Category Archives: Nutrition

Can the Mediterranean Diet Change Your DNA?

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According to a recent BMJ study, the Mediterranean diet may protect your chromosomes.  From the NY Times link –here’s an excerpt:

They found that the diet is associated with longer telomeres, the protective structures at the end of chromosomes. Shorter telomeres are associated with age-related chronic diseases and reduced life expectancy.

Researchers used data on 4,676 healthy women, part of a larger health study, whose diets were ranked on a scale of one to nine for similarity to the ideal Mediterranean diet. Researchers measured their telomere lengths with blood tests and followed them for more than 20 years with periodic examinations.

The study, published in the journal BMJ, controlled for body mass index, smoking, physical activity, reproductive history and other factors, and found that the higher the score for adherence to the diet, the longer the telomeres. The difference in telomere length for each point on the adherence scale, the researchers estimate, was equivalent to an average 1.5 years of life.

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2015 Wish List

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A recent policy article (JAMA Pediatr 2014; 168: 1155-63 –thanks to Ben Gold for this reference) outlines “10 urgent priorities for the health and health care of US children.”  These priorities and some of the action steps are as follows:

  1. Poverty: “16.1 million children (22%) live in poverty. ” Action steps include enacting measures to improve employment in families and extending child tax credits.
  2. Food Insufficiency: “>16 million children live in food-insecure homes.” Actions could include investing rather than cutting children’s nutrition programs.
  3. Lack of health insurance: affects “7 million children (9%)” though two-thirds are eligible for coverage by Medicaid and CHIP. Actions could include fully funding CHOP and Medicaid and abolishing ACA family glitch along with improving outreach to enroll eligible children.
  4. Child abuse/neglect (maltreatment): “In 2011, 681,000 children experienced maltreatment and 1570 died” as a consequence.  Everyday, a child is abused or neglected every 47 seconds.  Action steps included focusing on domestic violence and treatment and funding more screening and preventative treatment research.
  5. Obesity: “32% of children are overweight and 17% are obese.”  Actions could include passing FIT kids Act (HR 2178) and maximizing funding for USDA’s Farmers market promotion program and the Fresh fruit and vegetable program.
  6. Firearms deaths/injuries: 5 children die daily by firearms.  Actions could include better background checks, along with regulations to require safer storage and safety classes.  Other options include higher taxation on weaponry and ammunition to “better represent societal costs.”
  7. Racial disparities: Action steps include monitoring and disclosing disparities and working to ensure all children have a medical home.
  8. Mental Health: up to 20% of children experience a mental health disorder annually.  Actions could include increasing the number of qualified mental-health providers (by enhancing reimbursement).
  9. Immigration: “children living in immigrant families are the fastest growing group of US children.” Action could include obtain health insurance for all children.
  10. Research: Increase funding for children.  Overall NIH pediatric funding is 12% of total budget whereas children represent 24% of US population.

The problems faced by this nation’s children will reverberate for a long time.  For example, with childhood poverty, it is “associated with substantially higher mortality rates in adults, regardless of adult socioeconomic status (i.e., even affluent adults who were poor as children have elevated death rates), and this increased mortality risk extends across 2 generations.”

Bottomline: Children receive a disproportionately low share of federal expenditures and this extends to healthcare.  In addition, federal spending on children in 2014 has decreased by more than $20 billion (14%) since 2010.

Blog post:

Can an Altered Microbiome Explain Persistent Symptoms in Treated Celiac Disease?

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A recent study (Am J Gastroenterol dii:10.1038/ajg.2014.355) from Helsinki examined 177 patients with celiac disease.  Their goal was to investigate whether altered intestinal microbiota may be associated with persisting gastrointestinal symptoms in celiac patients who had been following a strict gluten-free diet (GFD) for at least 3 years.

After administering a questionnaire (Gastrointestinal Symptom Rating Scale or GSRS) to those with negative celiac antibodies and normal small bowel mucosa (n=164), the researchers identified the 18 subjects with the highest total score (persistent symptom group) and compared them to the 18 subjects with the lowest total score.  Three duodenal biopsies during endoscopy had been frozen and were subsequently analyzed for their microbial DNA.  In each group, one microbial profile was unsuccessful.

