Category Archives: Nutrition

Walking with a “Z” or an “X”

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In a number of media outlets, there has been a push for a highly successful (and under appreciated) treatment: walking.

Advantages:

  • No/Low cost
  • Easy
  • Often fun
  • Excellent side effect profile

Here’s a link (Every Body Walk!) and here’s an excerpt:

Researchers have discovered a “wonder drug” for many of today’s most common medical problems, says Dr. Bob Sallis, a family practitioner at a Kaiser Permanente clinic in Fontana, California. It’s been proven to help treat or prevent diabetes, depression, breast and colon cancer, high blood pressure, cardiovascular disease, obesity, anxiety and osteoporosis, Sallis told leaders at the 2013 Walking Summit in Washington, D.C.

“The drug is called walking,” Sallis announced. “Its generic name is physical activity.”

Recommended dosage is 30 minutes a day, five days a week, but children should double that to 60 minutes a day, seven days a week. Side effects may include weight loss, improved mood, improved sleep and bowel habits, stronger muscles and bones as well as looking and feeling better.

Comment: If only “walking” was marketed better.  Physicians know that successful treatments need to have an “x” or a “z” or both to really do well (“X and Z in favor”).

 

 

 

Drug Therapy for Celiac Disease

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While a life-long gluten-free diet (GFD) is effective in most individuals with Celiac disease (CD), it is not effective in some. This could be related to cross contamination of food products, improper/inaccurate labeling and perhaps other factors as well.  As a consequence, there is a rationale for the development of medical therapy.  A recent study (Gastroenterol 2014; 146: 1649-58) has shown the ability of ALV003, a mixture of 2 recombinant gluten-specific proteases administered orally, to protect patients with celiac disease from gluten-induced mucosal injury in a phase 2 trial.

Methods: In a 6-week challenge study, adults with biopsy-proven celiac disease were divided into a treatment group with ALV003 (n=20) or a placebo group (n=21).  The 2.0 g gluten dose (equivalent to 1/2 slice of bread) for the study was determined after an optimization study (using 1.5 g, 3.0 g or 6.0 g of gluten (bread crumbs) in three divided doses).  Biopsies were taken before and after the gluten challenge.

Key finding:

  • No significant mucosal deterioration was observed in biopsies from the ALV003 group based on biopsies after the challenge period.  In contrast, the placebo group did have evidence of mucosal injury.

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What I Didn’t Know About Vitamin B12 and Crohn’s Disease

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This month I learned from a recent publication (Inflamm Bowel Dis 2014; 20: 1120-23) that Crohn’s disease without ileal resection does not seem to increase the risk of Vitamin B12 (cobalamin) deficiency.  To reach this conclusion, the authors did an extensive literature search and identified 42 relevant articles with 3732 IBD patients.

Key findings:

  • Ileal resections >30 cm were associated with B12 deficiency.
  • Resections <20 cm were not associated with B12 deficiency; whereas the findings were inconsistent when resections were 20-30 cm.

Take home message:  Crohn’s disease, regardless of disease location, did not increase the risk of B12 deficiency in the absence of ileal resections >20 cm.

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Connecting the Dots: Selenium and Keshan Disease

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With the recent concerns regard micronutrient deficiencies (see links below), I was intrigued with a recent article on Keshan Disease and how it was determined that the cause was selenium deficiency (NEJM 2014; 370: 1756-60).

Here’s the background:  “In 1958, Muth and colleagues demonstrated that the addition of selenium to the diet provides protection against the development of white muscle disease in sheep” (Science 1958; 128: 1090).  Prior to this, in 1935, there had been “an outbreak of rapidly progressive and fatal cardiomyopathy” in Keshan (northeastern China).  So, when the disease reappeared in the 1960s in the Sichuan and Yunnan provinces in southwestern China, at autopsy, heart tissue showed myocardial pallor.  “For this reason, Zheng concluded in 1962 that there were morphologic similarities between Keshan disease and white muscle disease.”  Subsequently, “oral selenium supplementation…virtually eliminated Keshan disease in areas where it was endemic.”

The referenced NEJM article goes on to discuss the mechanisms of action of selenium and its important role in preventing oxidant stress and injury through many selenoproteins.

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Missing Bacteria in Refractory Malnutrition

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A recent article in the NY Times reports on a Nature study (Link: Bacteria and Malnutrition) which showed that certain bacteria were essential in resolving malnutrition.  Here is an excerpt:

“When children are starving, the bacteria that live in their intestines may determine whether they can be saved, scientists working in Bangladesh are reporting. And they say it may become imperative to find a way to give children bacteria as well as food.

