Category Archives: Nutrition

“The Paramount Health Challenge for Humans in the 21st Century”

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I had the privilege recently of introducing William Balistreri as the keynote speaker for the Georgia AAP Nutrition Symposium.  Dr. Balistreri is a personal hero for me; someone I admire greatly.  Hopefully, if he reads this, he will forgive me for forgetting to mention in my introduction that he also is a Lacrosse coach for one of his grandchildren’s team.

He gave a tour de force presentation on the global challenge of obesity.  In addition, he discussed undernutrition, endobariatrics, gastroenteritis, climate change and even food waste; 40% of U.S. food is thrown away. In Finland, there is a ‘Grocery Store Happy Hour‘ for distribution of reduced cost/free groceries which may help reduce food waste.  In general, I try to condense what I read or hear –that was pretty much impossible with this lecture which was packed with information based on the latest research as well as information dating back to the 5th Century BC/Plato.  What follows are some of my favorite slides.

Here is a link to the full talk: WHAT’S HOT in Pediatric Gastroenterology? Global Nutrition Lecture (10-10-19)

Two Articles received the most attention:

  1. LANCET Commission on Global Syndemic (Obesity, Undernuturition, and Climate Change)
  2. EAT- LANCET Commission on Healthy Diets

What Can Be Done?

Additional References:

A recent book (not discussed in lecture) provides related information. “We Are The Weather” by Jonathan Foer, was reviewed this past weekend in the NY Times: Meat is Murder: “[This book] has a point, and that is to persuade us to eat fewer animal products. Foer makes the case that, for Americans and citizens of other voracious meat-eating countries, this is the most important individual change we can make to reduce our carbon footprints.” However, the reviewer, Mark Bittman, states that “we’re not good at making positive decisions about our future. And we’re really not good at denying ourselves cheap pleasures like cheeseburgers.”  He advocates for stronger laws, government leadership, and pricing the products to account for their true costs in terms of their contributions to climate change, public health, and environmental degradation.

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NASPGHAN/ESPGHAN Position Paper: Nutrition Support for Children with Chronic Liver Disease

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M Mouzaki et al. JPGN 2019; 69: 498-511. Full text link: Nutrition Support of Children with Chronic Liver Diseases: A Joint Position Paper of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition 

Figure 2 (above) outlines an approach to assuring adequate intake of nutrients

Table 2 (above) provides an approach to laboratory monitoring. The authors recommend measuring every 3-6 months for most of the vitamins and micronutrients listed in this table

Table 3 (above) provides recommendations for specific elements of nutritional support.

Figure 1 (above) describes pathophysiology of malnutrition.

My take: This position paper provides useful advice for approaching nutritional support in children with chronic liver disease. Defining the specific patients in which these guidelines may be applicable requires individual assessment.  Thus, the authors note that the guidelines “should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment.”

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

Nutrition Group: OK to Continue Red Meat Consumption

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Here’s the full text study: Unprocessed Red Meat and Processed Meat Consumption: Dietary Guideline Recommendations From the Nutritional Recommendations (NutriRECS) Consortium (Published: Ann Intern Med. 2019. DOI: 10.7326/M19-1621)

In the same issue, there are several studies and an associated commentary: Meat Consumption and Health: Food for Thought by Aaron Carroll and Tiffany Doherty.

  • The recommendations from this study relate to the health effects of meat consumption.  Considerations of environmental impact or animal welfare did not bear on the recommendations.
  • “We developed the Nutritional Recommendations (NutriRECS) international consortium to produce rigorous evidence-based nutritional recommendations adhering to trustworthiness standards…”
  • “We suggest that individuals continue their current consumption of both unprocessed red meat and processed meat (both weak recommendations, low-certainty evidence).”
  • “Despite our findings from our assessment of intake studies versus dietary pattern studies suggesting that unprocessed red meat and processed meat are unlikely to be causal factors for adverse health outcomes (13, 14, 16), this does not preclude the possibility that meat has a very small causal effect.”
  • “Other dietary guidelines and position statements suggest limiting consumption of red and processed meat because of the reported association with cancer (1, 2, 44–46).”
  • “In terms of how to interpret our weak recommendation, it indicates that the panel believed that for the majority of individuals, the desirable effects (a potential lowered risk for cancer and cardiometabolic outcomes) associated with reducing meat consumption probably do not outweigh the undesirable effects (impact on quality of life, burden of modifying cultural and personal meal preparation and eating habits). The weak recommendation reflects the panel’s awareness that values and preferences differ widely, and that as a result, a minority of fully informed individuals will choose to reduce meat consumption.”**

