Category Archives: Nutrition

Briefly Noted: Breastfeeding and Microbiome Diversity

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A recent study (JH Savage et al J Pediatr 2018; 203: 47-54) examined the impact of breastfeeding compared with formula on microbiome diversity in 323 infants; this included 95 exclusively breastfed, 169 exclusively formula fed at time of stool collection.

Breastfed infants were more likely to have been born vaginally (74% vs 62%) and less likely to be African-American (11% vs. 36% for hispanic infants, and 52% for caucasian).

Key finding:

  • Breastfeeding was independently associated with infant intestinal microbiome diversity at age 3-6 months
  • Maternal diet during pregnancy and solid food introduction were less associated with infant gut microbiome changes than breastfeeding status

My take: We still don’t understand the long-term implications of these differences in microbiome alterations between breastfeeding and formula.  That being said, the development/evolution of breastmilk has taken place over thousands of years and it is likely that formula, while an important substitute, will never replicate all of the useful components.

Related blog posts:

Chattanooga Riverwalk Sculpture

NASPGHAN Toolbox App -Review

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To all my colleagues and to others who follow this blog, I wish you a happy new year.  Thank you to all of you, especially to those who provide feedback to help improve the content and usefulness.

Recently NASPGHAN released an App, titled NASPGHAN Toolbox.  There are some very useful features but also some areas where more work is needed.

Work in progress: Many of the algorithms that are listed are dated and no longer accurate.  To list a few examples:

  • The UC Algorithm suggests holding off on anti-TNF therapy in severe disease for 7-14 days
  • The EoE Algorithm lists only diet treatments and topical steroids and does not list PPIs as a treatment option
  • The GERD guidelines are from 2001 rather than more recent recommendations

Also, this ‘algorithms’ section should probably be renamed into ‘algorithms and tables’ as a large amount of the information is not algorithmic.

What I Like:

  • Scores and Calculators for items like MELD score, PUCAI score, Mayo score
  • Extensive patient education handouts and image atlas -this could facilitate “airdrop”ing or messaging of these items to families.  (To be picky –the normal esophagus image could be better)
  • Formula charts –though the lists for infants and older children could be more comprehensive
  • Bristol charts (especially children version) -listed in algorithm section

My take: This is a very good start and a very helpful toolbox for pediatric gastroenterologists but I would not rely on the algorithms.

 

My Favorite Posts from the Past Year

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Recently, I listed the posts that had the most views in the past year –some dating back to 2012.  The following list includes less viewed but some of my favorite posts from 2018:

GI:

Nutrition:

LIVER:

Miscellaneous:

Flowers in Calgary

Most Popular Posts 2011-2018

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Since this blog’s inception, there are now more than 2500 posts; these are the most popular (most views):

Most of these posts are referenced in more recent posts on the same or similar subjects.

Near Banff

 

Most Popular GutsandGrowth Posts from Past Year

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These five posts were the most popular (most views) in the past year:

This is a bike path from Canmore to Banff. I had a chance to ride an electric bike which was a lot of fun.

Rolling Back School Lunch Standards

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NY Times: Trump Administration Rolls Back Obama-Era Rules for School Lunches

An excerpt for 12/8/18:

This week, the United States Department of Agriculture announced its final plans to lower nutrition standards for grains, flavored milks and sodium in school cafeterias that were part of the Healthy, Hunger-Free Kids Act of 2010 …

The Obama-era rules required that schools must serve entirely “whole grain-rich” foods, meaning that the product — whether it is pizza, pasta or hamburger buns — must contain at least 50 percent whole grains…Under the new rules, only half of the grain products on the cafeteria’s weekly menu must be whole grain-rich….

It was unclear why the Trump administration would backtrack when schools were in good standing with the nutritional goals… more than 99 percent of schools in the country reported that they were meeting the Obama-era standards…

“It seems like a small thing,” she said. “But the behavioral research shows you have to offer nutritious food to kids over and over and be consistent.”

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Evidence-Based IBS Treatment Recommendations from ACG

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A recent  American College of Gastroenterology Task Force conducted a systematic review (AC Ford et al. The American Journal of Gastroenterology 2018;113:1–18 ) to update management recommendations for irritable bowel syndrome -Link:

American College of Gastroenterology Monograph on Management of Irritable Bowel Syndrome

The highlights of this report are summarized at Gastroenterology & Hepatoloy: Highlights of the Updated Evidence-Based IBS Treatment Monograph

A few excerpts:

“There have been numerous studies performed on the roles of diet and dietary manipulation in IBS. Three fairly firm conclusions were made following the review of these studies: (1) the low–fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet seems to be effective for overall IBS symptom improvement; (2) a gluten-free diet is not effective for symptom improvement; and (3) conducting tests to detect various types of allergies or intolerances in order to base a diet on those results does not appear to be effective. Of these 3 conclusions, the most impressive data that came out of the research was the evidence for the low-FODMAP diet. Not only were there more studies on this diet, but the results were fairly consistent and favorable, at least for the short-term management of IBS.”