Key findings:

  • In the persistent symptom group, there was lower relative abundance of Bacteroidetes (15% vs. 25%, P=0.01), lower Firmicutes (33% vs 46%, P=0.05) and higher relative abundance of Proteobacteria (40% vs 21%, P=0.04).
  • The “microbial richness,” measured as a number of detected genera or operational taxonomic units (OTUs), was reduced in patients with persistent symptoms.  On average, patients with persistent symptoms had 32 genera and 72 OTUs per sample; in contrast, those without symptoms, on average had 37 genera and 106 OTUs.

Some of the strengths of this study include the normal villous architecture for all of the patients; this helps exclude refractory celiac disease as an etiology for the persistent symptoms.  In the discussion, the authors note that the “intestinal microbiota composition in healthy adults is relatively stable and can tolerate normal stress in the intestine caused by, e.g. daily changes in diet.” The speculate that long-term untreated celiac disease “may disrupt a stable intestinal microbiota community that, in some patients, could then reform in a dysbiotic state.”

The limitations of this study include the difficulty of excluding small intestinal bacterial overgrowth which could be related and the difficulty of excluding coexisting irritable bowel syndrome.  Like most studies regarding the micro biome, this study cannot “show causality or distinguish the effects of different bacteria to the persistent symptoms.”

Bottomline: Treated celiac patients with persistent symptoms have a different duodenal microbiome compared to treated celiac patients whose symptoms resolved with a gluten-free diet.

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Do Oral Nutrition Supplements Help Hospitalized Patients?

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A recent retrospective study suggests that oral nutrition supplements may shorten hospital stays and lower costs when matched against similar patients.

Here’s a link to the abstract: JPEN Oral Nutrition Supplement Study

Some of the details:

  • Retrospective analysis of 557,348 hospitalizations of children aged 2–8 years in the Premier Research Database
  • ONS were prescribed in 6066 of 557,348 inpatient episodes (1.09%).
  • ONS use was associated with a 2.9-day increase (95% confidence interval [CI], 2.32–3.39), or 51.6% increase in LOS, from 5.5 to 8.4 days. ONS use was also associated with increased episode cost of $8568
  • Using a matched sample of 11,031 episodes, hospitalizations with ONS use had 14.8% shorter LOS (6.4 vs 7.5 days). Hospitalizations with ONS use had 9.7% lower cost ($16,552 vs $18,320)

Bottomline: Despite the large numbers of patients, the retrospective nature of the study makes it difficult to determine whether these supplements are effective.  Only a randomized study can answer this blog’s title question.

Rough Skin -Tough Case

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Briefly noted:

“D is Delay” NEJM 2014; 371: 2218-23.  This case presentation described how a 47-year-old homeless man presented with a neuropathy and over the course of FIVE YEARS developed dermatitis, diarrhea, and dementia.  Ultimately, he was diagnosed with niacin deficiency or pellagra. It is almost painful reading the case report knowing how long it took to establish the diagnosis. Take home points from this case report:

  • Pellagra is derived from the Italian pelle agra which means “rough skin”
  • Nutritional deficiencies are difficult to diagnose in this country due to their rarity/lack of pattern recognition

Family Feud with Allergies and Celiac Disease

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A recent article in Allergic Living highlights the common phenomenon of other family members not believing or not willing to make changes in the face of food allergies and celiac disease.

Here’s an excerpt:

Every day, adults and kids are diagnosed with food allergies or celiac disease, and they naturally expect that the people closest to them will take the most care – as they would with any serious health condition. After all, you should be able to trust your mom to keep gluten out of her gravy, and assume that, when your brother babysits your peanut-allergic daughter, he carefully reads the ingredients on that chocolate bar, right?

For too many living with food allergies and celiac disease, sadly the answer is no. In the fall of 2010, Allergic Living sent out a request for anecdotes of family experiences (both good and bad), and within days we were inundated with responses…

In the end, there is no magic cure that will work for every family because complex problems cannot be solved with simple solutions – and, as they say, you don’t choose your family. But clear and calm communication is vital, as is the ability for those living with allergies to put themselves in their relatives’ shoes.

