Category Archives: Nutrition

Breastfeeding: Protection from Inflammatory Bowel Disease

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Xu L, et al. Systematic review with meta-analysis: breastfeeding and the risk of Crohn’s disease and ulcerative colitis. Aliment Pharmacol Ther. 2017;46:780-789.

https://doi.org/10.1111/apt.14291Thanks to Mike Hart for this reference.

From abstract:

Results

A total of 35 studies were included in the final analysis, comprising 7536 individuals with CD, 7353 with UC and 330 222 controls. Ever being breastfed was associated with a lower risk of CD (OR 0.71, 95% CI 0.59-0.85) and UC (OR 0.78, 95% CI 0.67-0.91). While this inverse association was observed in all ethnicity groups, the magnitude of protection was significantly greater among Asians (OR 0.31, 95% CI 0.20-0.48) compared to Caucasians (OR 0.78, 95% CI 0.66-0.93; P = .0001) in CD. Breastfeeding duration showed a dose-dependent association, with strongest decrease in risk when breastfed for at least 12 months for CD (OR 0.20, 95% CI 0.08-0.50) and UC (OR 0.21, 95% CI 0.10-0.43) as compared to 3 or 6 months.

From associated editorial by David Rakel:

This meta-analysis of 35 studies shows that there is a dose–response protective effect of the duration of breastfeeding on inflammatory bowel disease. The association shows as much as an 80% reduction in risk for both Crohn’s disease and ulcerative colitis for breastfeeding more than 12 months.

Breast Feeding Graph

Inflammatory bowel disease arises from a complex set of interactions related to genetic susceptibility, environmental exposures, and a dysregulated immune response to dysbiotic intestinal microbiota, according to the study authors. These data will give us one more reason to encourage breastfeeding, ideally for a year or more.

Related blog post: Nutrition Week (Day 7) Connecting Diet and Epidemiology in IBD

 

 

Fructose Restriction Improved Fatty Liver Disease in Children

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A recent study (J-M Schwarz et al. Gastroenterol 2017; 153: 743-52, editorial MB Vos, IR Goran Gastroenterol 2017; 153: 642-5 ) showed that restriction of fructose quickly improved fatty liver disease.

Several points from the editorial:

  • “The metabolic driver of buildup of fat storage in the liver is de novo lipogenesis (DNL) and fructose is a major substrate of DNL”
  • “In the healthy state, DNL is not expected to be a major contributor to lipid accumulation in the liver….[but] in a fatty liver, it has been estimated that 26% of the fat originates from DNL.”
  • Fructose is “limited in a natural diet…However, it is added to many processed foods and drinks in the form of cane sugar..and other types of sugars, going by ≥57 different names.”
  • Fructose is “commonly used in animal models to induce hepatic steatosis.”

The study is summarized in a recent AGA Journals Blog: Can Restricting Fructose Intake Reduce Fatty Liver Disease in Children?

An excerpt:

Jean-Marc Schwarz et al performed a clinical trial to investigate the effects of reducing fructose intake for 9 days in obese Latino and African American children with habitual high sugar consumption (fructose intake >50 g/day). They measured the effects of isocaloric fructose restriction on de novo lipogenesis, liver fat, visceral fat, subcutaneous fat, and insulin kinetics.

In their study, 41 children, 9−18 years old, had all meals provided for 9 days. The meals had the same energy and macronutrient composition as their standard diet, but with starch substituted for sugar, yielding a final fructose content of 4% of total kilocalories. The authors measured metabolic factors before and after fructose restriction. They measured liver fat, visceral fat, and subcutaneous fat by magnetic resonance spectroscopy and imaging.

Schwarz et al found that on day 10 of the diet, liver fat decreased from a median 7.2% at baseline to 3.8%, and visceral fat decreased from 123 cm3  at baseline to 110 cm3. Liver fat decreased in all but 1 of the 38 participants for whom paired data were available…

De novo lipogenesis decreased significantly after 9 days of fructose restriction; the de novo lipogenesis area under the curve value on day 10 decreased from 68% at baseline to 26% after the diet, in childen with low or high baseline levels of liver fat.

Insulin secretion during fasting and in response to an oral glucose tolerance test decreased significantly in children with low and high baseline levels of liver fat…

In an editorial that accompanies the article, Miriam B. Vos and Michael I. Goran say that it will be important to determine whether the effects of fructose reduction are sustained past 9 days…Vos and Goran state that it is important for physicians, nutritionists, schools, and parents to find ways to reduce fructose in the diets of children and patients with NAFLD.

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Rarely Seen and “Do Not Miss” Explanation for Failure to Thrive

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A fascinating case report (MA Curran et al. NEJM 2017; 377: 1468-77) provides a useful exercise in understanding how to evaluate difficult cases of “failure to thrive.”