” We did not find evidence supporting the idea that prebiotics and synbiotics were effective in IBS management… In ­contrast, studies demonstrated that probiotics did improve global gastrointestinal symptoms, as well as the individual symptoms of bloating and flatulence in patients with IBS. However, determining which probiotic is best was difficult”

“Three prosecretory agents are available: linaclotide (Linzess, Allergan/Ironwood Pharmaceuticals), lubiprostone (Amitiza, Takeda), and plecanatide (Trulance, Synergy Pharmaceuticals), with plecanatide being the most recently approved agent. All 3 of these agents had convincing data to support their use in patients with constipation-predominant IBS”

My take: In IBS patients, if dietary therapy is recommended, current evidence favors a low FODMAP diet rather than a gluten-free diet.

Related blog posts:

near Banff

Image above -Parker Ridge Trail

TARGET Study: Does Energy-Dense Nutrition Improve Outcomes in the Critically Ill

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A recent double-blind randomized study (NEJM 2018; 379: 1823-44) examined the outcomes of 3957 adult patients undergoing mechanical ventilation who received either a 1.5 kcal formula or 1.0 kcal formula for provision of enteral nutrition.

Key Findings:

  • While the volume of formula was similar, the 1.5 kcal group received a mean of 1863 kcal/day compared to 1262 kcal/day for the 1.0 kcal group.
  • Yet, this did not translate into a survival benefit.  By day 90, 26.8% of the 1.5 kcal group had died compared with 25.7% of the 1.0 kcal group (RR 1.05, 95% CI 0.94-1.16, P=0.41)
  • Higher caloric delivery did not affect survival, receipt of organ support, duration of hospital stay, the incidence of infective complications or adverse events.
  • Regurgitation was more common in the 1.5 kcal group: 18.9% vs 15.7%, RR 1.20, 95% CI 1.05-1.38)
  • The 1.5 kcal group were more likely to receive promotility medications (47.4% vs 39.6%, RR 1.20)
  • The 1.5 kcal group were more likely to receive insulin (55.8% vs 49.0%, RR 1.14)

In their discussion, the authors note that only 2% of patients had a BMI less than 18.5; thus, their cohort is unable to determine whether these patients could benefit from increased calories.

My take (borrowed in part from authors): “Increasing energy intake with the administration of energy-dense enteral nutrition did not affect survival among critically ill adults.” These types of studies are important in challenging assumptions that meeting calorie needs (with enteral or parenteral nutrition) will improve outcomes in hospitalized patients–though, this may be true in some populations.

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Interesting Study -Detrimental Dose-Response of Screen Time

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In 1995, there was a Batman movie, “Batman Forever,” in which one of the central villains, the Riddler, places these brainwave devices over the TVs to gain control of Gotham.  The sad part, according to a recent study (J Zhao et al. J Pediatr 2018; 202; 157-62) is there is no need to add a brainwave device to a TV set.  Excessive screen time alone is quite detrimental.

In this cross-sectional survey in Shanghai with more than 20,000 children, the authors found the following:

  • Mean screen time for preschool children was 2.8 hrs per day.  78.6% exceeded 1 hour per day and 53% exceeded 2 hrs per day.
  • Every additional hour of screen time was associated with increased risk for poor psychosocial well-being; this effect on well-being had a number of mediators including reducing parent-child interaction as well as increased body mass index and reduced sleep duration.

My take: This study reinforces the consequences of excessive screen time  –now, the hard part — how to translate these findings into reduction in screen time.

Related blog posts:

 

 

Why Pureed Food Pouches Are Not a Good Idea for Young Children

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A recent editorial (B Koletzko et al. JPGN 2018; 67: 561-3) explain why pureed fruit/food pouches can be detrimental for child health.  An easy-to-read editorial in NY Times discusses some of the same issues –Link: Rethinking Baby Food Pouches

Key points:

  • Pouches may interfere with learning to eat from a spoon.
  • Feeding infants “a variety of food textures and lumpy foods by spoon feeding and finger foods provides great opportunities for intensive reciprocal interaction between parent and infant”
  • These products generally have high energy density, high sugar content, and a very sweet taste and likely predispose towards bad food choices/selection as the child gets older.
  • Also, these food pouches may increase the risk of dental caries

Additional points from NY Times:

  • The popular pouches, introduced about a decade ago, now account for 25 percent of baby food sales in the United States, according to Nielsen’s Total Food View.
  • The features that make pouches so convenient, though — the smooth texture and squeeze packaging — have some experts concerned. They caution against relying on them too much, saying that they can be a gateway to bad long-term snacking habits and routine overeating
  • If given these pouches when irritable, children also run the risk of learning to associate sweet snacks with calming down, and to think of snacking in general as an activity to satisfy emotional rather than physiological needs.
  • “Feeding is truly a developmental process, just like learning to crawl, walk, run. We would never do anything to keep a child from crawling,” Ms. [Melanie] Potock [a feeding specialist] said. “Let’s not do anything that would stall them in the development of eating.”