Category Archives: Nutrition

It’s Alimentary (Part 3)

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A recent ‘clinical quality forum’ sponsored by The Children’s Care Network (TCCN) and Nutrition4Kids featured several good lectures. The symposium was titled “It’s Alimentary.” What follows are my notes –the full lectures from these talks will be available in the coming weeks on the Nutrition4Kids website. My notes may include some errors in transcription and errors of omission.

“The Importance of Intestinal Microbiota in Pediatric Health and Disease” by W Allan Walker (Harvard Medical School, Director of Division of Nutrition) reviewed data showing how changes in the microbiome, likely related to a ‘Western lifestyle’ has resulted in numerous health consequences.

Key points:

  • The hygiene hypothesis has correlated a greatly reduced risk of infections inversely to an increase in immune-mediated diseases including Crohn’s disease, multiple sclerosis, type 1 diabetes mellitus, and metabolic syndrome/obesity.
  • The consequences of improved hygiene are likely mediated by alterations in gut microbiome
  • To counter alterations in a ‘healthy’ microbiome, perhaps most important is normal neonatal colonization.  This, in turn, is related to healthy pregnancy/full term gestation, vaginal delivery, absence of antibiotics in the first year of life (if feasible), and exclusive breastfeeding.
  • A healthy first-year-of-life microbiome leads to improved tolerance (less allergies) and absence of chronic diseases.
  • In those at risk for altered microbiome, probiotics may be beneficial.
  • By 12-18 months, the microbiome has an ‘adult’ pattern of colonization with a bacterial signature that is present for the rest of someone’s life

Related blog posts:

A subsequent segment addressed “Weight Bias in Healthcare Professionals and What We Can Do About It” by Sheethal Reddy (Strong4Life Clinical Psychologist).

Key points:

  • Physicians have been shown to exhibit decreased empathy with obese patients (KA Gudzune et al. Obesity 2013; 21: 2146-52)
  • Bias can not be eliminated but can be better understood. The Implicit Attitude Test can help ascertain one’s level of bias. https://implicit.harvard.edu/implicit
  • Ways to address obesity as a topic: “Is it OK to talk about…”, use of health report cards to review BMI
  • “The most important thing you can be is kind”

Related blog posts:

In another talk was related to obesity: “ERAS Nutrition in Bariatric Surgery” by Mark Wulkan (Emory University Professor of Surgery). ERAS is an acronym for Enhanced Recovery After Surgery –pioneered in colorectal surgery (Previous post on ERAS: ERAS-Enhanced Recovery after surgery)

Key points:

  • Using ERAS protocol, hospital length of stay has been shortened from 2 days to 1 day
  • ERAS protocol has been associated with minimal use of narcotics –occasionally for breakthrough pain.
  • Current bariatric surgery favored by Strong4Life team –Laparoscopic Sleeve Gastrectomy

Related blog entries:

Bariatric Surgery Candidates

It’s Alimentary (Part 2)

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A recent ‘clinical quality forum’ sponsored by The Children’s Care Network (TCCN) and Nutrition4Kids featured several good lectures. The symposium was titled, “It’s Alimentary.” What follows are my notes –the full lectures from these talks will be available in the coming weeks on the Nutrition4Kids website. My notes may include some errors in transcription and errors of omission.

In my view the best lecture from this symposium was given by Kathleen Zelman (WebMD, Director of Nutrition): Diet and Nutrition Trends Impacting Health

Key points:

  • There have been more individuals pursuing vegetarian and vegan diets.  Though increasing vegetables/fruits is a good trend, vegan diets are particularly challenging (& potentially dangerous) in children.  In those who take milk and eggs, this diet is much more likely to meet nutrient needs.  These diets necessitate the assistance of a dietician.
  • Unfavorable trends: increased consumption of highly processed foods and restrictive food fads.  Some processed foods (eg. canned beans) can be a healthy addition to diet.
  • ‘Organic diets are not more nutritious. They are great if you can afford it. Key is eating more vegetables and fruits.’
  • GMOs are safe.
  • MyPlate.gov is a good resource
  • Encourage families to eat together and to shop for a ‘rainbow of colors’

Related posts:

A subsequent lecture on “Nutrition for the Premature Infant” by Heidi Karpen (Emory University, Professor of Pediatrics) provided a good overview of the ongoing efforts to improve nutritional outcomes for premature infants.

Key points:

  • Good nutrition is crucial for better neurodevelopmental outcomes and stronger bones.
  • Despite efforts like instituting TPN on first day of life, most neonates are losing ground during their hospitalization.
  • Breastmilk is best at reducing sepsis, necrotizing enterocoliitis, and improving IQ.  However, it is not perfect  –less protein, less calcium, and less phosphorus than formulas; thus, breastmilk needs to be augmented and/or supplemented.
  • Informal breastmilk donation can be dangerous.  Donor breastmilk needs to be carefully screened.

