Category Archives: Nutrition

The Peanut Story -From NEJM Blog

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If you listen to any news source over the last day, there is a buzz about a new study regarding early peanut exposure in the prevention of peanut allergy.  A link to a blog that summarizes the study and the associated editorial:  NEJM Blog -Peanut Consumption in Infants For those who prefer a 1 minute video summary: Here’s a brief excerpt: The Learning Early About Peanut Allergy (LEAP) study, now published in NEJM, was a randomized, open-label, single-center study designed to compare two strategies to prevent peanut allergy: consumption or avoidance of peanuts. The trial enrolled children 4-11 months of age who were thought to be at high risk for developing a peanut allergy based on a history of severe eczema or egg allergy.  Participants were given a skin prick test to evaluate for sensitivity to peanut.  Children with a negative skin prick result (meaning no measureable skin wheal) or moderately positive (1-4mm wheal) were included in the study; children with a highly positive result (wheal >4mm) were excluded.  Infants were then stratified based on their skin prick test results. 530 infants in the skin prick test negative group and 98 infants in the skin prick test positive group were randomly assigned to either consume 6g of peanut protein per week or to avoid peanuts.  The primary outcome was the proportion of participants with a peanut allergy at age 5, determined by response to an oral peanut protein challenge. The results were impressive:  in the negative skin prick test group, the prevalence of peanut allergy at age 5 was 13.7% in the avoidance group versus 1.9% in the consumption group (P<0.001).  In the positive skin prick test group, 35.3% of those who avoided peanuts were allergic as compared with 10.6% of the consumption group (P=0.004).

This study (NEJM 2015; 372: 803-13) showed that the early introduction of peanuts (median age 7.8 months) significantly decreased the frequency of the development of peanut allergy among children at high risk for this allergy.  These results will result in changes in practice recommendations.  It is noted that approximately 10% of children who had a wheal of more than 4 mm develop after skin-prick testing were excluded.  The associated editorial (pages 875-77) by Rebecca Gruchalla and Hugh Sampson recommends a cautious approach: “any infant between 4 months and 8 months of age believed to be at risk for peanut allergy should undergo skin-prick testing for peanut. If the results are negative, the child should be started on a diet that includes 2 g of peanut protein three times a week for at least three years.” For those with mild positivity, “the child should undergo a food challenge…by a physician who has experience performing a food challenge.”

Will Fitness Devices (like your phone) Help?

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A recent NY Times article reviewed a JAMA study looking at the 10 new devices geared at measuring activity. Better Fitness Through Your Phone

N of 1: As a personal aside, since I know that big brother (ie. my phone) is watching and I want to compare favorably to my wife, I definitely am taking more steps and using the stairs a bit more.

Here’s an excerpt:

The pedometer and the accelerometers were generally quite accurate, but one of the wristbands, the Fuelband, underreported the number of steps the volunteers had taken by more than 20 percent.

Others of the monitors were more accurate but, by and large, no more so than the smartphone apps, which cost much less and would likely be more convenient for many people.

The upshot, said Dr. Mitesh S. Patel, an assistant professor of medicine at the University of Pennsylvania who oversaw the study, is that smartphones could offer “an easy, less expensive, but still accurate” means for people to track their activity.

But the broader issue, as Dr. Patel and his colleagues pointed out in a related commentary published recently in JAMA, is that no fitness tracker of any kind has yet proved able to motivate people disinclined to exercise to start moving

Changing Story Regarding Dietary Cholesterol

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From USA Today: Limiting Dietary Cholesterol May Not Be Needed

Here’s an excerpt:

In a draft report issued in December, an influential federal panel — the Dietary Guidelines Advisory Committee — scrapped longstanding guidelines about avoiding high-cholesterol food…The committee will send its final recommendations to the Department of Health and Human Services and the U.S. Department of Agriculture, which issue the dietary advice. Those departments are expected to issue Dietary Guidelines for Americans, 2015 later this year…

“It’s the right decision,” said Steven Nissen, chairman of cardiovascular medicine at the famed Cleveland Clinic. “We got the dietary guidelines wrong. They’ve been wrong for decades.”

He noted that only 20% of a person’s blood cholesterol — the levels measured with standard cholesterol tests — comes from diet. The rest comes from genes, he said.

“We told people not to eat eggs. It was never based on good science,” Nissen said.

Advice to avoid foods high in fat and cholesterol led many Americans to switch to foods high in sugar and carbohydrates, which often had more calories. “We got fatter and fatter,” Nissen says. “We got more and more diabetes.”

Related blog posts:

Good News for Starbucks & Coffee Vendors

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This blog has posted a number of favorable reports on coffee, even though I’m not a coffee enthusiast.  In general, coffee has favorable health effects when it is not paired with alcohol or tobacco.

A recent coffee study (Gastroenterol 2015; 148: 118-25) shows an association between coffee intake and reduced incidence of liver cancer and death from chronic liver disease in the U.S.