From NEJM twitter feed

In essence, a 19 month girl with good linear growth had stopped gaining weight around 7 months of age.  After exhaustive evaluation, detailed in this report, the patient had an MRI which revealed a brain tumor and she was diagnosed with diencephalic syndrome. Key features include good appetite/caloric intake, happy appearance, and cachexia.

The discussion explains that in most children, poor weight gain results from poor caloric intake, which can be related to social issues including poverty, neglect, parental mental health issues, and lack of understanding by caregivers.

In children with good caloric intake, the potential reasons for poor growth are reviewed:

  • Endocrine causes: thyroid dysfunction
  • Renal, pulmonary, cardiac, liver, and pancreatic disease
  • GI diseases: Celiac disease, Inflammatory Bowel disease
  • Infections including tuberculosis, parasites, HIV

Despite the numerous potential causes, beyond basic laboratory assessment,  “extensive testing is usually not warranted: in one study, only 1.4% of additional laboratory tests were helpful in making the diagnosis.”

In many cases of diencephalic syndrome, symptoms like vomiting may be present on an intermittent basis as well as nystagmus or strabismus; these symptoms develop due to obstructive hydrocephalus.

My take: In children with good caloric intake, diencephalic syndrome is a rare but important etiology.

 

 

Too Much Zinc

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An interesting case report (DL Saly et al. NEJM 2017; 377: 1379-85) describes a 61 year old woman with multiple medical problems who developed numbness and tingling in hands/feed which progressed to unsteady gait and inability to stand.

Her medical problems included end-stage renal disease requiring dialysis, COPD, hepatitis C, depression,reflux, breast cancer, hypertension, and chronic back pain. Due to dysgeusia and suspected zinc deficiency associated with dialysis, she had been started on zinc therapy and this was doubled when she did not improve.

Ultimately she was diagnosed with copper deficiency which can result from zinc toxicity, “because zinc upregulates the protein to which copper binds in enterocytes, and an excess of zinc forces copper to be trapped in the enterocyte and unavailable for absorption.”

My take: Too much zinc (as well as other micronutrients/vitamins) can result in adverse effects.

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Do these antibiotics make me look fat?

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There has been a lot of interest and conflicting reports about whether antibiotics contribute to obesity.  Another interesting study on this theme:

  • ET Rogawski et al. JPGN 2017; 65: 350-6. 

The authors followed 1954 children twice weekly from birth to 2 years of age as part of the MAL-ED study.  There were 8 study sites, including in Bangladesh, India, Brazil, Pakistan, Nepal, South Africa, Peru, and Tanzania. Key finding:

  • Antibiotic use before 6 months of age was associated with increased weight from 6 months to 2 years of age.
  • Antibiotic use after 6 months did not affect growth.

The authors speculate: “If treatment of infections were the main mechanism, we would expect antibiotic exposure after 6 months to also have an impact.” Thus, they conclude that effects on the microbiome are likely a more important explanation.

My take (borrowed from te authors):  “Antibiotic use in low-resource settings” can improve growth, though the long-term consequences are not known.  In high-income settings, weight gain secondary to antibiotic exposure is more likely to be detrimental.

Related blog posts:

Patient T-shirt

 

Diet and Stress in Pediatric Eosinophilic Esophagitis

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When it comes to eosinophilic esophagitis (EoE), I sometimes worry that some treatments are worse than the disease, depending on the severity of the EoE. A recent study (C Case et al. JPGN 2017; 65: 281-84) indicates that dietary therapy is often stressful for families.

This study examined children ages 2-18 during an annual American Partnership for Eosinophilic Diseases (APFED.org) patient education conference. What I found most interesting was Table 3. “Stress associated with eosinophilc esophagitis.”

Some of the data:

  • In response to ‘how stressful do you find the following since your child’s diagnosis of EoE?’ Family structure at mealtimes: Not stressful 13.5%, somewhat stressful 21.6%, moderate stressful 16.2%, significant stressful 32.4%, and severe stressful 16.2%
  • In response to ‘how stressful do you find the following since your child’s diagnosis of EoE? Buying and cooking separate foods/meals for your child: Not stressful 2.6%, somewhat stressful 21.1%, moderate stressful 21.1%, significant stressful 31.6%, and severe stressful 23.7%
  • In response to ‘how stressful do you find the following since your child’s diagnosis of EoE? Financial strain due to cost of food: Not stressful 10.5%, somewhat stressful 21.1%, moderate stressful 18.4%, significant stressful 23.7%, and severe stressful 36.3%
  • What is your current stress level in response to your child’s EoE? Not stressful 2.6%, somewhat stressful 15.8%, moderate stressful 36.8%, significant stressful 42.1%, and severe stressful 2.6%
  • 62% of respondents indicated that child’s EoE has affected marital relationship.