Related blog posts:

 

It’s Alimentary (Part 1)

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A recent ‘clinical quality forum’ sponsored by The Children’s Care Network (TCCN) and Nutrition4Kids featured several good lectures. The symposium was titled, “It’s Alimentary.”  What follows are my notes –the full lectures from these talks will be available in the coming weeks on the Nutrition4Kids website. My notes may include some errors in transcription and errors of omission.

“The Fiber Movement: Why Kids Need It and How to Get It” by Maria Oliva-Hemker (Director of Division of Pediatric Gastroenterology, Johns Hopkins). This was a terrific lecture which pulled together a lot of useful information.   Despite hearing a lot about fiber, this lecture showed me that there is a lot that I still need to learn.

Key points:

  • Institute of Medicine recommends 14 grams of fiber per 1000 kcal of dietary intake.  This is a higher amount of fiber than prior recommendations.
  • Most adults are consuming about 50% of the fiber that they should
  • Whole foods should be encouraged over fiber supplements
  • Increased fiber associated with lower risk of obesity, stroke, coronary heart disease, and diabetes

Related blog posts:

“The LEAP Study and Its Implication for the Future of Food Allergies” Kiran Patel (Professor Pediatrics, Division of Allergy and Immunology, Emory University)  This was the second opportunity that I had to hear Dr. Patel in the past 6 months –see An Allergy-Immunology Perspective on GI Diseases

Key points:

  • There has been an increasing incidence of peanut allergies
  • Early introduction of peanuts helps reduce peanut allergies. Suggested algorithm
  • To reduce allergies, placing a best practice alert in electronic record could be necessary as rates of encouraging early peanut introduction in at risk children remains low

Related blog posts:

 

LEAP study results

Slides with information on introduction of peanuts –this should be discussed with physician before implementation.

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 Colloquium: Assessing and Nourishing the High-Risk Feeding Patient

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A recent CHOA Nutrition Colloquium provided a lot of useful information regarding speech language assessment, nutrition assessment, and craniofacial team assessment.

Full slide set: Nutrition Colloquium Jan 2018

Here are a few slides –Thanks to Kipp Ellsworth for coordinating these talks and making slides available. The first group of slides explains who and how to evaluate for feeding problems, the next group discusses the specific role of the craniofacial team, and the last group of slides discusses nutritional management.

 

Parental Fat Stigma

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A recent NY Times article, Do Parents Make Kids Fat, explores the issues of parents being considered responsible for enabling their children to become fat.

Here’s an excerpt:

“When you are the parent of an obese child, there is tremendous stigma,” said Dr. Julie Lumeng, a professor of pediatrics at the University of Michigan. “Everyone looks at the parent and thinks: That parent is incompetent. They don’t care about their child. Why can’t they just make the child eat less and exercise?”

There’s an underlying assumption here about what adults can control, and about how children can be controlled, if only their parents would take the trouble, or make and enforce healthy rules for the whole family, or read the nutritional information on the back of the cereal box….

So yes, for all children, whatever their risk for obesity, good parental decisions about nutrition really matter: It’s important not to overfeed babies, to keep junk food and sugary drinks out of the house, to not let kids eat in front of the screen, and to encourage kids to “eat the rainbow” of fruits and vegetables. But those who rush to judgment should be aware that it is not at all simple to “say no” all the time to an extra-hungry child, or to “feed more vegetables” to the kid who refuses to eat anything green.

Most parents — really — are doing our best, in the complicated food environment in which our children are growing up, with the daily struggles of family life…

“The good parenting that a lot of families exercise when it comes to health,” said Dr. Lumeng, “that may be good enough for a lot of kids, but with some kids with a genetic makeup that predisposes them to obesity, it’s not enough.”

Related blog posts:

 

“Is There a Downside to Going Gluten-Free if You’re Healthy?” Yes

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From NY Times: Is There a Downside to Going Gluten-Free if You’re Healthy?

Yes. This short commentary explains a lot of reasons why going gluten-free is not a great idea for healthy individuals.

  1. Often, a gluten-free diet incorporates more fat, more sugar, more salt and less fiber –all bad for your health.  A gluten-free diet can increase the risk of weight gain, type 2 diabetes, and cardiovascular disease.
  2. A gluten-free diet may make definitive testing for celiac disease inaccurate after more than a few weeks.
  3. “While much has been written in books and online sources about the purported benefits of avoiding gluten, such as weight loss, cognitive well-being and overall wellness, these claims are not supported by evidence….Though some patients with irritable bowel syndrome, or I.B.S., may see symptoms improve after cutting out gluten-containing foods, research suggests it’s likely to be a result of something other than gluten.”

My take (borrowed): “There’s no reason for someone who feels well to start a gluten-free diet to promote wellness,” said Dr. Benjamin Lebwohl, director of clinical research at the Celiac Disease Center at Columbia University. “It is not an intrinsically wellness-promoting diet.”

