Category Archives: Nutrition

“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.”

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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:

 

How to Talk About Childhood Obesity

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Pont SJ, et al. Pediatrics. 2017. doi: 10.1542/peds.2017-3034. A policy statement from the American Academy of Pediatrics addresses the issue of stigma associated wtih pediatric obesity.  This is summarized in the following links:

An excerpt form NY Times piece:

Dr. Pont is one of the lead authors of a new policy statement from the American Academy of Pediatrics titled “Stigma Experienced by Children and Adolescents With Obesity.” The statement, published online Monday in the journal Pediatrics, advises pediatricians to use neutral words like “weight” and “body mass index” rather than terms like “obese” and “fat.” …

In a study published earlier this year in the journal Preventive Medicine, Dr. Puhl and her colleagues looked at the longitudinal effects of teenagers being teased about their weight. The study involved over 1,800 people who had been followed for 15 years and are now in their mid 30s…

“These teasing experiences have long-lasting implications for health and for health behavior.” For women especially, these adolescent experiences of teasing by peers or family members were associated with binge eating, poor body image, obesity, and a higher B.M.I. 15 years later, she said; for men there were some of the same associations, including obesity as adults, if they had been teased by their peers as adolescents…

Weight stigma does exactly the opposite; criticizing and inducing shame only make people feel terrible about themselves, not motivated or capable of making changes…

“Recognize that a child is far more than what their weight is, praise them for all the positives, so when we get to some of the more challenging topics, they can still maintain their self-esteem,”…

The most effective way for parents to help a child is to make healthy changes for the whole family, regardless of shape or size, Dr. Pont said. Try making small changes slowly, like adding one new green vegetable into the family diet, not keeping sugary drinks in the home or walking to school instead of driving.

Related blog posts:

Smoke in Grand Canyon after recent brush fires

Fatty Liver Disease with Craniopharyngioma and with Down Syndrome

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A recent retrospective study (SY Yung et al. Ann Pediatr Endocrinol Met 2017; 22 https://doi.org/10.6065/apem.2017.22.3.189 –thanks to Jeff Schwimmer for this reference) describes the problem of nonalcoholic fatty liver disease (NAFLD) in long-term survivors of childhood-onset (CO) craniopharyngioma.

This study reviewed 75 children with CO-craniopharyngioma who had surgery prior to 15 years of age. The mean followup was 4.3 years.

Key findings:

  • 51 had either elevated AST or ALT above 40 IU/L. ALT ≥60 IU/mL was observed in 15 patients.
  • Estimated prevalence of NAFLD based on mainly imaging was 47%. 27 underwent ultrasonography and 5 underwent CT scan.
  • Among those with available growth data, 41% were obese and 18% were overweight.
  • NAFLD developed within a year after surgery in many patients.

This study had many limitations, including reliance of ultrasonography for diagnosis and incomplete evaluations.  Despite this, it is clear that hypothalamic obesity places patients at a high risk for developing NAFLD.  In addition, NAFLD in this population may be more aggressive.

My take: This study documents the well-recognized phenomenon of NAFLD in CO-craniopharyngioma with obesity.  Current treatment relies on trying to preserve hypothalamic function and optimizing lifestyle/nutrition.

Briefly noted: D Valentini et al. J Pediatr 2017; 189: 92-7.  Using ultrasound in 280 Italian children with Down syndrome, the authors identified NAFLD in 45% of those considered nonobese and 82% of those overweight/obese. In a related commentary (pg 11-13 Full text: Down syndrome and Pediatric NAFLD …), the authors (AD Matteo, P Vajro) note that Down syndrome patients may have increased NAFLD due to less activity, more obesity including possible excess adiposity in those with normal BMI, obstructive sleep apnea, or perhaps other mechanisms.

Related blog posts:

 

 

 

 

Infant Feeding, Opportunity, and Asthma

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A recent study (A Kloop et al. J Pediatr 2017; 190: 192-9) examined the relationship between mode of infant feeding and the development of asthma.  The authors used prospective data from 3296 Canadian children in the Canadian Healthy Infant Longitudinal Development (“CHILD” study) cohort.

Key finding:

  • “Compared with infants who received direct breast milk only [at 3 months of age], those who received some expressed milk had a 43% increased odds [of asthma at 3 years of life] …and those who received only formula had a 79% increased odds.”

The authors speculate that the direct breastfeeding may offer some advantages over expressed breast milk:

  • There may be alteration in breast milk components with storage
  • A nursing infant may trigger an increased immune response and be directly exposed to some beneficial commensal bacteria

Since this is an observational study and patients were not randomized there may be other unrecognized confounding variables.

Another study in the same issue (AF Beck et al. J Pediatr 2017; 190: 200-6) assessed whether the Child Opportunity Index (COI) was associated with asthma outcomes in a retrospective cohort of 5462 children in Hamilton County, Ohio.  The COI (see below for the measures in this index) has previously been linked to life expectancy, low birth weight, and prematurity.  Interestingly, one can go to diversitydatakids.org to see how this affects your location (here is the link for a heat map of this index in the Atlanta area: Atlanta COI)

Key finding:

  • Median hospitalization rates varied based on COI –those with very high opportunity had a rate of 1.8 per 1000.  The other quintiles of COI were the following: high opportunity 2.1, moderate opportunity 4.6, low opportunity 7.6, and very low 9.1

My take: The first study indicates that direct breastfeeding is associated with lower rates of asthma.  The second study shows that issues related to education, environment, and social/poverty have an enormous impact on need for asthma-related hospitalization.

 

 

Advice on Arsenic in Baby Foods

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The issue of arsenic, mainly in rice cereal, has been discussed on this blog: Arsenic in Rice –New Recommendations

Renewed widespread publicity on this is likely following a recent NY Times Article: Should You Be Worried About the Arsenic in Your Baby Food?

Here’s an excerpt:

Rice cereal is often a baby’s first solid food, but it contains relatively high amounts of arsenic, a source of growing concern…rice cereals still contain six times more inorganic arsenic, on average, than infant cereals made with other grains like barley or oatmeal.

The new report comes from Healthy Babies Bright Futures, an alliance of scientists, nonprofit groups and private donors that aims to reduce children’s exposures to chemicals that may harm developing brains. One step parents can take immediately to reduce children’s exposure to arsenic is to feed infants cereals made with other grains, the group suggests…

For years, pediatricians have encouraged parents to introduce babies to a wide variety of grains in order to minimize exposure to arsenic…

The Healthy Babies Bright Futures alliance … found that over all, oatmeal, barley, buckwheat, organic quinoa, wheat and rice-free multigrain baby cereals contained much lower amounts of inorganic arsenic than rice cereals..

The average level of arsenic in the rice cereals tested recently was 85 parts per billion, down from an average level of 103 parts per billion found by the F.D.A. when it tested baby cereals in 2013 and 2014…

To reduce your family’s exposure to arsenic, the report suggests choosing a variety of grains including those low in arsenic.

My take: While the levels of arsenic are low, for the infants who are likely more vulnerable, it makes sense to recommend oatmeal cereal rather than rice cereal when introducing solid foods.

 

Projected Obesity Rates: Majority of Today’s Children Will Be Obese in U.S.

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A recent study (ZJ Ward et al. NEJM 2017; 377: 2145-53) pooled observations from 41,567 children and adults.  They extrapolated this data to created 1000 virtual  populations of 1 million children through the age of 19 years.  They performed simulations to predict future obesity levels.

Key findings:

  • Given current levels of childhood obesity the authors predict 57.3% of today’s children will be obese at the age of 35 years.  They defined obesity for adults as BMI ≥35 and for children as 120% or more of the 95th percentile.
  • For children with severe obesity at age 2 years, approximately 80% will be obese at 35 years; whereas approximately 95% of severely obese 19 year olds will be obese at 35 years of age.
  • About half of the total prevalence of obesity at age 35 years begins in childhood in these models.

Because these are simulations, these projections could be influenced by changing circumstances.  Though, the authors note that these projections have corresponded well to measurable trends thus far in NHANES data.

My take: The increasing rates of obesity projected in these models will have profound effects for health but has implications for a wide range of issues: transportation, housing, social, etc.

South Kaibab Trail, Grand Canyon