A useful commentary from the NY Times: Eat less Red Meat, Scientists Said. Now Some Believe That Was Bad Advice.

An excerpt:

{According to the new report] If there are health benefits from eating less beef and pork, they are small, the researchers concluded. Indeed, the advantages are so faint that they can be discerned only when looking at large populations, the scientists said, and are not sufficient to tell individuals to change their meat-eating habits…

Already they have been met with fierce criticism by public health researchers. The American Heart Association, the American Cancer Society, the Harvard T.H. Chan School of Public Health and other groups have savaged the findings…

Dr. Hu, of Harvard, in a commentary published online with his colleagues. Studies of red meat as a health hazard may have been problematic, he said, but the consistency of the conclusions over years gives them credibility…

Questions of personal health do not even begin to address the environmental degradation caused worldwide by intensive meat production. Meat and dairy are big contributors to climate change, with livestock production accounting for about 14.5 percent of the greenhouse gases that humans emit worldwide each year.

My take:  Though the title says it is ‘OK to Continue Red Meat Consumption’ –overall, my suspicion is that limiting red meat is probably good for one’s health, though the effect is probably small.

**After publication of these guidelines, it was subsequently revealed that lead author had not disclosed previous research ties to meat and food industry.  See Here: Scientist Who Discredited Meat Guidelines…

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

Dietary Therapy for Inflammatory Bowel Disease –Useful Update

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Recently, Lindsey Albenberg, DO (from CHOP) provided an excellent update on dietary therapy for Crohn’s disease.  She was an invited speaker from CHOA as part of a nutritional support professional development series.  Thanks to Kipp Ellsworth for coordinating this.

Full Slide Set: Nutritional therapies for IBD

Key points from lecture:

  • At CHOP, exclusive enteral nutrition (EEN) is the main dietary approach for Crohn’s disease (CD) advocated due to better proof of its effectiveness
  • In children, EEN is as effective as steroids for clinical improvement and better in terms of mucosal healing
  • EEN therapy can be given regardless of CD location
  • For EEN, there is no difference in response between elemental and nonelemental formulas
  • For EEN to be effective, at least 80-90% of all calories need to be administered during induction
  • At CHOP, EEN is often administered at time of diagnosis and oral approach is tried first
  • Newer dietary approaches are being studied and may be effective.  Diets like the specific carbohydrate diet (SCD) can be considered, particularly in patients with milder disease.

 

The following slide presents SCD diet studies –mostly small studies except for 2016 survey study.

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

 

What Infants and Toddlers Should and Should NOT Be Drinking

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NY Times: What Should Young Children Drink? Mostly Milk and Water, Scientists Say

An excerpt:

A panel of scientists issued new nutritional guidelines for children on Wednesday, describing in detail what they should be allowed to drink in the first years of life. The recommendations, among the most comprehensive and restrictive to date, may startle some parents.

Babies should receive only breast milk or formula, the panel said. Water may be added to the diet at 6 months; infants receiving formula may be switched to cow’s milk at 12 months. For the first five years, children should drink mostly milk and water, according to the guidelines.

Children aged 5 and under should not be given any drink with sugar or other sweeteners, including low-calorie or artificially sweetened beverages, chocolate milk or other flavored milk, caffeinated drinks and toddler formulas.

Plant-based beverages, like almond, rice or oat milk, also should be avoided. (Soy milk is the preferred alternative for parents who want an alternative to cow’s milk.)…

Young children should drink less than a cup of 100 percent juice per day — and that none at all is a better choice…Children do not need juice and are better off eating fruit, the panel said. ..