Related blog posts:

 

Overweight Children (like Adults) Are Prone to Underestimate Their Body Size

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Reference: Steinsbekk Silje, Klöckner Christian A., Fildes Alison, Kristoffersen Pernille, Rognsås Stine L., and Wichstrøm Lars. Body Size Estimation from Early to Middle Childhood: Stability of Underestimation, BMI, and Gender Effects. Front. Psychol., 21 November 2017. DOI: 10.3389/fpsyg.2017.02038

This recent study examined how children perceive their own body size.  Given the prevalence of overweight/obesity, an accurate understanding of body size is needed if one is going to try to work on this issue.

An excerpt of a summary from Brinkwire: Overweight children more likely to underestimate their body size

The study is based on data from the Norwegian research project Tidlig Trygg i Trondheim, a longitudinal population-based study that looks at the risk and protective factors contributing to children’s psychological and social health…

The children were shown seven pictures of girls and boys with known body mass index and asked which picture looked the most like them. The researchers then calculated the difference in BMI between the figure identified by the children and the children’s own BMI based on measured height and weight…

Generally, the researchers found that children more often underestimated than overestimated the size of their body, although the majority made accurate estimates…

“We also found that the higher the children’s BMI, the more they underestimated their size over time,” Steinsbekk says.

The largest children thus underestimated their body size the most and showed an increased degree of underestimation over time (that is, from 6 to 8 and from 8 to 10 years old).

My take: Given the prevalence of overweight/obese children, this has skewed our perception of what a normal weight should be.

Related blog post: Can parents not know if their child is overweight?

Bright Angel Trail, Grand Canyon

Why Fiber (Fruits and Veggies) is Good for You

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A recent NY Times piece provides a summary of recent studies in mice which show that a low fiber diet promotes inflammation throughout the body and results in changes in the microbiome: Fiber is Good For You. Now Scientists May Know Why

An excerpt:

A diet of fiber-rich foods, such as fruits and vegetables, reduces the risk of developing diabetes, heart disease and arthritis. Indeed, the evidence for fiber’s benefits extends beyond any particular ailment: Eating more fiber seems to lower people’s mortality rate, whatever the cause…

The ability of these bacteria to survive on fiber we can’t digest ourselves has led many experts to wonder if the microbes are somehow involved in the benefits of the fruits-and-vegetables diet. Two detailed studies published recently in the journal Cell Host and Microbe provide compelling evidence that the answer is yes.

In one experiment, Andrew T. Gewirtz of Georgia State University and his colleagues put mice on a low-fiber, high-fat diet… the scientists were able to estimate the size of the gut bacterial population in each mouse. On a low-fiber diet, they found, the population crashed, shrinking tenfold.

Dr. Bäckhed and his colleagues carried out a similar experiment, surveying the microbiome in mice as they were switched from fiber-rich food to a low-fiber diet…Along with changes to the microbiome, both teams also observed rapid changes to the mice themselves. Their intestines got smaller, and its mucus layer thinner. As a result, bacteria wound up much closer to the intestinal wall, and that encroachment triggered an immune reaction…

“It points to the boring thing that we all know but no one does,” Dr. Bäckhed said. “If you eat more green veggies and less fries and sweets, you’ll probably be better off in the long term.”

Related blog posts:

Methylmalonic Acid as a Biomarker of Vitamin B12

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A recent case study (L Jimenez et al. J Pediatr 2018; 192: 259-61) showed that methylamalonic acid (MMA) can be elevated in the absence of vitamin B12 deficiency.

Background:

  • Risk factors for vitamin B12 deficiency: terminal ileal resection and gastric acid blockade
  • Manifestations of vitamin B12 deficiency: megaloblastic anemia, bone marrow failure, demyelinating diseases, thrombosis, and psychiatric symptoms
  • Early assessment of vitamin B12 deficiency can be aided by MMA levels and homocysteine levels both of which are metabolized via vitamin B12-dependent pathways and are elevated in vitamin B12 deficiency.
  • MMA levels have higher sensitivity for vitamin B12 deficiency than vitamin B12 levels alone.

Key findings of this report:

  • In three children with short bowel syndrome, MMA levels were persistently elevated despite vitamin B12 supplementation and without other evidence of vitamin B12 deficiency
  • MMA levels declined after treatment of bacterial overgrowth
  • “It is hypothesized that propionate, a precursor to MMA, produced by excessive gut fermentation, is responsible for the elevation in plasma MMA levels.”

My take: this study is a good reminder of how MMA is useful in detecting vitamin B12 deficiency and points out that bacterial overgrowth may be an alternative explanation for elevated MMA levels.

Related blog posts:

Resources for Short Bowel Syndrome:

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.

Bright Angel Trail, Grand Canyon

Last Year’s Most Popular Posts

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I want to thank the many people who have helped me with this blog –now with 2180 posts over more than 6 years.  This includes my wife, my colleagues at GICareforKids, and colleagues from across the country who have provided critical feedback as well as useful publications to review.  I hope this blog continues to be a useful resource.

Here are the top dozen most popular blog posts from 2017: