Category Archives: Nutrition

Better Diet, Lower Mortality

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Nutrition science is hampered by the inability to randomize people into various treatment approaches.  Thus, when we see that some individuals who, for example, eat more fish, we are unable to conclude that the difference in their outcome is related to their diet or related to other factors that we cannot control.  It could be that individuals who eat fish may exercise more, have more money, smoke less or have less stress.

That being said, we can find associations that may be meaningful.  Into this mix, another study (M Sotos-Prieto et al. NEJM 2017; 377: 143-53) find that a better diet quality is associated with lower total and cause-specific mortality.

This study analyzed two large cohorts:

  • The Nurses’ Health Study -a prospective study with 121,700 RNs –enrollment initiated in 1976
  • The Health Professionals Follow-up Study with 51,529 health professionals enrollment initiated in 1986

Diet quality was evaluated with three scoring systems:

  • The Alternate Healthy Eating Index with 11 food components
  • The Alternate Mediterranean Diet Score with 9 food components
  • The Dietary Approaches to Stop Hypertension (DASH) with 8 food components

Key findings:

  • “A 20-percentile increase in diet-quality scores was associated with an 8 to 17% reduction in mortality”
  • “Worsening diet quality over 12 years was associated with an increase in mortality of 6 to 12%.”
  • “Taken together, our findings provide support for the recommendations of the 2015 Dietary Guidelines Advisory Committee that it is not necessary to conform to a single diet plan to achieve healthy eating patterns.”
  • “Common food groups in each score that contributed most to improvements were whole grains, vegetables, fruits, and fish or n-3 fatty acids.”

Like most nutrition studies, this one has limitations.  Strengths of this particular study include the prospective design, large sample sizes, repeated assessments of diet/lifestyle, multiple diet assessments, and high rates of followup.

My take: There is no doubt that diet quality is associated with improved longevity. Better diets are highly likely to be the reason why many people live longer.

Dupont Forrest, NC

Afraid to Eat -Could be “Avoidant Restrictive Food Intake Disorder”

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A recent case report (JJ Thomas et al. NEJM 2017; 376: 2377-86) provides insight into something I’ve seen a lot but did not have a good label for previously: Avoidant Restrictive Food Intake Disorder (ARFID).

This report highlights an 11 year old who after a having a piece of meat briefly lodged into an orthodontic palate expander, stopped eating solid foods because she was “afraid I can’t chew it up enough to swallow it so I don’t choke.”  Even before this event, she had been a highly selective eater since infancy.  “Similar to many patients with ARFID, this patient had a long-term failure to gain weight appropriately and now had more acute weight loss.”  She did desired to gain weight and did not have any body distortion typical for anorexia nervosa.

This report provides a good list of etiologies which could trigger acute food refusal as well as conditions that could cause chronic poor weight gain.

  • For acute food refusal, etiologies included acute oromotor dysfunction, foreign body ingestion, gastrointestinal ulceration, anorexia nervosa/other psychiatric reasons (including globus hystericus).
  • For chronic failure to gain weight: chronic oromotor dysfunction (numerous neurologic causes), achalasia, inflammatory bowel disease, celiac disease, endocrine etiologies (eg. Addison’s, hyperthyroidism, type 1 diabetes mellitus), infections (eg. tuberculosis, HIV), insufficient food/abuse & neglect, stimulant use, cancers, and other chronic diseases (pulmonary, cardiac, or renal)

Definition of ARFID:

  • “The presence of avoidant or restrictive eating that results in persistent failure to meet nutritional needs; evidence of ARFID includes low weight or failure to have expected gains or growth, nutritional deficiencies, reliance on nutritional supplements or enteral feeding, psychosocial impairment, or a combination of these features. Restrictive eating may be motivated by low appetite or lack of interest in eating, sensitivities to certain sensory aspects of foods, or fear of adverse consequences of eating, such as choking or vomiting.”
  • It is noted that coexisting psychiatric conditions “appear to be common among patients with ARFID. Concurrent anxiety disorders are the most prevalent; they occur in more than 70% of patients in some clinical samples.”

Treatment of ARFID:

There is little data to guide treatment.  Treatment of coexisting psychiatric conditions is recommended and behavioral interventions to improve eating.  In this patient with a choking phobia, the treatment included a gradual stepwise progression in food textures:

  • Liquids–>Purees (eg yogurt, applesauce)–>Textured purees (eg. oatmeal, mashed potatoes) –>Soft solids (eg. rice, mac & cheese, pasta, bread, potatoes, pizza) –>Crunchy solids (eg. chips, pretzels, crackers) –>Hard-to-chew solids (eg. meats)

My take: I think being able to use this relatively new term of Avoidant Restrictive Food Intake Disorder will improve disease classification and ultimately help promote better treatments.

