K Puri et al. J Pediatr Gastroenterol Nutr. 2025;81:1–4. Nutritional and growth concerns of vegetarian diets in children
Key points:
“Although vegetarian diets have become popular due to their benefits on environment, they pose nutritional challenges due to the risk of developing nutrient or caloric deficiencies which may impact health or growth in children and adolescents.”
“Any child or family who adheres to a strict vegetarian diet [needs to] work with a nutrition specialist or registered dietitian familiar with the nutritional concerns of a vegetarian diet. This includes calcium and iron intake as well as sufficient and diverse protein intake. B12 and vitamin D supplementation should be considered in vegetarian children”
“While data suggest that average anthropometrics are similar between vegetarian/vegan and omnivorous children, there is some concern regarding the risk of being underweight while following a vegetarian diet…. a vegetarian diet can be a safe and complete diet for children when detailed and longitudinal attention is given to diversification of nutrient intake.”
My take: This article provides a useful review of the dietary issues that need to be monitored for pediatric vegetarians. I agree that a visit with a nutritionist is worthwhile for these children.
Methods: This retrospective cohort study used electronic health record data from a large health system in Ohio and Florida to identify adults with overweight or obesity without type 2 diabetes who initiated injectable semaglutide or tirzepatide between 2021 and 2023; 6109 received semaglutide, and 1772 received tirzepatide. Classification as high maintenance doses for semaglutide were 1.7, 2.0, or 2.4 mg and for tirzepatide 10.0, 12.5, or 15.0 mg, and all other dosages classified as low. The study grouped patients who discontinued pharmacotherapy into those who discontinued early (within 3 months of the index date) and late (within 3–12 months)
Key findings:
80.8% had low maintenance dosages
Mean (SD) percentage weight reduction at 1 year was 8.7% (9.6%)
~50% discontinued medication within 1 year
Patients receiving tirzepatide had more weight loss than those receiving semaglutide (see below). Among patients who did not discontinue obesity pharmacotherapy at year 1, the mean (SD) percentage reduction in weight was 10.9% with semaglutide and 15.3% with tirzepatide
In those receiving high dose medication, mean (SD) percentage reduction in weight was 14.7% with semaglutide and 18.0% with tirzepatide
Patients who continuing therapy had more weight loss than those who discontinued therapy (see below); Mean (SD) percentage weight reduction at 1 year was 3.6% (8.1%) with early discontinuation, 6.8% (9.1%) with late discontinuation, and 11.9% (9.2%) with non-discontinuation (p < 0.001).
DISCONTINUATION OF THERAPY:
Cumulative incidence of obesity pharmacotherapy discontinuation by index medication. s. Discontinuation of obesity pharmacotherapy was defined as a greater than 90-day gap between exhaustion of previous supply and next dispense or between exhaustion of last supply and end of study follow-up
SEMAGLUTIDE VS TIRZEPATIDE:
RESULTS WITH ONGOING TREATMENT VS TREATMENT DISCONTINUATION:
My take: This study showed higher rates of medication discontinuation in a real world setting compared to prior publications. In addition, the majority were receiving lower doses yet still achieving good results. However, increased discontinuation and lower doses likely explain the discrepancy in weight loss in this cohort which was less than in prior studies. It is important that patients taking these medications receive adequate counseling at the start to improve rates of adherence and long-term outcomes, including mitigation of muscle loss and bone loss.
From the commentary: “In 2019, the EAT-Lancet Commission on Food, Plant, and Health proposed a planetary health diet, known as the EAT-Lancet reference diet, that promotes human health and sustainable food production globally…and recommends fruits, vegetables, whole grains, plant-based proteins (eg. legumes, nuts) and unsaturated plant oils, with limited or moderate amounts of animal-based proteins such as meat and dairy….[it] has been associated with multiple health benefits, including reducing the risks of type 2 diabetes, cardiovascular disease, certain cancers, and all-cause mortality.”
Methods: This prospective multicohort study comprised more than 191,000 adults from several cohorts. In addition, 228 Chinese adults from the Prospective Epidemic Research Specifically of Non-alcoholic Steatohepatitis (PERSONS) with biopsy-proven MASLD were included.
Key findings:
Participants in the highest tertiles of the EAT-Lancet diet index had a lower risk of MASLD compared with those in the lowest tertiles with HR ranging in different cohorts from 0.73 to 0.87
Liver-controlled attenuation parameter decreased with increasing the diet index in individuals with biopsy-proven MASLD (β = −5.895
My take (borrowed from the authors): Adherence to the EAT-Lancet reference diet was inversely associated with the risk of MASLD as well as its severity.
Of >105,000 participants with 30-year follow-up, only 9.3% achieved healthy aging (age 70, w/o any chronic diseases). Their diet was significantly associated with this outcome
A Mediterranean type diet high in fruits, vegetables, legumes, nuts, whole grains, low fat dairy products, plant-based foods, and a diet with reduced sodium, trans fats, animal-based foods, sugary beverages, ultra- processed foods was the optimal pattern
These are the specific foods that were linked with healthy aging and other outcomes. Green-favorable; Red-unfavorable
Eric Topol has provided an excellent commentary on this article for those interested in a deeper analysis: Our Diet and Healthy Aging
Dr. Topol notes that there has been a decline in interest in plant-based foods. “In The Atlantic magazine this week [among other big Signal things ;-)] there was an article (←gift link) on the loss of appeal of plant-based eating…” He also previews his new book Super Agers.
AM Jastrebofff et al. NEJM 2025; 392: 958-971. Tirzepatide for Obesity Treatment and Diabetes Prevention
Methods: In this phase 3, double-blind, randomized, controlled trial, there were 2539 participants with obesity, of whom 1032 also had prediabetes. They were assigned in a 1:1:1:1 ratio to receive tirzepatide at a once-weekly dose of 5 mg, 10 mg, or 15 mg or placebo.
Key findings:
Weight loss: At 176 weeks, the mean percent change in body weight among the participants who received tirzepatide was −12.3% with the 5-mg dose, −18.7% with the 10-mg dose, and −19.7% with the 15-mg dose, as compared with −1.3% among those who received placebo (P<0.001 for all comparisons with placebo).
Type 2 Diabetes Reduction: Fewer participants received a diagnosis of type 2 diabetes in the tirzepatide groups than in the placebo group (1.3% vs. 13.3%; hazard ratio, 0.07). After 17 weeks off treatment or placebo, 2.4% of the participants who received tirzepatide and 13.7% of those who received placebo had type 2 diabetes (hazard ratio, 0.12)
My take: This study shows durable effectiveness of tirzepatide over a three year period with no new safety signals.
Consumer Reports published a report on the levels of heavy metals in U.S. infant formulas. In response, we want to share some important information with parents regarding the report.
First and foremost, Abbott’s Similac infant formulas are safe, and parents can use them confidently.
The results reported by Consumer Reports for our infant formulas meet the regulations for heavy metals already set by the European Commission and Health Canada. FDA is currently developing limits for infant formula in the U.S.
Abbott has a multi-step quality process for heavy metals to ensure that levels are below the relevant regulatory requirements in the countries we serve.
Occurrence of Heavy Metals
Heavy metals are naturally occurring in the environment, including in the soil, water, or air where foods are grown. As a result, they are present in low levels in almost anything we eat or drink, including in baby food, all brands of infant formula, fruits and vegetables, and human breast milk.
Commitment to Safety and Quality…
The levels of heavy metals that Consumer Reports detected in Abbott’s formulas are very low—just a few parts per billion. To put that in perspective, a single ppb equals a single grain of sand in 730 pounds of sand.
Approach to Heavy Metals…
Individual ingredients that we believe may contain trace heavy metals (due to absorption from the natural environment) are tested during the qualification process before we approve them for use in our products.We also have an ongoing surveillance testing program after the qualification process designed to periodically test samples of ingredients and finished products to ensure that our supplier and ingredient qualification process is working as intended...Parents can continue to use them with confidence.