Related blog post:

Save a life with free allergy education | gutsandgrowth

Update on Enteral Nutrition in Pediatric Intestinal Failure

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It is always nice to see how other centers manage clinical problems.  In a recent review (J Pediatr 2014; 165: 1065-90) from Boston Children’s, the authors provide details on how they use enteral nutrition in pediatric intestinal failure (IF) patients.  Prior to reviewing their approach, the authors provide a few definitions:

  • “IF occurs when there is a reduction of functional intestinal mass necessary for adequate digestion and absorption for nutrient, fluid, and growth requirements, resulting in the need for intensive nutritional support.”
  • “IF resulting from extensive intestinal resection is termed SBS” (short bowel syndrome)

The authors also discuss intestinal adaptation and factors that predispose to improvement.  Enteral nutrition (EN) stimulates adaptation and ‘gut rest’ results in atrophy of intestinal mucosa.

Key points:

  • “Prompt initiation of enteral feeding after bowel resection has been shown to decrease the duration of hospitalization”
  • “The optimal choice for EN in infants with IF seems to be human milk…If human milk is unavailable, amino acid-based formulas have been associated with improved outcomes.”
  • If intact colon with ileocecal valve, supplementation with dietary fiber (e.g.. green beans) at 2 g/kg/d may be helpful.
  • In this population, there is a high prevalence of micronutrient deficiencies while on partial PN support, TPN (depending on availability of components), and when on exclusive enteral feedings.
  • “We commonly employ an approach that uses … continuous feeding at night and bolus feeding during the day.
  • Outcomes of IF are reviewed (noted in previous blog entry –see below). Citrulline can be useful predictor of enteral autonomy.

Feeding Advancement Principles -Figure 1:

When feeds are held, usually held for 8 hours and then restarted at 75% of previous rate

Stool output:

  • If <10 mL/kg/d or < 10 stools/d —->advance rate by 10-20 mL/kg/d
  • If 10-20 mL/kg/d or 10-12 stools/d —>no change
  • If >20 mL/kg/d or >12 stools/d  —->reduce or hold feeds

Ostomy output:

  • If 2 mL/kg/h —> advance rate by 10-20 mL/kg/d
  • If 2-3 mL/kg/h –>no change
  • If >3 mL/kg/h  –>reduce or hold feeds

Also suggested to reduce or holding feeds when/if:

  • signs of dehydration
  • stool reducing substances >1%
  • gastric aspirates > four times previous hour’s infusion rate

Oral feeds:

  • When developmentally appropriate, offer one hour’s worth of continuous feeds BID-TID after 5 days of continuous feeds.  Hold tube feeds during oral feeds.
  • More than an hour’s worth of oral feeds once infant has reached full volume of feeds by continuous route and gaining weight.

Take-home message: Outcomes of IF have improved.  This review provides one approach towards optimizing enteral nutrition.

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Is Drinking Milk Healthy?

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A recent article in the Washington Post (thanks to Ben Enav for forwarding this link) which summarizes a study from Sweden questions the long held assumption that milk is a beneficial dietary element in adults.  In fact, drinking a lot of milk may have detrimental effects.

Here’s an excerpt:

a new study from researchers in Uppsala University in Sweden suggests that consuming more milk could actually be associated with higher mortality and bone fractures in women and higher mortality in men.

The study, published in the British Medical Journal, utilized data from two large, long-term Swedish studies of adult men and women, which asked about their dietary habits — how much and what types of milk and dairy products they consumed…

Recently, Americans — and indeed much of the world — have been coming down from their milk high for some time.

Since the 1970s, milk consumption in the United States has dropped from about 1.5 cups a day to about 0.8 cups a day today….

In children, encouraging milk consumption through the National School Lunch Program often takes the form of sugar-sweetened chocolate milk, which has sugar content similar to soda, points out David Ludwig, a Harvard professor of nutrition.

In a 2013 paper Ludwig co-wrote, he suggested that there is not enough scientific evidence to support federal milk consumption recommendations.

And in fact, he added, there is more evidence that humans — who only recently began consuming milk with the domestication of large animals — don’t need it at all.