I thought this candy store icon was funny due to the missing tooth

8 Cups of Water: Weight Loss or Worthless?

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A recent study: JMW Wong et al. JAMA Pediatr 2017; 17 e170012 (Thanks to Ben Gold for this reference)

Full Text Link: Effects of Advice to Drink 8 Cups of Water per Day in Adolesents with Overweight or Obesity: A Randomized Clinical Trial

Among 38 adolescents with overweight or obesity, participants were divided into a water group and a control group.  The water group received “well-defined messages about water through counseling and daily text messages, a water bottle, and a water pitcher with filters.”

Key findings:

  • The water group consumed 2.8 cups of water per day compared to 1.2 cups per day for the control group
  • The 6-month chnage in BMI z score was identical z= -0.1.

My take: Advice and behavioral supports to consume 8 cups of water per day are likely to fall short and do not seem to enhance weight loss.

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Normandy American Cementary

Little Evidence to Support Dietary Intervention in Autism Spectrum Disorders

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Thanks to Kipp Ellsworth Twitter feed for reference:  Nutritional and Dietary Interventions for Autism Spectrum Disorder: A Systematic Review N Sathe Pediatrics 2017; vol 139.

Abstract:

CONTEXT: Children with autism spectrum disorder (ASD) frequently use special diets or receive nutritional supplements to treat ASD symptoms.

OBJECTIVES: Our objective was to evaluate the effectiveness and safety of dietary interventions or nutritional supplements in ASD.

DATA SOURCES: Databases, including Medline and PsycINFO.

STUDY SELECTION: Two investigators independently screened studies against predetermined criteria.

DATA EXTRACTION: One investigator extracted data with review by a second investigator. Investigators independently assessed the risk of bias and strength of evidence (SOE) (ie, confidence in the estimate of effects).

RESULTS: Nineteen randomized controlled trials (RCTs), 4 with a low risk of bias, evaluated supplements or variations of the gluten/casein-free diet and other dietary approaches. Populations, interventions, and outcomes varied. Ω-3 supplementation did not affect challenging behaviors and was associated with minimal harms (low SOE). Two RCTs of different digestive enzymes reported mixed effects on symptom severity (insufficient SOE). Studies of other supplements (methyl B12, levocarnitine) reported some improvements in symptom severity (insufficient SOE). Studies evaluating gluten/casein-free diets reported some parent-rated improvements in communication and challenging behaviors; however, data were inadequate to make conclusions about the body of evidence (insufficient SOE). Studies of gluten- or casein-containing challenge foods reported no effects on behavior or gastrointestinal symptoms with challenge foods (insufficient SOE); 1 RCT reported no effects of camel’s milk on ASD severity (insufficient SOE). Harms were disparate.

LIMITATIONS: Studies were small and short-term, and there were few fully categorized populations or concomitant interventions.

CONCLUSIONS: There is little evidence to support the use of nutritional supplements or dietary therapies for children with ASD.

Related blog post: Gluten-free, Casein-free -No improvement in Autism

Bayeux, France

Favorable Fish Oil Outcomes in High Risk Preterm Infants

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Briefly noted: M Sorrell et al. JPGN 2017; 64: 783-88. In this small study with 13 infants (mean gestational age of 28 weeks) who had short bowel syndrome or severe dysmotility and direct bilirubin ≥4 mg/dL (mean 9.8 at enrollment), patients received a fish oil-based lipid emulsion (1 g/kg/d). They were compared with 119 GA-matched controls.

Overall, the authors found the fish oil supplement to be safe.  All patients had resolution of cholestasis. They note the difficulty of proving effectiveness and performing studies in this population.  “Neonatologists…find themselves faced with …a growing body of uncontrolled data that suggests benefits of an unapproved treatment…An attempt to perform a randomized controlled comparison of a plant-based lipid emulsion to FishLE in preventing PNALD in infants at risk was terminated early after an interim analysis revealed much lower than expected incidence of PNALD…[making] trials ethically problematic.”

My take: The data remain incomplete and make it difficult to use a therapy like Omegaven that is quite expensive (not covered) and not FDA approved.  The availability of SMOFlipid is likely to result in less usage of plant-based soy products.

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Rodin Museum

Lipid Emulsions and Unbound Bilirubin in Preterm Infants

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Happy birthday Stan!

In previous work, it had been shown that free bilirubin (Bf) and unbound free fatty acids (FFAu) were increased in extremely low birth weight infants who received intralipid (soybean) at 3 g/kg/d.  A recent study (T Hegyi et al. J Pediatr 2017; 184: 45-50) showed that Bf and FFAu are increased with increasing intralipid dosage (1 to 3 g/kg/d) in all gestational ages (23-34 weeks).