The study, done by researchers from Washington University School of Medicine in St. Louis and the International Center for Diarrheal Disease Research in Dhaka, the Bangladeshi capital, was published by Nature last week…stool samples showed that severely malnourished children often lack the needed species and do not acquire them even when they are fed nutrition-dense therapeutic foods like the peanut-based Plumpy’Nut or lentil-based porridges for weeks. As a result, they may remain stunted and mentally handicapped although they are getting enough calories to live.“

Another “chilling” story from NY Times describes E.P.R. (Link: “Emergency Preservation and Resuscitation“) which involves rapidly chilling catastrophic trauma victims by draining their blood and replacing with cold salt water.  This has the potential to dramatically improve survival and has been effective in animal models.

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Another Reason for Inflammatory Bowel Disease Patients to Take Vitamin D

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According to a recent study (Clin Gastroenterol Hepatol 2014; 12: 821-27), “in a large mulit-institutional IBD cohort, a low plasma level of 25(OH)D was associated with an increased risk of cancer, especially colorectal cancer.”  The study reviewed data from 2809 patients who vitamin D levels check (total cohort 11,028 persons with IBD); nearly a third had vitamin [25(OH)D] levels less than 20 ng/mL.  The median followup was 11 years.  During this period, 7% developed cancer (excluding nonmelanoma skin cancer).  Vitamin D deficiency was associated with an adjusted odds ratio of 1.82 of increased cancer risk.

Like so many other studies, this study is another reason for vitamin D manufacturers to feel pretty good.  The associated editorial provides some helpful context (pgs 828-30). The evidence regarding vitamin D dates back to at least 1980 when there was an observed higher incidence of colorectal cancer (CRC) mortality in regions with low solar radiation levels.  Similar findings were noted with breast cancer.

There is biologic plausibility to the importance of vitamin D with regard to cancer as it is involved in “cell signaling, cell proliferation, cell apoptosis, cell adhesion, angiogenesis and it can up-regulate tumor suppressor genes.” A number of reviews have shown an inverse relationship to vitamin D levels and CRC risk.

The editorial points out a number of potential flaws.  “For instance, those who had vitamin D measured may have been among the more ill patients…they may have been the most malnourished.”  “Whether patients had concurrent …primary sclerosing cholangitis was also omitted.”

Take-home message (from editorial): “Although the authors have identified an association, for several reasons it may be spurious…the jury is still out as to what impact maintaining normal vitamin D levels may have on reducing inflammation and modulating cancer risk in chronic inflammatory diseases. However, it is healthful to have adequate vitamin D.” In Manitoba, the authors recommend that all of their patients receive vitamin D supplementation.  In areas with more sun, checking levels may be worthwhile.

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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.

Is Water The Best Beverage for Dieters? Maybe Not

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According to a recent study in Obesity (2014; 22: 1415-21), during the first 12 weeks of a weight loss program water is not as helpful as non-nutritive sweetened drinks (eg. diet soda) when trying to lose weight (Thanks to Jeff Schwimmer for this reference).

The study describes the findings from the 12-week weight loss phase of a 1-year randomized, clinical trial to test the hypothesis that the amount of weight lost (12 weeks) and maintained (9 months) in a behavioral weight management program will be equivalent in participants consuming beverages containing non-nutritive sweetened beverages (NNS) compared to water.

  • Demographics: n=303, mean age ~48 years, 82% female, mean BMI 33
  • Design: “Participants randomized to the NNS beverage group were asked to consume at least 24 fluid ounces of NNS beverage per day and their water consumption was not restricted. An NNS beverage qualified if it had <5 kcal per 8 ounce-serving, was pre-mixed, and contained non-nutritive sweeteners.” Similarly, in the water group, individuals were instructed to consume at least 24 fluid ounces of water per day, and not drink any NNS beverages.
  • Results: “The two treatments were not equivalent with the NNS beverage treatment group losing significantly more weight compared to the water group (5.95 kg versus 4.09 kg; P < 0.0001) after 12 weeks. Participants in the NNS beverage group reported significantly greater reductions in subjective feelings of hunger than those in the water group during 12 weeks.”
  • Conclusion: “These results show that water is not superior to NNS beverages for weight loss during a comprehensive behavioral weight loss program.”

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Why I’m Not a Fan of the “1-Step” PEG

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A recent article describes a single-center retrospective review of the 1-Step Low-Profile percutaneous gastrostomy (PEG) tube (“EndoVive” from Boston Scientific) (JPGN 2014; 58: 616-20).  The potential rationale for the 1-Step PEG tubes:

  • 1-time procedure for a low-profile device

My personal experience with these devices is quite limited.  However, I did have one patient who resumed walking after placement of a 1-step dome device gastrostomy tube. He had stopped walking several months before, mainly due to some mild neurological problems.  After receiving this PEG tube, he said he was in so much pain when he was sitting down that he started walking again.  He was able to continue walking after switching to a different gastrostomy tube.  This particular ‘miracle’ explains one of the pitfalls of this device.  This patient had an embedded bolster.