“Until very very recently, from an evolutionary perspective, humans would have consumed no milk products at all and would have consumed calcium from other sources,” Ludwig said. “Populations that drink no milk at all have perfectly fine bones.

 

 

Maternal Obesity and Neurodevelopmental Outcomes

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If there were not enough reasons to be concerned about the prevalence of obesity already, here’s another: there is growing evidence that maternal obesity (i.e. obesity in the mother at the beginning or prior to pregnancy) is associated with an increased risk for a number of neurodevelopment outcomes (J Pediatr 2014; 165: 891-6).  According to this medical progress report, there are a number of limitations in interpreting the studies associating obesity with these outcomes.

  1. Unclear what is the best measure of obesity and the best timing of measuring obesity
  2. “It is unclear whether obesity per se is the entity that causes adverse outcomes, or whether  obesity is only a marker for other factors” (eg. diet and activity)

With these limitations in mind, the authors review a number of studies.  Key points:

  • Cerebral palsy: “a dose-response relationship was seen, with any diagnosis of maternal obesity carrying a relative risk (RR) of 1.30 (95% CI 1.09-1.55) for CP.  With any diagnosis of morbid obesity, the RR was 2.70 (CI 1.89-3.86)
  • Autism: the risk of developing ASD (OR 1.67; CI 1.10-2.56) and NDD [neurodevelopmental delay] (OR 2.08; CI 1.20-3.61)
  • Cognitive deficits: maternal BMI “was inversely associated wit age 5 years IQ”
  • Behavioral/psychiatric disorders: “children of women who were both overweight and gained excess weight during pregnancy had a 2-fold (OR 2.10; CI 1.19-3.72) increased risk of ADHD symptoms compared with offspring of normal-weight women.” Also, some studies have shown an increased risk for schizophrenia in children of mothers with BMI >30.

Bottomline: obesity is not good for individuals and is associated with increased neuodevelopmental risk in offspring as well.

 

NASPGHAN Postgraduate Course 2014 -3rd Module

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This blog entry has abbreviated/summarized the presentations. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.  All of the speakers had terrific presentations.  The course syllabus is attached:

PG Course Syllabus 2014

The 3rd Module had a “potpourri” of GI problems.

Extraesophageal Manifestations of Gastroesophageal Reflux –Ben Gold, MD (GI Care For Kids, Atlanta) (pg 86)

“Is reflux really the scurge of the earth and the cause of every malady known to human-kind in the head, neck, and lungs…?“

Key points:

Airway protection: “Aerodigestive disease reflexes are intact by 38 weeks gestation.”

Central deglutition apnea: a normal protective mechanism to prevent aspiration during swallowing. (Hasenstab KA, Jadcherla, S. J Pediatr 2014; 165:250-255).  No proof at present that central apnea is caused by reflux though there is a biologic plausibility.

“Although reflux causes physiologic apnea, it causes pathologic apneic episodes in only a very small number of newborns and infants.”  “When reflux causes pathological apnea, the infant is more likely to be awake and the apnea is more likely to be obstructive in nature.”

Laryngeal Reflux:

  • Chronic cough, chronic laryngitis, hoarseness, and asthma may be associated with GERD BUT the data showing a relation between reflux and upper airway disease are weak
  • Airway symptoms attributed to reflux in adults include hoarseness, chronic cough, and globus sensation
  • Affected adults rarely have typical reflux symptoms
  • The sensitivity of laryngoscopic findings to identify reflux disease are poor. Sherman et al. Am J Gastroenterol. 2009;104:1278-95. Vandenplas et al. J Pediatr Gastroenter Nutr. 2009;49:498-547.

Asthma:

“Chronic cough, chronic laryngitis, hoarseness and asthma are multifactorial disease processes and acid reflux can be an aggravating cofactor.” GER is an unlikely contributor to asthma if reflux testing is negative.