Here’s a link to a summary of the article: GastroHepNews Coffee and Liver Disease

  • During an 18-year follow-up period, there were 451 incident cases of hepatocellular carcinoma and 654 deaths from chronic liver disease.
  • Compared with non-coffee drinkers, the researchers noted that those who drank 2–3 cups per day had a 38% reduction in risk for hepatocellular carcinoma.
  • Those who drank ≥4 cups per day had a 41% reduction in hepatocellular carcinoma risk.
  • Compared with non-coffee drinkers, participants who consumed 2–3 cups coffee per day had a 46% reduction in risk of death from chronic liver disease, and those who drank ≥4 cups per day had a 71% reduction.
  • The inverse associations were similar regardless of the participants’ ethnicity, sex, body mass index, smoking status, alcohol intake, or diabetes status.

Related blog posts:

More liver-related news: Man with infected hepatitis C sentenced to 3 years for spitting in officer’s face (from The Republic/AP News)

Does Anyone Know Why This Toilet is in our Parking Garage?

Does Anyone Know Why This Toilet is in our Office Parking Garage?

Leptin Deficiency and Early-Onset Extreme Obesity

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A brief report (NEJM 2015; 372: 48-54) details a case of 2.5 year old who weighed 33.7 kg (>99.9% and z score of 7.2) and had BMI of 38.6 (>99.9% and z score of 5.8).

Link to article (and picture/growth curve)

The authors determined that he had a mutation which caused biologically inactive leptin.  Subsequently, treatment with metreleptin injections, improved eating behavior and resulted in substantial weight loss.

Key points:

  • “Current clinical recommendations advise that leptin serum concentrations be measured in children who have rapid weight gain in the first months of life.” (“The severely obese patient –a genetic work-up.” Nat Clin Pract Endocrinol Metab 2006; 2: 172-7)
  • This case report demonstrates that normal circulating levels of the hormone “do not rule out disease-causing mutations in the gene encoding leptin.”

Related blog posts:

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Walking May Lower Risk of Death

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From NBC news:  A walk a day may keep early death away

Here’s the “skinny:” (an excerpt)

The findings that a daily, stroll of 20 minutes may reduce a person’s risk of premature death by up to 30 percent are consistent… with the physical activity guidelines for Americans.

Related blog post:

Walking with a “Z” or an “X” | gutsandgrowth

Don't Run Over When You Walk

Don’t Get Run Over When You Walk

Water -Often Missing from Diet

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A recent NPR report indicates that a faction of scientists is pushing for a water icon to be added to the government’s MyPlate.

Here’s the link: Missing from MyPlate? Water

Here’s an excerpt:

“Consumption of sugary beverages is the leading contributor to added sugar in the American diet,” says Christina Hecht, senior policy adviser at the UC Nutrition Policy Institute and one of the water advocates. “If people could make that one change to drink water to quench their thirst instead of sugar beverages, that would solve a big piece of the problem.”

Related blog posts:

What’s Wrong with “I Want My Kid Tested For Food Allergies”

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Most parents, and many physicians, do not understand the limitations of food allergy testing.  As I am sure is common among physicians, I frequently receive requests for food allergy testing; parents do not realize that the strategy for food allergy testing is not straight-forward and has not advanced significantly for decades.  This information is detailed in a recent study and associated editorial (J Pediatr 2015; 166: 97-100, editorial 8-10: “Pitfalls in Food Allergy”).

The study was a retrospective review of all new patients seen at a pediatric food allergy center (2011-2012).  This involved a review of 797 new patients.

Key findings:

  • Of 284 patients who had received a food allergy panel, only 90 (32.8%) had a history warranting evaluation for food allergy.
  • Among 126 individuals who had food restrictions imposed based on food allergy panel testing, 112 (88.9%) were able to re-introduce at least 1 food into their diet.
  • The positive predictive value of food allergy testing was 2.2%.

So what can we learn from this study and editorial?

Misdiagnosis often relates to a lack of understanding regarding serum IgE-based testing.  First of all, many children with atopic dermatitis (and other atopic conditions) have elevated total IgE which results in more false positives.  In addition, a positive IgE test for a specific food indicates sensitization but not necessarily an allergy.

Strategy for testing (recommended by editorial):

  • “The key to the diagnosis of food allergy cannot be overstated; it begins with a detailed clinical history”
  • Testing should be “limited in general to the food(s) in question.”
  • When there is uncertainty, oral food challenges can be performed by specialists.
  • “If a patient is consuming a food without clinical symptoms of allergy, allergy testing should not be done to that food.”

Bottomline (from authors’ conclusion): “Food allergy panel testing often results in misdiagnosis of food allergy, overly restrictive dietary avoidance, and an unnecessary economic burden on the health system.”