In the current series, the authors’ conclusion was that the 1-step PEG “has complication rates and outcomes comparable with standard PEGs.”  However, their reported results suggest a higher rate of complications: embedded bolster occurred in 5%, cellulitis in 23% (6.6% needing IV antibiotics), and perforation occurred in 0.8%.

Given the relatively small number of patients (n=121 who met inclusion) and retrospective nature of the study, whether these complication rates are significantly higher is a matter of debate.  It should be noted that there may have been some selection bias given that there were only 31 patients less than one year in the study.

With regard to embedded PEG tubes, the authors note that this complication rate typically is 2.3% with a traditional PEG.  The authors minimize the discrepancy of their higher rate, noting the “importance of choosing the right size of the 1-step PEG.”  For those who perform this procedure, this admonition sounds easy but in practice can be problematic.  In addition, the main advantage of this procedure is the “1-step” procedure.  Yet  in Figure 2, the authors note that 67 (more than 50%) underwent a change to a balloon device.

Bottomline: The authors state that the 1-step PEG, “in our opinion, is a preferable PEG technique for children who need long-term enteral feeds.”  My opinion: I’m not a fan and think the 1-step, for initial placement, is less safe overall.

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Looking Beyond the Headline for Ultra-Short Bowel Syndrome

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A quick glance at a recent study (JPGN 2014; 58: 438-42) suggests a favorable outlook for patients with ultra-short bowel syndrome (U-SBS). U-SBS has been defined as having a residual small bowel length <10 cm distal to the ligament of Treitz.  A more cynical definition by a colleague years ago was that U-SBS was when patients can fart and burp at the same time.

Looking at the details:  This study enrolled 11 patients into a prospective Italian database since 2000 and examined their outcomes.  Inclusion criteria included U-SBS diagnosed in the neonatal period (<28 days) and necessitating home parenteral nutrition at discharge.

The demographics note that these patients were bigger at birth and less premature than typical series of patients with SBS:

  • Only one of the patients had necrotizing enterocolitis as the sole underlying disease and six patients had volvulus.
  • All but two had ≥50% of their colons, with five having their entire colon.
  • All but one of these patients had gestational age ≥32 weeks and only two  patients had documented birth weight less than 2300 gm.

The authors note that these patients currently receive SMOFlipid as outpatients and Omegaven as inpatients.  All patients receive some enteral feedings.  Loperamide is used selectively.

Results:

  • Inpatient hospital care ranged from 23 to 104 days/year, but had improved during the last year of followup.
  • With >5 years of followup, 2 of the 11 patients had died.  One of these patients had severe intestinal failure associated liver disease (IFALD) despite use of Omegaven.
  • One patient underwent isolated intestinal transplantation.
  • No children in this series underwent a bowel-lengthening…”given the shortness of the residual small bowel, the gain of length after any procedure will not significantly improve absorption.”

Given their results, the authors note that despite recommendations for early referral for intestinal transplantation in patients with U-SBS, this may not result in a survival benefit.  They note a study by Pironi et al (Gut 2011; 60: 17-25) that showed that among 80 intestinal transplant candidates, 5-year survival was greater in those who were not transplanted.

Bottomline: This small cohort shows that certain populations of U-SBS may do well clinically for a long time with medical management. Caution should be used in extrapolating these results to SBS patients with different demographics.

Parenteral Omega-3 Lipid Emulsions and Risk of Bleeding

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A recent study indicates that patient’s placed on omega-3 lipid emulsions (eg. Omegaven) may be at risk for bleeding due to platelet dysfunction (J Pediatr 2014; 164: 652-4).

While omega-3 lipid emulsions have received a lot of attention due to improvements in intestinal failure associated liver disease (IFALD) (see previous links to prior posts below), the amount of data supporting their usage and potential advantages compared with standard lipids at similar dosing remains limited.

This case report describes a 9-month old who developed life-threatening hemorrhage following a standard central line placement.  Due to difficulty stopping the bleeding, the patient’s omegaven was discontinued.  Standard workup for bleeding disorders were negative.  Subsequently, the authors investigated clot formation and platelet function in a neonatal animal model.

Key Result: Piglets treated with omegaven had a doubling of time to clot formation and marked platelet agonist inhibition.

The discussion notes that “there is an acknowledged risk of high dose O3FA lipids [omegaven] increasing bleeding time because of competitive inhibition of AA [arachidonic acid] production, hence decreased TxA2 [thromboxane A2].  In addition, platelet-derived growth factor-like protein and endothelial platelet activation factor are decreased.”

Take home points (from the authors):

  • “the case report and piglet studies together demonstrate that there is potential for a significant antiplatelet effect and inhibition of the coagulation cascade with O3FA therapy…”
  • “We would suggest discontinuation of Omegaven therapy 72 hours preoperatively in high-risk cases where bleeding may be difficult to directly control.”
  • “Institutionally, we have abandoned the sole use of Omegaven therapy.”

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