With the exception of soy milk, plant-based milks are poor in protein. Though they are often fortified, scientists do not know whether people are able to absorb these nutrients as efficiently as those naturally present in other foods.

Formulas marketed for toddlers are usually unnecessary, since most toddlers eat solid food

My take: These recommendations provide good advice.

 

Good Food and Bad Food for Crohn’s Disease -No Agreement

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As noted in a previous blog (IBD Briefs August 2019), there have been numerous diets proposed to help with Crohn’s disease.   The chart below illustrates the lack of any consensus.

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NY Times: “Our Food is Killing Too Many of Us”

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NY Times: D Mozaffarian, D Glickman Our Food is Killing Too Many of Us

“Improving American nutrition would make the biggest impact on our health care”

An excerpt:

“Instead of debating who should pay for all this, no one is asking the far more simple and imperative question: What is making us so sick, and how can we reverse this so we need less health care? … our food…

Poor diet is the leading cause of mortality in the United States, causing more than half a million deaths per year. Just 10 dietary factors are estimated to cause nearly 1,000 deaths every day from heart disease, stroke and diabetes alone…

Taxes on sugary beverages and junk food can be paired with subsidies on protective foods like fruits, nuts, vegetables, beans, plant oils, whole grains, yogurt and fish….Levels of harmful additives like sodium, added sugar and trans fat can be lowered through voluntary industry targets or regulatory safety standards…

Nutrition standards in schools, which have improved the quality of school meals by 41 percent, should be strengthened; the national Fresh Fruit and Vegetable Program should be extended beyond elementary schools to middle and high schools…

Coordinated federal leadership and funding for research is also essential. This could include, for example, a new National Institute of Nutrition at the National Institutes of Health. Without such an effort, it could take many decades to understand and utilize exciting new areas, including related to food processing, the gut microbiome, allergies and autoimmune disorders, cancer, brain health, treatment of battlefield injuries and effects of nonnutritive sweeteners and personalized nutrition.”

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Crater Lake, OR

 

Sunshine and Inflammatory Bowel Disease

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A recent provocative study (EA Holmes et al. JPGN 2019; 69: 182-88) describes an inverse association between sunshine exposure and the development of pediatric inflammatory bowel disease (IBD).  Among a cohort of 99 children with IBD and 396 controls, the authors used questionnaires to estimate past sun exposure along with other variables.

Key finding:

  • “For each 10 min increment in leisure-time sun exposure in summer or winter there was a linear 6% reduction in the odds of having IBD (P=0.002)”

There was no corresponding data with regard to vitamin D status.

My take:  Being active and going outside are likely good for one’s health and there have been other studies suggesting more sun exposure could reduce the rate of Crohn’s disease. Does Sun Exposure Lower the Risk of Crohn Disease? | gutsandgrowth  Despite this, in my view, this study’s findings have limited value.

  1. There may be many confounders that separate children with more sun exposure from those with less exposure, including diets, exercise, camping, exposure to animals and soil, and many other variables. In addition, there may have been problems with recall bias.
  2. The role of vitamin D was not studied. In previous studies, the importance of vitamin D in its effect on the IBD/immune system have yielded inconsistent results.
  3. In those with IBD, suggesting that more sun exposure may have prevented IBD would not be helpful; this is due to the flimsy evidence and this information could be interpreted  as blaming the family.
  4. Correlation does not prove causation.  For example, a far-fetched association of correlation that is not likely to have a causal association: Rates of Drowning by Falling in Pools and Nicholas Cage Films (National Geographic: Nicholas Cage Movies vs. Drownings)

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View from Wahkeenah Falls Trail, OR

 

 

Jejunal Tube Feeding –ESPGHAN Position Paper

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A recent position paper (IJ Borekaert et al. JPGN 2019; 69: 239-58) makes 33 recommendations on the use of jejunal tube feedings.

