolescents than adults (19 vs 10 reoperations per 500 person years). The authors comment that the reason for this finding is unclear, possibly related to recall bias or closer monitoring of the adolescents.
- Nutrient deficiencies were common in adolescents at followup. After 2 years, 48% of adolescents had low ferritin compared with 29% of adults (98% of participants had normal ferritin prior to RYGB. The authors note that this is likely related to adherence to vitamin/mineral supplementation (which is needed lifelong).
Limitations: observational study design
The associated commentary::
- “Almost 6% of adolescents in the U.S. are severely obese and bariatric surgery is now the only successful long-term management…Negative health outcomes of bariatric surgery reported in adolescents mirror those reported in adults — including, for example, potential for self-harm (including suicide) and increased risk of alcohol or drug abuse.”
- “Adolescent patients may not have fully developed the capacity for decision making, especially about a procedure that will have lifetime consequences.”
My take: This study and commentary point out some clear health benefits for adolescents who undergo RYGB. Given the lifelong need for monitoring and adherence with medical treatment as well as some of the negative health outcomes, it is also clear how challenging it is to proceed with RYGB in teenage years.
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Square in Toledo, Spain
A recent systematic review and meta-analysis (Y Lee, et al. Clin Gastroenterol Hepatol 2019; 17: 1040-60) included 32 cohort studies with 3093 liver biopsy specimens from patients with nonalcoholic fatty liver disease (NAFLD).
- Bariatric surgery resulted in a biopsy-confirmed resolution of steatosis in 66%, inflammation in 50%, ballooning degeneration in 76%, and fibrosis in 40%.
- Bariatric surgery resulted in worsening features of NAFLD in 12%.
- The authors note that Roux-en-Y Gastric Bypass (RYGB) “showed greater reduction of liver side effects and higher: resolution of NAFLD.”
- Jejejnoileal bypass (JIB) and biliopancreatic diversion (BPD) “both have been associated with higher liver function morbidity.”
- The overall GRADE quality of evidence was considered very low.
My take: Though better studies are needed, the majority of patients’ livers appear to benefit from bariatric surgery.
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Nature volume 569, pages260–264 (2019) : Full Text: Rising rural body-mass index is the main driver of the global obesity epidemic in adults
- Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017.
- We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in rural areas.
- In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women.
According to a recent study (EL Yu et al. J Pediatr 2019; 207: 64-70), about one-third of boys and one-fourth of girls with obesity have nonalcoholic fatty liver disease (NAFLD).
This study from San Diego with 408 children aged 9-17 years (mean 13.2 years) with obesity evaluated for NAFLD with laboratories (to exclude other etiologies) and with liver MRI proton density fat fraction (PDFF), with ≥5% considered the threshold for NAFLD.
- Prevalence of NAFLD was 26% in this population, with 29.4% in males and 22.6% in females
- The optimal cut offs of ALT for detecting NAFLD in this study were ≥30 U/L for females and ≥42 U/L for males. These are much lower than NASPGHAN guidelines which proposed ≥80 U/L or twice the ULN as thresholds for further investigation. (The NASPGHAN recommendations are likely to have higher specificity in identifying children at greater risk for nonalcoholic steatohepatitis (NASH).)
- 77% of this cohort were hispanic, thus prevalence may vary significantly in other populations.
- MRI-PDFF -the exact cut off is unclear. The authors note that if 3.5% were chosen, the NAFLD prevalence jumped to 49.3% (according to Table II –though the discussion stated 53.2%)
My take: Understanding the likelihood of NAFLD in children at risk is a helpful first step. This study points to the growing use of non-invasive diagnosis with MRI.
On a related topic, briefly noted: “Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery” (A Khattab, MA Sperling. J Pediatr 2019; 207: 18-22). In this review, the authors refer frequently to endocrine society guidelines (J Clin Endocrinol Metab 2017; 102: 709-57). These guidelines generally recommend bariatric surgery only under specific conditions (eg. completion of Tanner 4 or 5 along with a BMI of 40 kg/m-squared or BMI of 35 with significant extreme comorbidities after failure of lifestyle modifications & without untreated psychiatric illness). This review predicts increasing use of bariatric surgery in adolescents “as more data on long-term outcomes in larger cohorts become known.”
Related blog posts on fatty liver disease:
Related blog posts on bariatric surgery:
Yesterday’s post highlighted a study which indicated that low quality diets result in signiificant mortality. The tweets below refer to a study which indicated that supplements generally do not help one achieve a good diet. For a diet to be effective, the nutrients need to be present in the diet.
Link: Home Blenderized Tube Feedings: A Practical Guide for Clinical Practice
This article provides a lot of useful advice for blenderized formulas, but is not a substitute for the help of a qualified dietician/nutritionist.