This Consumer Reports article is likely to generate a lot of attention. Thanks to Dr. Seth Marcus for sharing this reference.
An excerpt:
While some formulas had concerning levels [of arsenic and lead], there are safer choices. After seeing our results, the FDA is pledging further action…
Consumer Reports tests in the past have found elevated levels of inorganic arsenic in fruit juice, baby food, and bottled water…Our tests found the highest inorganic arsenic level in Abbott Nutrition’s EleCare Hypoallergenic, at 19.7 parts per billion (ppb), and the second highest in Similac Alimentum at 15.1 ppb, also made by Abbott.
As we had expected, CR’s tests found lead in almost all the formulas. Lead levels ranged from 1.2 ppb to 4.2 ppb, which is below the FDA’s Closer to Zero goal, but CR’s experts believe those levels are too high...
Together the formula made by these three companies—Abbott, Mead Johnson, and Perrigo—makes up 79 percent of the U.S. market…They also said trace levels of heavy metals in the food supply are not an issue that is unique to infant formula…
Perrigo, which makes Dr. Brown’s formula and many popular store brands we tested, including Kirkland, Parent’s Choice, Member’s Mark, and Up&Up, also told us that it routinely screens its formulas for heavy metals. “These compounds and PFAS are also found in breast milk,” a spokesperson wrote. “Their levels in infant formula are insignificant and well below regulations in the United States and around the world.”
Contaminants from the environment pose a problem for our entire food supply, CR experts say. But the problem is much more urgent for formula, given how vulnerable babies who depend on it are.
The FDA has long been limited by a lack of both resources and authority to carry out all the oversight it’s tasked with. ..
Keep these test results in perspective. Environmental pollutants are pervasive in our food supply, and all the contaminants in our tests—arsenic, lead, BPA, acrylamide, and PFAS—have also been previously detected in breast milk, food, and water…
Never ever try to make your own baby formula or offer alternative foods. It’s unsafe from a nutrition standpoint…
Use clean water to mix into your powdered formula. The EPA sets limits on contaminants in tap water for most of the country, but not every part of it. If you drink water from a well, for instance, that water is not regulated by the EPA. So it’s a good idea to get well water tested for heavy metals and PFAS before using it…
“Good Choices”
A2 Platinum -A2 Milk Company
ByHeart Whole Nutrition -ByHeart
Happy Baby Organics -Danone
Kendamil Organic -Kendal Nutricare
Neocate Hypoallergenic -Danone
Parent’s Choice Infant -Perrigo
Similac 360 Total Care -Abbott Nutrition
Similac 360 Total Care Sensitive -Abbott Nutrition
Similac Sensitive -Abbott Nutrition
Similac Soy Isomil -Abbott Nutrition
“Worse Choices”
Dr. Brown’s SoothePro -Perrigo
Elecare Hypoallergenic -Abbott Nutrition
Enfamil Nutramagen -Mead Johnson
Enfamil ProSobee Simply Plant-Based -Mead Johnson
Kabrita Goat Milk-Based -Ausnutria
PurAmino Hypoallergenic -Mead Johnson
Similac Alimentum -Abbott Nutrition
Similac NeoSure -Abbott Nutrition
Similac Total Comfort -Abbott Nutrition
Up&Up (Target) Soy -Perigo
My take: Formula companies need to continue to work on minimizing all of the contaminants. Yet, if all families selected only CR’s “top choices,” there would not be enough formula for infants who are not breastfed. In addition, this problem is even more of an issue in children needing specialized hypoallergenic formulas.
First of all: Bilberries are similar to blueberries, but have red inner flesh rather than white flesh.
Background: The authors note that some small studies have shown that anthocyanin-rich extract (ACRE), the bioactive ingredient of bilberries, has been effective for ulcerative colitis (UC)
“ACs have been associated with many protective biological effects, including anti-oxidative, anti-carcinogenic, antimicrobial, and anti-inflammatory properties [17,20,21]. Due to their phenolic structure, ACs exhibit an anti-oxidative capacity in vivo as they scavenge reactive oxygen species (ROS) [20,22], also a classical effect of 5-ASA [23]. After ingestion, ACs largely bypass absorption in the upper gastrointestinal tract, reaching the colon intact, where they are metabolized by microbiota through deglycosylation and further degraded into vanillic, protocatechuic, p-coumaric, gallic, and syringic acids (i.e., phenolic acids) [24]. ACs interrupt the pro-inflammatory signaling and are inhibitors of 5-lipoxygenase, a key enzyme implicated in the arachidonic acid pathway for the biosynthesis of active leukotrienes.”
Methods: A multi-center, randomized, placebo-controlled, double-blind study with a parallel group was conducted. Due to COVID-19’s effect on study enrollment, only 34 patients were randomized and only Eighteen ACRE and eight placebo patients could be analyzed (per protocol set)
Key finding:
Half (9/18) of ACRE patients and 3/8 of placebo patients responded clinically (p = 0.278). An improvement in the Mayo score was observed in the ACRE arm (77.8% vs. 62.5% placebo).
Fecal calprotectin (FC) dropped from 1049 ± 1139 to 557 ± 756 μg/g for ACRE but not for the placebo group (947 ± 1039 to 1040 ± 1179; p = 0.035).
The authors state that the placebo group had an unusually high response and that improved FC with ACRE patients indicates efficacy in UC.
Figure 2Figure 3
My take: This is a negative study (despite the secondary finding of improved FC at some timepoints). Importantly, the study did not demonstrate any harms in the ACRE group. It did help me understand more about bilberries!
The authors utilized prospectively collected data from 3 population-based birth cohorts (Danish National Birth Cohort, Norwegian Mother, Father, and Child Cohort, and All Babies in Southeast Sweden). This collectively included nearly 170,000 offspring.
Key findings:
During median follow-up of 16.3–22.3 years, between 1996 and 2021, 543 offspring were diagnosed with IBD
In each country, there was no association between exclusive breastfeeding duration and offspring IBD risk
Discussion:
“In contrast to majority of case-control studies, both cohort studies reported null association between breastfeeding, treated as a binary exposure (any versus no breastfeeding) or by duration, and offspring IBD risk. Similarly, 2 nested case-control studies, leveraging prospectively collected data on early life exposures as part of the population-based Jerusalem Perinatal Study and 2 United Kingdom birth cohorts (the 1946 National Survey of Health & Development and the 1958 National Child Development Study) reported null associations between breastfeeding and IBD risk.22,23 Data from these studies, which are more rigorous in methodology compared with case-control studies, are consistent with findings from our analyses.”
My take: While this study has some limitations inherent in observational data, this study with prospectively-collected data indicates that breastfeeding did not modulate the risk of developing IBD.
Methods: The authors used a cross-sectional study using data from the National Health and Nutrition Examination Survey (2005-2010) and they used two 24-hour dietary recalls and, based on the Nova classification, calculated intakes of ultra-processed foods (UPFs) and minimally-processed foods (MPFs). N=12,716 adults.
Key Findings:
Median UPF and MPF intakes were 26.5% and 66.2% of total grams per day, respectively
Greater UPF consumption (in % gram/d) was associated with higher odds of constipation (adjusted OR [aORQ4 vs Q1], 2.20]
Discussion point: The authors did not find an association with diarrhea. “UPF consumption has been associated with increased risks of GI disorders that can cause chronic diarrhea including IBD and irritable bowel syndrome (IBS). This was thought to be related to alteration of the gut barrier integrity and activation of the immune response in the setting of microbial dysbiosis. The overall effect induces a pro-inflammatory micro-environment in the intestine and alterations in bowel function. However, the amount of UPFs needed to be consumed by individuals such that the risk of diarrhea would be higher is unknown and likely varies between individuals.”
My take: Limiting UPFs and promoting fresh foods/minimally-processed foods is better for our health.
gutsandgrowth 