Full Text Link: The Use of Jejunal Tube Feeding in Children: A Position Paper by the Gastroenterology and Nutrition Committees of the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition 2019.

Here are a few of the recommendations:

  • #1 Jejunal feeding is route of choice for enteral nutrition with failure of oral and intragastric feeds or gastric outlet obstruction
  • #5 Expert group recommends the use of jejunal feeding in children with acute pancreatitis only in cases in which oral or gastric feeding is not tolerated
  • #6 Recommends trial of continuous gastric feeds or a hydrolyzed or elemental formula prior to jejunal feedings
  • #8 & 9 Expert group recommends to consider UGI/SBFT and an upper GI endoscopy in all patients before jejunal tube placement
  • #12 Recommends NOT to use jejunal tube feedings in preterm infants (<37 weeks gestation).  This is based on systemic reviews including Cochrane review which concluded “that there is no evidence of any benefit for transpyloric feeding in preterm infants compared to gastric feeding”
  • #21 Recommends monitoring for nutrient deficiencies –checking copper, zinc, selenium, and iron every 6-12 months (Low level of evidence).  The authors note that some studies have shown reductions in these nutrients; this may be related in part to be due to bypassing the duodenum
  • #24 Avoiding using jejunal tube for medication unless absolutely essential or delivery into the stomach is not possible

Hood River Bridge (crossing Columbia River). Hood River, OR

 

Ensuring Safe Infant Formula Use -More Complicated Than You Think

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A recent commentary (SA Abrams, SR Daniels. J Pediatr 2019; 211: 201-6) highlight some important issues regarding infant formula use/misuse.

The authors indicate that their commentary is not intended to undermine the use of breastmilk in infants.  However, they note that only about 25% of infants are exclusively breastfed until 6 months of age; thus, utilizing formula appropriately is crucial.

Annual Costs per article estimates (based on powder formula):

  • $1109 generic store-brand formula
  • $2021 name-brand routine formula
  • $222 Typical out-of-pocket for WIC clients –store brands (this assumes about 20% of formula is not covered by WIC)
  • $404 Typical out-of-pocket for WIC clients –name brands (this assumes about 20% of formula is not covered by WIC)
  • $215 Whole cow milk (not recommended)

Key points:

  • The authors discuss the role of the WIC program which is a supplemental program –does not provide 100% of an infant’s needs.
  • They describe deceptive formula marketing practices and the difficulty of ascertaining the best value of formulas.  In addition, “marketing of more expensive formula choices as having unique health benefits can easily lead families to spend more money than might be necessary” based on “meaningless” claims of being ‘closest to mother’s milk.’
  • Additives such as oligosaccharides and formulas marketed as organic or free of genetically modified organisms can be used to increase the cost of formula.
  • Use of WIC has decreased by 15% from 2010 to 2017; some may be related to fears related to immigration status of some WIC recipients.
  • Families faced with increased costs may dilute formula or use inadequate substitutes (eg. juice, cow’s milk, prepare home-made alternative)
  • Recent government shutdown placed many infants at risk.

Mistrust Concerns:

  • Many families, abetted by social media, have become distrustful of standard formulas as well as government and even pediatrician advice.
  • There has been an increase in importation of foreign formulas, especially from Europe.  THESE FORMULAS ARE NOT FDA MONITORED OR APPROVED. These illegally imported formulas have no proven advantages and their safety has not been ensured.  They do not undergo routine testing for 30 nutrients which are required by FDA monitored formulas.
  • Raw cow’s milk and raw goat milk have been promoted to ‘improve immune or gastrointestinal function.’ These products have no scientific proof of any advantage and place infants at risk as they are unpasteurized and nutrient deficient.

Author Recommendations:

  • Provide educational programs focused on formula feeding for medical providers and families
  • Increase information and regulation from government and industry about contamination issues
  • Protect the WIC program from consequences of potential government shutdown
  • Mandate improved price clarity
  • Fund research into all aspects of formula feeding, including behavioral interventions to limit inappropriate formula use
  • Monitor social media and provide correct information

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Outside Portland, OR