The concern with Bf and FFAu is that elevated concentrations could have adverse neurologic effects; intralipids may act to displace bilirubin from binding to albumin. For most infants in this study, the levels “would not be expected to pose a neurotoxic risk” (per editorial pg 6-7).  Factors that enhance the generation of FFAu include infection, steroids, carnitine deficiency, and low albumin conditions. Phototherapy, in this study, reduced total serum bilirubin but not Bf in those receiving 2-3 g/kg/d of intralipid.

My take: This study does not provide any information regarding neurotoxicity.  It shows that potentially toxic levels of Bf & FFAu can occur in infants born <28 weeks who receive 2 g/k/day or more of intralipid.  While this is a concern, we also know that poor growth is associated with worsened neurocognitive outcomes (Nutrition Week: Downside of Lipid Reduction)

Breastfeeding and IQ -the Latest Data

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A recent study (JY Bernard et al J Pediatr 2017; 183: 43-50) takes a look at the relationship between breastfeeding, specific polyunsaturated fatty acid (PUFA) levels and intelligence quotient at age 5-6 years.

The authors used the French EDEN cohort with 1080 children.

Key findings:

  • Breastfed children had higher IQs by 4.5 points on Wechsler Scales –though this dropped to 1.3 (not significant) when adjusted for confounders
  • DHA was positively associated with higher IQ.  Children exposed to colostrum high in linoleic acid (LA)/ow in docosahexaenoic acid (DHA) had lower IQs than those exposed to colostrum high in DHA/low LA

The authors speculate that one reason that supplemental DHA has not been shown to be effective could be related to a high intake of LA.

Related article: CT Collins et al. NEJM 2017; 376: 1245-55.  In this study, the authors showed that enteral supplemental of DHA (60 mg/kg) did not result in a lower risk of physiological bronchopulmonary dysplasia in a randomized trial of 1273 born before 29 weeks gestation.

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With a new ballpark in town, there are a lot of firsts: first HR, first hit, etc. And now this

 

NY Times: Do DHA Supplements Make Babies Smarter?

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Do DHA Supplements Make Babies Smarter?

Excerpt:

A systematic review of studies published this month by the Cochrane Collaboration concluded there was no clear evidence that formula supplementation with DHA, or docosahexaenoic acid, a nutrient found mainly in fish and fish oil, improves infant brain development. At the same time, it found no harm from adding the nutrient. The findings are consistent with a review of the effects of omega-3 supplements in pregnancy and infancy published by the Agency for Healthcare Research and Quality last fall that found little evidence of benefit.

Still, many experts believe there is value in including DHA in formula. “Even if you can’t easily prove it, because it’s hard to prove developmental outcomes, it makes sense to use it,” said Dr. Steven Abrams, a professor of pediatrics at Dell Medical School at the University of Texas at Austin. “It’s probably a good idea to keep it in there, and it’s certainly safe.”..

The review combined data from 15 randomized controlled trials into a meta-analysis including nearly 1,900 children, many tracked from infancy into mid-childhood. Some studies found small improvements in vision or cognition, but many did not, and when the results were pooled, there was no clear pattern of benefit from DHA added to formula…

 “If you don’t have a deficient population, then it probably doesn’t matter” if people take a supplement, said Dr. Susan Carlson, professor of nutrition at the University of Kansas Medical Center.

But in the United States, many women don’t seem to be getting enough DHA. Women of childbearing age consume an average of 60 milligrams of DHA per day, but many experts recommend at least 200 milligrams per day during pregnancy and breast-feeding.

Proof That Diet Changes Can Improve a Fatty Liver

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A recent prospective study (M Markova, O Pivovarova, et al. Gastroenterol 2017; 152: 571-85) showed that among individuals with nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes that a diet high in protein (animal or plant) reduced liver fat over a 6 week period.

Among 37 participants, body fat and intrahepatic fat were detected with MRI and spectroscopy, respectively. Protein was increased to 30% of the diet. Fat was reduced to 30% and carbohydrates to 40% of diet composition. .

Key findings:

  • With a high animal protein diet, liver fat was reduced by 36%.  In the high plant protein diet group, liver fat was reduced by 48%.
  • Theses changes were unrelated to change in body weight.  However, these changes were correlated with down-regulation of lipolysis and lipogenic indices.

Some of the findings may be limited to older patients as this cohort was older than 60 years of age.  In the pediatric population, the dietary factor that has been linked most closely to NAFLD has been fructose, mainly in sugar-sweetened beverages (R Patusco et al. Top Clin Nutr 2017; 32: 27-46 -thanks to Ben Gold for this reference).

My take: This study shows improvement in liver fat with increased protein/reduced dietary fat.  While this study indicates that dietary modification is important in treating NAFLD, the optimal dietary intervention (eg. higher protein, lower sugar, lower fat) remains uncertain.

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