Related blog posts:

 

Neonatal Nutrition Lecture -What We Know Right Now

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A recent terrific lecture at Northside Hospital’s neonatology conference by Reese Clark highlighted what we know about neonatal nutrition and what we should be striving to achieve.  This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Dr. Clark was willing to share slides from his talk and a related talk on necrotizing enterocolitis:

Here are a couple of key points from his talk regarding postnatal growth and feedings:

  • Every baby needs good nutrition.  While this is an obvious point, a lot of effort is focused on aspects of care needed in only a small number of neonates.
  • New target for weight gain in premature infants should be 20 gm/kg/day.  This growth is associated with better outcomes (Pediatrics 2006; 117: 1253 Ehrenkranz RA).  In this study, which controlled for a large number of variables, those in the top quartile of growth had much lower rates of cerebral palsy and neurologic impairments.  These improvements were also significant when comparing those in the top quartile to those in the 2nd and 3rd quartiles who were not sicker than those in the top quartile.
  • Most premature neonates are not achieving adequate growth with z-scores for weight and height lower at discharge from the NICU than their z-scores at birth. That is, despite advances in enteral and parenteral nutrition, premature neonates are falling behind while in the NICU. (Clark RH, et al. Pediatrics 2003; 111: 986)
  • Recognizing the supremacy of human milk has been the most important advance and has lead to much lower rates of necrotizing enterocolitis.  There is now a great case for exclusive human milk (J Pediatr 2013; 163: 1592-95; BMC Res Notes 2013; 6: 459)
  • With parenteral nutrition, higher amounts of amino acid have been associated with less issues with hyperglycemia. (Pediatrics 2007; 120: 12: 86-96; Pediatrics 2013; 163: 1278-82)
  • Insulin for hyperglycemia has been associated with poorer outcomes.
  • Does carnitine help with lipid metabolism? No one really knows –no randomized trials.
  • Continuous NG feeds are not associated with fewer signs/symptoms (e.g.. apnea, bradycardia, arching) than NG bolus feeds.
  • Acid suppression in neonates is not effective and potentially harmful
  • We need to use the best growth curves for premature infants: Fenton and Olsen growth charts

Since there are not going to be any trials randomizing neonates into groups assigned to poor growth, we will not know with certainty the impact of good nutrition on long-term outcomes.  Issues with reverse causation and selection bias make it difficult to know whether those with poor growth had other factors besides their nutritional plan which contributed to their outcomes.

Bottomline: We need to continue to optimize nutrition in premature infants; this includes using human milk and preventing necrotizing enterocolitis (which includes avoid acid blockers).  Our goal should be to have infants leave the NICU better nourished than when they arrived.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  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.

 

Arsenic in Rice –New Recommendations

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Over the last two years, there has been increased concern about arsenic in rice.  This has been addressed by consumer reports, the American Academy of Pediatrics (AAP), and is being looked into by the FDA.

Due to the concerns about arsenic in rice, the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) committee on nutrition has published a consensus statement (JPGN 2015; 60: 142-145).  Pediatric gastroenterologists and pediatricians need to familiarize themselves with the report and their recommendations.

Key points:

  • Inorganic arsenic is a carcinogen.
  • “Arsenic content in raw rice varies from 0.1 to 0.4 mg of inorganic arsenic/kg of dry mass.  Rice has a much higher arsenic level than that in other grains.”
  • “Brown rice contains higher concentrations of arsenic.”
  • There is increased inorganic arsenic in products made from rice bran such as rice drinks is much higher due to the concentration of arsenic in the bran layers.
  • “Traditionally in European adults, an average of 9g of rice is consumed daily compared with 300g/day in Asian diets.”
  • “In the US population, mean childhood (1-6 years of age) dietary intake of inorganic arsenic is 3.2 mcg per day”
  • Currently, in the UK, the Food Standards Agency recommends against substitution of breastmilk, formula, or cow’s milk formula by rice drinks up to 4.5 years of age;  in contrast, in Sweden, recommendations advise no rice-based drinks for children <6 years.

Committee Conclusions/Recommendations:

  • “Inorganic arsenic intake during childhood is likely to affect long-term health”
  • “There is a lack of published data on the amount of arsenic in rice protein-based infant formula”
  • Inorganic arsenic in childhood should be as low as possible and the content in dietary products needs to be regulated
  • Rice drinks should not be used in infants and young children
  • Inorganic arsenic exposure can be reduced by including a variety of grains such as oat, barley, wheat, and maize.
  • Rice protein-based infant formulas remain an option in those with cow’s milk protein allergy,,.”the potential risks should be considered”

This is a link to the full length article (available via JPGNonline twitter feed): JGPN “Arsenic in Rice: A Cause for Concern”

This topic has been addressed by Nutrition4Kids website as well. Nutrition4Kids FDA Studying Arsenic

Bottomline: If there is an impact of arsenic in rice on long-term health, it is unclear; the amounts of these exposures are tiny in most cases.  Yet, given the availability of alternatives to rice and rice-based drinks, some changes in practice (ie. adhering to these guidelines) may be worthwhile.