In addition, the study documented that “half of youth were affected by worry, anger, and sadness related to specialized diets.”  As this study relied on participants at an APFED meeting, this could skew the EoE population to be more severely affected.

My take: This study shows the emotional burden that dietary treatment of EoE places on families.

Related blog posts:

Berry College

WIC Formula Selection in Infants and Children

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Over the past year, I have been working with the Georgia Chapter of the American Academy of Pediatrics alongside Stan Cohen, MD and Kylia Crane RDN, LD to develop an algorithm to improve formula selection for young children who use the WIC program.  This project was modeled after a similar project for infants.  Here are two of the slides and then the entire slideset is included below:

Link to slideset: AAPformulaAlgorithmsWIC

Obesity Epidemic: Graphic Depiction

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From NY Times: How Big Business Got Brazil Hooked on Junk Food

Excerpt from article:

Across the world, more people are now obese than underweight. At the same time, scientists say, the growing availability of high-calorie, nutrient-poor foods is generating a new type of malnutrition, one in which a growing number of people are both overweight and undernourished…

For a growing number of nutritionists, the obesity epidemic is inextricably linked to the sales of packaged foods, which grew 25 percent worldwide from 2011 to 2016, compared with 10 percent in the United States, according to Euromonitor, a market research firm. An even starker shift took place with carbonated soft drinks; sales in Latin America have doubled since 2000, overtaking sales in North America in 2013, the World Health Organization reported…

In many ways, Brazil is a microcosm of how growing incomes and government policies have led to longer, better lives and largely eradicated hunger. But now the country faces a stark new nutrition challenge: over the last decade, the country’s obesity rate has nearly doubled to 20 percent, and the portion of people who are overweight has nearly tripled to 58 percent. Each year, 300,000 people are diagnosed with Type II diabetes, a condition with strong links to obesity.

Programming for Fatty Liver Disease May Occur Prior to Birth

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A recent study (KP Newton et al. J Pediatr 2017; 187: 141-6; associated editorial pg 13-15)) in a multicenter retrospective cross-sectional study of children (n=538) with biopsy-proven nonalcoholic fatty liver disease (NAFLD) showed that birth weight influenced the development of NAFLD.  The participants were enrolled in the Nonalcoholic Steatohepatitis Clinical Research Network (NASH CRN).

Key findings:

  • There was increased NAFLD among both low birth weight (LBW) and high birth weight (HBW).
  • LBW occurred more commonly in the NAFLD cohort 9.3% compared with the general population prevalence 6.1%.
  • HBW occurred more commonly in the NAFLD cohort 14.9% compared with the general population prevalence 10.5%

The authors speculate that the explanation/mechanisms for increase in both LBW and HBW are likely to differ. It has been recognized that LBW is associated with higher cardiovascular disease and type 2 diabetes.  HBW start bigger and often stay bigger; that is, there are increased risks of more severe obesity.

There are numerous limitations to this study -there is a lot of data that is not available, including gestational age, maternal weight, breastfeeding exposure, and antibiotic administration.

My take: These findings add to the literature that risks for NAFLD along with other metabolic problems may be present at birth.  Is there a way to modify this risk?

Related study: ET Jensen et al. J Pediatr 2017; 187: 50-7, editorial pg 10-12.  In this study of 535 ten-year-old children, enrolled in a prospective multicenter extremely low gestational age newborn cohort study, the authors found that maternal overnutrition and undernutrition affected the brain health of these children. The authors used neurocognitive assessment tools.

  • Children born to women with a pregravid BMI >30 scored “lower on measures of general cognitive ability, executive functioning, fine motor function, and academic achievement.”
  • Children born to women with inadequate maternal weight gain during pregnancy had “lower language and academic achievement.”

Hidden Falls, Highlands NC

 

What Happens to Picky Eaters

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“Little belly-achers grow up to be big belly-achers and big belly-achers beget little belly-achers” –John Apley

John Apley’s monographThe Child with Abdominal Pains indicates that children with recurrent abdominal pain often grow up to be adults with abdominal pains.  A recent study indicates the same type of phenomenon with picky eaters.

A summary of this study in Research Digest: The first study to see if fussy-eating children grow into fussy-eating adults (Thanks to Bonney Reed-Knight for this link.)

An excerpt:

60 per cent of fussy eating children in the study were also fussy eaters at age 23, but fussy eating young adults were no more likely to report signs of eating disorder than their non-fussy peers.

The researchers led by Meredith Van Tine at Stanford University School of Medicine managed to catch up with 61 individuals, now aged 23, who’d participated as children in a long-running study in which their eating habits had been scored by their parents at ages 2, 7, 9.5 and 11, including any signs of fussy eating (being a “selective eater”, having strong likes and dislikes, and only eating a limited variety of foods etc). The participants were now asked to rate themselves on whether they were selective or fussy eaters, and they answered questions about whether they engaged in behaviours related to eating disorders.

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