“Two NIH-funded blinded, randomized placebo-controlled trials (RCT), one in adults (using esomeprazole), one in children (using lansoprazole) showed NO difference in asthma outcomes comparing placebo and acid suppression therapy”

Multi-Channel Intraluminal Impedance/pH probe studies: Pediatric studies are critically needed to determine if knowing the amount of nonacid reflux changes treatment or outcome

Proton Pump Inhibitors can cause gastric bacterial overgrowth (Rosen R et al JAMA Pediatr 2014; JAMA Pediatr. doi:10.1001/jamapediatrics.2014.696)

Ben Gold (speaker) and Jay Hochman prior to 5K Run

Ben Gold (speaker) and Jay Hochman prior to 5K Run

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EoE: PPI, PPI-REE, TCS, OVB, SFED, 4FED….…Alphabet Distress — Sandeep K Gupta, MD (Indiana University) pg 105 in Syllabus

Treatment endpoints discussed -histologic, symptomatic, fibrosis, etc.

  • Proton pump inhibitor responsive eosinophilic esophagitis (PPI-REE) may work by blocking STAT6 binding to Eotaxin-3 promoter rather than by acid suppression (PLos ONE 2012;7:e50037).  PPIs work (eos <6/hpf) in in 30-40%.  May need high dose to work long-term (Dr Molina-Infante – DDW 2014)
  • Topical corticosteroids (TCS) -higher dose = better response.  (Budesonide. Gupta SK, Vitanza J, Collins, MH Clin Gastro Hepatol 2014 [ePub], Fluticasone. Butz BK. Gastroenterology 2014). Clinical symptoms do not correlate with histologic response. Discussed long term safety concerns.
  • Reviewed diets -elemental, targeted, 4-food elimination and 6-food elimination.

Related blog posts:

“Gotta keep on movin”: New tricks and treatments for motility disorders –Carlo DiLorenzo (Nationwide Children’s Hospital) pg 116 in Syllabus

Key points:

  1. Most important motility study is a normal study.  If normal study, then there is more concern for sensory dysfunction.   Look for significant findings on motility studies not minor changes.
  2. Key to confirm if motility disorder is present. Hx/o small intestinal transplant in medical child abuse/Munchausen syndrome by proxy (Trans Proc 1996; 28: 2790)
  3. New tool: wireless motility capsule (J Pediatr. 2013;162:1181-7)
  4. Easier to obtain full thickness biopsies (Gastrointest Endosc 2011;73:949-54)

Treatments reviewed -“try everything”

  • prucalopride (JPGN 2014; 57: 197-203
  • cisapride -still available
  • lubiprostone (JPGN 2014;58:283–291)
  • linaclotide boxed warning not for <17 years of age –though has been used by motility specialists
  • cyproheptadine (J Pediatr 2013; 163: 261-7) –use in dyspepsia
  • fludrocortisone -used in orthostatic intolerance
  • augmentin -for small bowel motility (JPGN 2012;54: 780–784)
  • octreotide -for bowel motility
  • pyridostigmine (Colorectal Disease 2010 12, 540–548)
  • iberogast
  • botulinum toxin (Gastrointest Endosc. 2012 ;75:302-9)
  • treat bacterial overgrowth
  • surgery: Jube, GJ tube, ileostomy. “Every child with pseudoobstruction on TPN needs a gastrostomy and an ileostomy –(me, now)”
  • gastric electrical stimulation
  • emerging treatment: Elobixibat (for constipation) Expert Opin. Investig. Drugs

Related blog posts:

What’s New in the Diagnosis and Management of Constipation –Manu Sood (Children’s Hospital of Wisconsin) -page 130 in Syllabus

Reviewed recent guidelines from NASPGHAN

“Miralax is considered a 1st line agent”

Outcomes in children with constipation:

  • Almost 50% of patients experienced at least one relapse in first 5 yrs.
  • Almost 20% of children were symptomatic at 10 yrs. follow up (Bongers ME, et al. Pediatrics. 2010)

Pointers:

  • Slow transit is common
  • Rectal compliance does not predict success with treatment. Van den Berg MM, et al. Gastroenterology 2009.  Patients with mega-rectum may have motility disturbance as well.
  • Success rates for antegrade continence enemas (ACE) 65% to 89%. Colon manometry can help predict ACE success.  Up to 40% may be able to stop ACE w/in 2 years

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